The chicken was dry and tough to chew when inspectors tested it at Beechtree Center for Rehabilitation and Nursing on August 25, 2025.
Nursing Home News — Page 719
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The resident told inspectors in August that he had repeatedly asked the maintenance director to repair the damage, but nothing had been done.
The July incident at Mount Miguel Covenant Village occurred when a certified nursing assistant and student nursing assistant were changing Resident 1.
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 resident, identified in federal inspection records as Resident 7, had been at the facility since September 2015.
The gaps weren't discovered through a routine audit of obscure records.