Federal inspectors found the same scene during three separate visits to Avir at Rose Trail between September 28 and October 2.
Nursing Home News — Page 393
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But the facility's original screening form indicated the resident had no primary diagnosis of cerebral palsy.
Licensed Practical Nurse #2 abandoned the cart at 10:17 AM on September 25 to attend to another resident behind a closed door.
The injuries prompted a complaint investigation that concluded October 2, 2025.
The 65-year-old resident disappeared on June 27, 2025, sometime before 5 p.m.
The admission came during a federal inspection on October 2nd at a facility caring for 55 residents.
The resident didn't report the incident until nearly two weeks later.
The patient came back with a PICC line inserted in their arm for long-term intravenous medication delivery.
That's when Resident B heard a pop.
The incident occurred around 11:30 pm on August 3, 2025, when the resident was found crying and complaining of chest pain.
The September 21 assault at Legacy Nursing at St.
Staff heard door alarms going off but didn't immediately investigate the source.
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