The facility's own abuse coordinator acknowledged that staff should have reported the allegations within two hours, as required by federal law.
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The resident's medication administration record at Valley Oaks indicated drugs were given on both dates.
Resident 1 had been admitted with a fractured vertebra, paraplegia, and urinary retention.
The resident was admitted to Arcadia Care Center on August 18 with diagnoses including hypertension, epilepsy, and unspecified dementia.
The violation involved a resident identified only as Resident 6, who had been prescribed hydrocodone-acetaminophen tablets for moderate to severe pain.
The September 2nd incident at Mesa Glen Care Center involved a resident known for verbal aggression and fluctuating behaviors.
The July incident was part of a pattern of missed neurological evaluations that federal inspectors documented during a September complaint investigation.
Resident 67 was discharged to the hospital on August 8, 2025 and never returned to the facility.
The nurse, identified as LVN1 in inspection records, continued working after her license became inactive in late August.
The facility received multiple warnings starting August 22 that employees should avoid the central nursing station area due to structural problems.
The September 10 inspection revealed the facility had fired CNA A on September 5, just days before state investigators arrived.
Resident #8 described the facility's wound care as "very inconsistent" during a September 9 interview.