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Mission Palms Post Acute: Wound Care Monitoring Lapse - AZ
The wound vac had been reapplied after a seal leak the week before....
Latest reports, citations, and penalties from CMS data
The wound vac had been reapplied after a seal leak the week before....
The dietary manager, interviewed the following morning, confirmed the number was wrong....
The resident, identified in inspection records only as R1, tripped on a worn floor mat near the staff breakroom door and struck her head....
The medications were controlled substances....
The incident happened on July 11, 2025, at approximately 7:15 in the morning....
The complaint came up at the facility's Resident Council meeting on February 11, 2025....
The incident happened on July 14, 2025, at Pilgrim Manor Skilled Nursing and Rehabilitation....
Inspectors visited Franklin Plaza Extended Care on August 28, 2025, as part of an investigation into four separate complaints filed against the facility....
On August 5, 2025, a physician ordered valproic acid along with a complete blood count and comprehensive metabolic panel for the resident....
Federal inspectors visiting Frederick Villa Healthcare on August 27, 2025, pulled the facility's pest problem logs for the year....
Inspectors reviewing medication and treatment administration records found blank spaces on multiple dates in February 2025, including February 23 and 24....
The pattern surfaced during a complaint inspection completed August 29, 2025....
The resident, identified in inspection records only as R82, was incontinent of bladder and had fallen multiple times....
On at least five separate dates â July 15, July 24, August 1, August 5, and August 27 â output was recorded as zero....
The fall on June 28 resulted in the resident being sent to the emergency room....
Three nursing aides said the same thing....
The logs showed temperatures as low as 30 degrees, recorded across morning and evening checks spanning more than three weeks....
The resident in question, identified in inspection records only as Resident 1, has lived at Garden Crest since July 30, 2021....
The resident, identified in inspection records only as R8, is cognitively intact and knows what is happening around her....
The resident, identified in inspection records as R801, was eventually sent to the hospital at 2:30 AM....