This critical oversight caused the resident to slide out of the lift, resulting in three minor skin tear injuries.
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WOODLAND HILLS, CA - Federal inspectors documented serious medication errors, infection control breaches, and food safety violations at Motion Picture and T.V.
The resident fell to the tile floor, hitting her head and landing on her right side.
The nurse was terminated on November 27, 2024, following the facility's internal investigation.
Food service staff acknowledged the violations when temperatures were measured.
The resident had been admitted in December 2024 with diagnoses including cerebral palsy, Type II diabetes, and depression.
Resident #47 was missing 60 tablets of oxycodone/acetaminophen 5/325mg, while Resident #57 was missing 30 tablets of oxycodone 5mg.
WanderGuard devices function as electronic monitoring systems that alert staff when residents with cognitive impairment approach exit doors.
The same nurse then handled a germicidal wipe to clean the glucometer without first applying gloves, creating multiple opportunities for cross-contamination.
An eight-page vendor aging report showed outstanding debts totaling millions of dollars, with some bills unpaid for over 151 days.
Inspectors determined there was **insufficient auditing and oversight** of the earlier citation, indicating the facility's corrective measures were inadequate.
**The nurse was unable to administer morning medications or required water flushes** due to the equipment malfunction.