Sarah Reed Senior Living.

“A resident in the secure dementia care unit was found on the floor at 5:40 a.m. with injuries including dried blood and a skin tear. Staff did not immediately alert supervisors, and the resident's condition deteriorated significantly throughout the day, eventually requiring hospitalization and discharge to a skilled nursing facility. The facility failed to prevent neglect and ensure proper monitoring of the resident.”

“An enabler bar attached to a resident bed was uncovered, exposing approximately 9 areas that were 18 inches high between the mattress and top rail support and 5 inches wide between rail supports, creating a potential entrapment hazard.”

“During three fire drills, residents did not adequately evacuate to a designated meeting place away from the building or within the fire-safe area: 26 of 78 residents on one date, 15 of 88 residents on another date, and 0 of 108 residents on a third date.”

“A resident admitted to the secure dementia care unit with documented mobility needs was found on the floor with injuries at 5:40 a.m. on 9/7/25. The facility failed to secure timely medical care, as the resident was not sent to the hospital until approximately 3:00 p.m. after significant deterioration, and was not assessed for injuries from the fall until staff noticed the resident could not bear weight and was in severe pain.”

“Resident #3 did not receive required toileting assistance every 2 hours as indicated in the assessment and support plan. On the overnight shift, the resident sat in a recliner all night without toileting assistance and was found saturated in urine on the morning of 4/7/25.”

“The resident-home contract dated for resident #2 was not signed by the resident.”

“Staff person A did not identify the correct resident during medication pass and administered resident #5's medication to resident #4. Resident #4 suffered physical effects of receiving numerous medications not prescribed and was hospitalized for Hypotension. The resident was admitted to the hospital and later transferred to a Skilled Nursing Facility before returning. This is a repeat violation from 4/16/24.”

“The home failed to implement safe storage and access procedures for medical equipment. A resident's glucometer reading was documented on the medication administration record but was not actually on the resident's glucometer device.”

“The home failed to immediately report suspected abuse of a resident. Staff discovered resident #2 in an inappropriate position with resident #1 in a locked bedroom, and resident #1 became upset and cried requesting to leave the facility. The home did not report this incident to the local Area Agency on Aging until a later date, violating the requirement for immediate reporting under the Older Adult Protective Services Act.”

“A resident was neglected and subjected to mistreatment. Resident #1 (with Alzheimer's disease, dementia, and anxiety who is easily manipulated) was found in an inappropriate situation with resident #2 (who has early onset Alzheimer's and anxiety) in a locked bedroom. Staff had previously observed resident #2 in resident #1's bedroom when resident #1 was uncomfortable and sleeping. The facility failed to adequately supervise and protect resident #1 from this situation.”

“An enabler bar attached to resident #3's bed was uncovered, exposing areas greater than 4 1/2 inches, creating an entrapment hazard and posing a safety risk to the resident.”

“Sanitary conditions were not maintained. On 4/8/24, resident #4's glucometer was used to measure blood glucose levels for residents #5 and #6, creating a cross-contamination risk and violating infection control protocols.”

“Resident #1 was administered an ordered Foley catheter change (18Fr coude every 42 days) on a date in 2023, but the medication administration record was left blank in the corresponding signature field, failing to document the treatment administration.”