The November 14 incident involved two residents enrolled in the facility's behavioral program.
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Resident 1 at Meadowbrook Post Acute was supposed to be checked every 30 minutes after her May 13, 2025 fall that sent her to the hospital with a head injury.
Columbia Crest Center denied readmission to a cognitively intact resident who used an electric wheelchair and required assistance with personal care.
Registered Nurse #30 entered Resident #26's room at 8:06 A.M.
The incident occurred December 4th at Lodi Creek Post Acute, where Resident 1's meloxicam was scheduled for 8:00 AM but not administered until 9:46 AM.
The assault was discovered through the facility's security camera system.
Federal inspectors found no care plan existed for any of the three residents during a December 30 complaint investigation.
The director told inspectors on December 30 that she relied on nurses to inform her of concerns from the reports rather than reviewing them herself.
Resident 1 had been placed in isolation due to suspected scabies and received a doctor's order for permethrin cream.
Resident 1 approached department heads complaining that items were missing related to use of their bank card.
Resident 3 was classified as high risk for falls and required frequent visual checks.
Resident 1, admitted in late 2025 with a urinary tract infection and weakness, had an uncovered urinal stored in the bottom drawer of their closet.