Resident #6 at Altoona Nursing and Rehabilitation Center has moderately impaired cognition and diagnoses of dementia and diabetes, according to her assessment.
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A witness described being "in shock" at the speed and force of the transfers.
The business office manager forwarded the email to the director of nursing an hour later but took no further action to fulfill the records request.
The social services director immediately notified the director of nursing and provided emotional support to the resident.
Federal inspectors found Atlas Healthcare at Daughters of Miriam violated incontinence care standards during an October 30 complaint investigation.
Resident 1 was admitted to Buena Park Nursing Center on October 8 with a specialized gastrojejunostomy tube, which has two separate ports.
The patient, identified as Resident #1, was admitted to the facility with a cerebrovascular accident, Parkinsonism, and vascular dementia.
Resident 1 was changing his brief with CNA 1 on September 25 when the nursing assistant instructed him to turn to his left side.
The incident began when CNA C was providing peri-care to Resident #1 and reported hearing the distinctive sound.
The DON acknowledged the serious consequences of failing to report.
The resident was found unresponsive on August 16, 2025, during the night shift.
The lift tray used to carry food was soiled and covered with debris.