The incident occurred at 11:22 a.m.
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The breakdown occurred on September 3rd when Nurse Practitioner #492 assessed the resident for complaints of coughing that had persisted for several days.
Resident #1 was last seen at 9:30 p.m.
Inspectors noted bruises and scabs on both his arms and legs.
The complaint at Oxford Nursing Home came just weeks after another resident made similar allegations of being physically pushed by staff.
The pain crisis at Majestic Mountain Care Center began July 25, 2025, when the resident fell.
The September 10 incident at Hyde Park Healthcare Center violated the facility's own infection control policies and basic wound care protocols.
The resident, who also suffered from anxiety disorder and failure to thrive, sustained two skin tears to her right knee during the June 17 incident.
The August incident involved Resident 4, whose cognition was moderately impaired according to facility assessments.
The September inspection found Resident 4 awake, fidgeting and visibly uncomfortable at 11:20 p.m.
"I hate the holes in the wall there," one resident told inspectors while walking upstairs past damaged wallboard.
But the facility's own administrator admitted they failed to develop and implement proper discharge planning.