Latest reports, citations, and penalties from CMS data
What they found was a month-long failure so basic that the facility's own Director of Nursing struggled to explain it....
Inspectors visited Matlock Place Health & Rehabilitation Center on November 23, 2025, responding to a complaint....
The capacity determination came first....
The inspection report does not name the resident whose complaint triggered the investigation....
Federal inspectors cited the facility following a complaint investigation completed November 25, 2025....
Federal health inspectors documented the deficiency on November 24, 2025, under a category covering resident assessment and care planning....
The citation against Whittier Hills Health Care Center was issued November 25, 2025, following a complaint investigation....
No resident was documented as harmed....
Christian Care Nursing Center apparently had doubts it didn't act on....
Around the perimeter of the same room....
Inspectors tagged the deficiency under F0761, which covers the safe and orderly storage of drugs and biologicals....
Management did not relocate them....
Inspectors touring the Rehabilitation Unit that day found the window in Resident 1's room had cracked glass that someone had patched with duct tape....
On the morning of October 2, 2025, an inspector walked the 300-hall medication cart at Pembroke Center alongside the facility's wound and treatment nurse....
The citation was classified as immediate jeopardy, meaning inspectors concluded the facility's failure placed residents at risk of serious injury or death....
The first fall happened on February 15, 2025....
The facility's own registered nurse confirmed the gap....
The inspection, conducted on November 25, 2025, was triggered by a complaint....
Inspectors determined the deficiency carried potential for actual harm and affected some residents at the facility....
The resident, identified in inspection records only as Resident 7, had a pressure ulcer on the left ischium, a bone in the lower pelvis....