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The facility has not submitted a plan of correction.

The facility's own Director of Nursing confirmed the lapse.

Resident 9 needed oxygen at 2 liters per minute to keep blood oxygen levels above 90 percent, according to February physician orders.

When this coordination breaks down, several risks emerge.

The incident occurred on August 31, 2025.

When facilities fall short of this standard, it can affect residents' emotional well-being, sense of autonomy, and overall quality of life.

The first incident occurred on September 20 at 3:47 PM when staff discovered the resident on the bathroom floor beside the toilet.

Federal inspectors found staff documented the missing socks but failed to follow their own policies for investigating and resolving the complaint.

That decision was not an oversight.

Bel Aire Center staff changed Resident #2's easily removable Velcro belt to a buckled seat belt that the resident could not unfasten independently.

Resident 11 had been prescribed oxygen therapy starting November 18 at 7:00 a.m.

The citation, tagged at the "actual harm" level, centers on a Qualified Medication Aide performing inhalation treatments.