The July incident at Mount Miguel Covenant Village occurred when a certified nursing assistant and student nursing assistant were changing Resident 1.
Nursing Home News — Page 346
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The facility's own abuse prevention policy requires staff to revise care plans when a resident's needs or preferences change.
The incident occurred on August 7th during the night shift, when Resident #1 was experiencing what staff described as behavioral issues.
Federal inspectors found the facility never filed the mandatory 24-hour report with the California Department of Public Health.
The deficient storage method affected every resident requiring insulin administration via pen devices.
Staff at Everett Center have been falsely documenting that residents and families "refused" bed hold notices when staff simply couldn't reach anyone by phone.
The policy stated this inventory must be kept in each resident's clinical record.
The breakdown occurred at Ararat Nursing Facility when staff failed to complete neurological assessments for Resident 1, who had fallen on August 25.
The incident at Stanley Post Acute involved a resident who had lived at the facility since September 2015.
Nursing schedules reviewed by inspectors showed no RN hours documented for any of those days.
STNA #210 immediately separated the residents and called for help.
The resident last received dialysis on July 23.