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Fallbrook Skilled Nursing: Medication Safety Failures - CA
Despite these parameters, nurses administered the medication when the resident's pulse was 58....
Latest reports, citations, and penalties from CMS data
Despite these parameters, nurses administered the medication when the resident's pulse was 58....
The female resident was lying sideways, facing him....
The resident had severe cognitive impairment and multiple serious conditions including Alzheimer's disease, kidney disease, and cancer....
Every time they brought her a washcloth for personal care, the cloth was lukewarm at best....
Facility policy requires two staff members to operate mechanical lifts safely....
But after searching both nursing stations with inspectors, RN 2 confirmed no such form existed....
The incident at Trinity Grove involved Resident #65, who had lived at the facility for six years without any previous problems....
Resident 38 arrived at the facility on July 25 with multiple serious conditions....
The hospital discharge summary was clear: continue to wean off oxygen, keep supplemental oxygen in the meantime, continue CPAP at night....
The undocumented care occurred repeatedly at Courtyard of Natchitoches during late August and early September, according to federal inspection records....
The facility's own care plan acknowledged his intermittent pain and called for medicating him as ordered by his physician....
In a 30-minute tour, they documented peeling paint, gouged walls, and torn wallpaper in 12 of the 41 resident rooms currently occupied in the 70-bed facility....
The resident had been admitted with diagnoses including dementia, PTSD and diabetes....
"Housekeeping usually comes into her room and only cleans the main area," the resident told the federal inspector on September 16....
Federal inspectors observed Licensed Practical Nurse CC skip multiple safety protocols during the 8:06 am feeding....
Federal inspectors observed the incomplete care during a September complaint investigation at Gillespie Health & Rehab Center....
Hospital discharge instructions specifically stated the resident should be re-evaluated by an ENT specialist within a week....
The resident at Avir at San Antonio told inspectors she felt something on her shoulder around 6:00 am and called for help from a certified nursing assistant....
Resident #4 at Manhattan Community Care Center described exactly what wasn't happening....
She had been living at the facility since October 2023 following a cerebral infarction that left her with paralysis affecting both sides of her body....