Latest reports, citations, and penalties from CMS data
The inspection, conducted on August 12, 2025, caught the problem during a routine review of one of two medication carts at the facility....
The resident, identified in inspection records only as R5, uses an indwelling urinary catheter because of a neuromuscular dysfunction of his bladder....
Resident R1, a man with chronic kidney disease, urinary retention, and a freshly placed urinary catheter, was alone....
What happened next became the subject of a complaint, a facility investigation, and ultimately a federal inspection citation....
The facility opened it before he ever saw it....
That was not the first time inspectors had seen the insects that week....
That was not the worst thing inspectors found that week....
That detail came from an interview inspectors conducted on August 12, at 10:22 in the morning....
Inspectors arrived on August 12 and spent nearly two hours observing the first floor nursing unit....
It was not the first time inspectors had found this....
The facility never notified the California Department of Public Health about the outbreak, according to a complaint inspection completed August 12, 2025....
The resident, identified in the inspection report only as R1, had a tracheostomy....
The finding, documented in a complaint inspection completed February 28, 2025, placed Capstone at the most serious level of federal deficiency....
The resident, identified in inspection records as R74, had been referred for a restorative nursing program after completing therapy....
The fall happened on July 25, 2025, at Maples Benzie County Medical Care....
It was, the aide explained, meant to make the narcotic count go faster....
The other residents who witnessed it were scared enough that they waited until the next day to report what they had seen....
That was on the night of August 10th....
The records, covering shifts from July 21 through August 10, showed one nurse clocked in at 6 p.m....
The resident had undergone cardiac surgery....