Windsor Gardens: Medication Error Violations - CA
Inspectors documented the nurse pouring 2.5 ml of the suspension into a dosage cup at 8:08 AM without first shaking the pharmacy bottle as required....
Latest reports, citations, and penalties from CMS data
Inspectors documented the nurse pouring 2.5 ml of the suspension into a dosage cup at 8:08 AM without first shaking the pharmacy bottle as required....
Inspectors observed these medical devices stored at residents' bedsides without protective covering over multiple days of observation....
This represents a fundamental failure in the facility's internal oversight system designed to protect residents from preventable injuries....
The violation was documented under federal regulation F 0880, which governs infection prevention and control standards....
Despite facility protocols requiring 72-hour alert monitoring after falls to watch for latent injuries, staff failed to implement these safety measures....
When staff returned one minute later, the resident was found unresponsive with his upper body on the bed and lower extremities hanging off the side....
The immediate jeopardy period lasted from December 13, 2024, to January 22, 2024, before being downgraded after the facility implemented corrective measures....
The funding structure presented additional obstacles to comprehensive programming....
Federal inspectors discovered that Villa Del Sol had no Legionella testing results for 2024 or 2025, despite facility policies requiring annual testing....
Properly fitted splints help maintain joint positioning and prevent further mobility loss....
## Excessive Work Hours Documented Federal inspectors documented that CNA1 worked an extraordinary schedule between March 8-11, 2025....
## Restraints Used Without Physician Orders Inspectors documented two residents subjected to restraint devices without proper authorization....
Resident 35, who has dementia and requires assistance with eating, received two slices of garlic bread with hard crust....
## Understanding Elopement Risks in Nursing Homes Elopement represents one of the most serious safety risks in long-term care facilities....
The inspection, completed on July 16, 2024, was conducted in response to a complaint filed against the 135 Vanderbilt Avenue facility....
Communication barrier violated resident's right to effective care at Marksville facility, inspection reveals dangerous gaps in basic assistance....
Anti-seizure medications work by stabilizing electrical activity in the brain....
The contamination discovery occurred during a routine federal inspection process that includes examining equipment used in food service and resident care....
Ka Punawai Ola faced federal scrutiny after inspectors found staff failed to follow basic skin care protocols for a rehabilitation patient....
These symptoms can lead to organ damage, particularly affecting the heart and brain, which require constant oxygen supply to function properly....