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Buckeye Care and Rehabilitation: Coffee Burn Violation - OH
On February 20, a nurse examined him after staff brought him back from the dining area....
Latest reports, citations, and penalties from CMS data
On February 20, a nurse examined him after staff brought him back from the dining area....
That same resident needed staff supervision to eat, brush their teeth, and manage personal hygiene....
That was the picture federal inspectors found during a complaint inspection at Live Oak Rehab Center, a skilled nursing facility in San Gabriel....
That is what federal inspectors found when they walked into Avalon Villa Care Center in Los Angeles on August 18 and 19, 2025....
That finding sits at the center of a complaint inspection completed August 19, 2025, by state surveyors reviewing care practices at the facility....
His physician had written an order for oxycodone 5 milligrams, immediate release, to be taken by mouth every four hours as needed....
Blood thinners are not a medication where missing doses is a minor inconvenience....
Resident 1, as he is identified in state inspection records, was last seen on August 16, 2025, at approximately 12:18 p.m., stepping into an elevator....
The requirement to share that plan within forty-eight hours of admission isn't a formality....
A standardized cognitive assessment gave her a score of 2 out of 15, placing her in the range of severe cognitive impairment....
The resident, identified in the report only as Resident 2, had two pinpoint openings in the sacral area, a wound site that demands careful infection control....
The resident was cognitively intact and required assistance with personal care, according to a June 2025 assessment of his abilities and care needs....
The facility's own nursing director said so out loud during an inspection on August 19, 2025....
She said a staff member at the nursing home told her the medication had not arrived yet....
Three months later, a federal inspector walked through all three units of the facility and found conditions that supported the complaint....
The wound care procedure involving Resident 18 unraveled in stages....
The resident, identified in inspection records only as Resident D, was already among the facility's most vulnerable....
The Director of Nursing later confirmed this directly to inspectors....
The resident, identified in inspection records only as Resident B, was admitted from her home and was already receiving hospice services when she arrived....
That gap, uncovered during a complaint inspection completed August 20, sits at the center of a deficiency citation against the facility....