Sanatoga Court.

“A resident was admitted to the Secure Dementia Care Unit but the medical evaluation was completed after admission and did not indicate the need for the resident to be in a Secured Dementia Care Unit, violating the requirement for evaluation within 60 days prior to admission documenting dementia diagnosis and need for secured unit placement.”

“Two and a half loose pills were observed in the Carrington medication cart, violating requirements for organized storage of medications under proper conditions.”

“No staff persons certified in first aid and CPR were present during three separate shifts (11p-7a and 3p-11p) when 39 residents were in the home, violating the requirement for at least one certified staff person per 50 residents at all times.”

“Bedside mobility devices attached to residents' beds had uncovered or loosely covered spaces between bars creating hazardous entrapment zones measuring 11 inches x 4.5 inches and 12 inches x 8 inches respectively.”

“Approximately 6 inches of snow accumulation was present on memory care courtyard walkways and outside exit door #4 in memory care at 9:48am.”

“The facility failed to report a resident fall with facial injury that required hospital transport to the Department within 24 hours. The incident occurred on 4/12/2025 but was not reported until 7/17/2025.”

“The Medication Administration Record (MAR) book was left unlocked, unattended, and accessible on the medication cart at 10:38 am, compromising resident record confidentiality.”

“A resident requiring assistance with all transfers waited approximately 2 hours after pressing their call pendant before attempting to self-transfer, resulting in a fall with facial injury requiring hospital transport. The resident's support plan required staff assistance for all transfers.”

“Class II violation subject to civil money penalty of $5 per day per resident, with census of 47 residents at time of inspection, totaling $235 per day.”

“The facility failed to report a resident fall with facial injury that required hospital transport to the Department within 24 hours. The incident occurred on 4/12/2025 but was not reported until 7/17/2025.”

“The Medication Administration Record (MAR) book was left unlocked, unattended, and accessible on the medication cart at 10:38 am, compromising resident record confidentiality.”

“A resident requiring assistance with all transfers waited approximately 2 hours after pressing their call pendant before attempting to self-transfer, resulting in a fall with facial injury requiring hospital transport. The resident's support plan required staff assistance for all transfers.”

“Class II violation subject to civil money penalty of $5 per day per resident, with census of 47 residents at time of inspection, totaling $235 per day.”

“A resident-home contract was not signed by the resident as required. The facility must obtain signatures from the resident, administrator or designee, and payer, with cosignature by the designated person if applicable.”

“A resident record did not contain a statement signed by the resident acknowledging receipt of resident rights and complaint procedures information, or documentation of efforts made to obtain the signature.”

“A caregiver was reported to have been rude and rushed a resident during morning care, indicating the resident was not treated with dignity and respect as required by regulation.”

“The facility failed to provide the required minimum of 2 hours per day of direct care services per resident with mobility needs. On the inspection dates, the home had 16 residents with mobility needs requiring 66 hours of direct care service, but provided only 62 hours and 61.5 hours respectively.”

“At least 75% of required personal care service hours must be available during waking hours. The facility only provided 71% and 70% of required hours during waking hours on the inspection dates, falling below the 75% requirement.”

“Staffing was not provided to meet the needs of residents as specified in their assessment and support plans. The facility lacked trained staff to administer medications during overnight shifts, had only two staff members for 50 residents (16 with mobility needs) during night shifts, and insufficient staff for emergency evacuation.”

“An expired medication blister card was found in the home's medication cart, indicating medications were not stored in an organized manner under proper conditions in accordance with manufacturer's instructions.”