Nursing Home News — Page 70

Inspectors touring the Rehabilitation Unit that day found the window in Resident 1's room had cracked glass that someone had patched with duct tape.

On the morning of October 2, 2025, an inspector walked the 300-hall medication cart at Pembroke Center alongside the facility's wound and treatment nurse.

The citation was classified as immediate jeopardy, meaning inspectors concluded the facility's failure placed residents at risk of serious injury or death.

The first fall happened on February 15, 2025.

The facility's own registered nurse confirmed the gap.

The inspection, conducted on November 25, 2025, was triggered by a complaint.

Inspectors determined the deficiency carried potential for actual harm and affected some residents at the facility.

The resident, identified in inspection records only as Resident 7, had a pressure ulcer on the left ischium, a bone in the lower pelvis.

The specific finding involved manual transfer equipment, including gait belts, and mechanical lifting devices.

The citation, issued November 25, 2025, falls under the regulatory category of pharmacy service deficiencies.

The complaint inspection at Antelope Valley Care Center, a skilled nursing facility at 44567 North 15th St.

Just a decision, made from outside the building, that what had happened wasn't abuse.