Latest reports, citations, and penalties from CMS data
The facility terminated the nursing assistant within two hours and reported the abuse to authorities....
The facility admitted the 83-year-old resident in August with vascular dementia....
She walked to the medication cart near the first-floor dining room and requested anti-anxiety medication from Staff E, a trained medication assistant....
Federal inspectors discovered the oversight during a complaint investigation completed in October....
Federal inspectors found the same scene during three separate visits to Avir at Rose Trail between September 28 and October 2....
But the facility's original screening form indicated the resident had no primary diagnosis of cerebral palsy....
Licensed Practical Nurse #2 abandoned the cart at 10:17 AM on September 25 to attend to another resident behind a closed door....
The injuries prompted a complaint investigation that concluded October 2, 2025....
The 65-year-old resident disappeared on June 27, 2025, sometime before 5 p.m....
The admission came during a federal inspection on October 2nd at a facility caring for 55 residents....
The resident didn't report the incident until nearly two weeks later....
The patient came back with a PICC line inserted in their arm for long-term intravenous medication delivery....
That's when Resident B heard a pop....
The incident occurred around 11:30 pm on August 3, 2025, when the resident was found crying and complaining of chest pain....
The September 21 assault at Legacy Nursing at St....
Staff heard door alarms going off but didn't immediately investigate the source....
Yet nursing staff failed to document whether the resident ate breakfast on August 3, 4, 9, 15, 22, 23, and September 1, 2025....
The facility's own policies outlined detailed requirements for managing medical orders that weren't being followed....
Resident #13 required tube feeding because she couldn't swallow safely, yet she routinely tampered with her medical equipment and consumed dangerous items....
The assistant administrator discovered the employee in the resident's room asking for money during what should have been her day off....