đ° News
Madera Rehabilitation Falls Prevention Failures CA
Despite this knowledge, a certified nursing assistant left him unsupervised on the patio during lunch service....
Latest reports, citations, and penalties from CMS data
Despite this knowledge, a certified nursing assistant left him unsupervised on the patio during lunch service....
The resident had recently been hospitalized on a psychiatric hold for threatening to kill staff and blow up a hospital....
Federal regulations mandate that facilities investigate all injuries of unknown origin to rule out potential abuse, neglect, or mistreatment....
This violation represents a fundamental breakdown in the facility's internal oversight mechanisms designed to prevent and correct regulatory violations....
During the inspection, the resident was observed sitting up in bed with noticeable tremors in both hands and arms....
On March 10, 2025, the aggressive resident pinched another resident's leg during a witnessed altercation....
However, inspectors found that crucial diabetes medications were not properly carried over from the resident's previous care orders....
This pattern of repeated injuries suggests fundamental failures in the facility's fall prevention protocols....
Additionally, inspectors discovered two health shakes that were not purchased by the facility, also completely lacking any identification labels....
The severity of this delay cannot be understated....
Licensed Nurse 10 was administering medications to a resident who required **Enhanced Barrier Precautions** due to an implanted feeding device....
The MCU houses residents with dementia and cognitive impairments who require specialized supervision to prevent wandering and potential harm....
A Certified Nursing Assistant eating lunch in the parking lot spotted the resident and called the front desk to ask if she was supposed to be outside....
When staff incorrectly implement these orders, the consequences can be fatal....
These regulations establish mandatory standards for resident care, facility operations, and safety protocols that all licensed nursing facilities must follow....
Inspectors observed a teardrop-shaped brownish liquid on the cable portion of the hood and additional residue on protruding tubes....
Inspectors found discrepancies in the controlled substance tracking system on medication cart 1C....
The violations revealed a concerning pattern where serious resident concerns were either inadequately investigated or dismissed without proper follow-up....
**Five residents collectively missed 18 scheduled showers** during this timeframe, with some residents going without proper bathing for extended periods....
However, interviews with nursing staff revealed that many were unaware of the unauthorized medications....