They said it happened on every shift.
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Resident 35, as he is identified in the report, was admitted to the Rosemead facility sometime before February 2026.
Federal inspectors documented the lapse during a complaint inspection on March 27, 2026.
Federal inspectors cited the facility following a complaint inspection on March 27, 2026.
The incident at North Pointe Care Center, a skilled nursing facility at 500 Jessie Avenue in Sacramento, took place on February 6, 2025.
The resident, identified in inspection records as R10, transferred from an assisted living home in October 2025.
The resident had a fractured shoulder.
Inspectors documented the lapse during a March 2026 survey.
He came into a conference room that afternoon holding a piece of paper with the drug's generic name written on it.
LPN-A removed the old dressing, discarded it, took off her gloves, and sanitized her hands.
The facility used to keep a cordless phone in the nurses' office.
That is what federal inspectors found when they arrived at Goldwater Care Gibson City on December 23, 2025, following a complaint.