Latest reports, citations, and penalties from CMS data
The violations affected residents who remained at the facility for weeks without anyone determining their preferences for future living arrangements....
The resident required the extra-large sling based on measurements from the base of their spine to the top of their shoulder, the DON explained to inspectors....
The nurse failed to secure the resident's urinary catheter and committed a basic error that could increase infection risk....
None of these assessments appeared in the resident's official care plan or MDS evaluation upon admission....
Instead, multiple visit notes sat unsigned and unrecorded until the physician uploaded them in batches weeks later....
Resident #15 had a suprapubic catheter that required a securement device to prevent dangerous dislodgement....
The man has Alzheimer's disease, kidney disease, and requires maximum assistance with nearly every daily activity....
But the care plan told a different story....
Federal inspectors examining the facility's Treatment Administration Records found systematic gaps in documentation spanning July and August 2025....
The facility's own assessment classified the resident as high risk for wandering, with a score of 14 on their Wandering Risk Scale....
The medication error came to light only after Resident #2 fell and staff discovered two rivastigmine patches on his body during examination....
The MOLST documents guide critical decisions about cardiopulmonary resuscitation and other emergency interventions....
CNA #20 admitted multiple safety violations during her interview with inspectors....
The October 23 complaint investigation centered on Resident #3, who developed blisters on both hips during their stay....
Yet the family remained unaware until they happened to be present when the wound care provider came to the resident's room....
The incident at CareOne at Livingston reveals a breakdown in basic wound care protocols that left a facility-acquired injury undocumented for 10 days....
The facility's computer system was designed to prompt nurses to enter a blood sugar reading when they signed off on administering the insulin....
The finding triggered an emergency state survey that confirmed the facility had implemented corrective measures by October 15....
The contradiction emerged during an October complaint investigation that revealed systemic failures in the facility's elopement prevention program....
Federal inspectors found that both the charge nurse and assistant director of nursing assumed the other would make the required family notification call....