Resident 1 had been admitted with osteoporosis and rheumatoid arthritis.
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The incident occurred on July 5 at approximately 9:15 PM when Licensed Practical Nurse 1 allegedly forced a resident to take medication.
Resident 2, who has type 2 diabetes and high cholesterol, requires a controlled carbohydrate diet to manage his blood sugar levels.
Resident #72 was at moderate risk for falls and required supervision for eating and personal hygiene.
Resident 2 fell three times in ten days.
She did not do the treatments that day.
"She had to go to the bathroom and couldn't find her call light," according to the inspection report.
Resident 1 had stumbled in his bathroom around 4:00 a.m.
Federal inspectors found the driver had received wheelchair transport training just four days before the incident but chose not to follow safety procedures.
The incident at South Pasadena Care Center came to light during an August 27 state inspection triggered by a complaint.
The resident had been admitted to Legacy Nursing and Rehabilitation of Pollock on July 24 with diagnoses including dementia, anxiety, and psychosis.
Resident 2 had been admitted to the 74-350 Country Club Drive facility with diagnoses that included the left arm fracture.