The citation, tied to intake number 2636500, documents a failure to report a suspected crime against a resident.
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The risk manager looked at supervision levels across the facility and reported full compliance.
The device at the center of the finding is called a left ventricular assist device, or LVAD.
The woman, identified in inspection records only as Resident 104, was weighed on July 10, 2025, using a mechanical lift.
The resident, who had suffered a stroke and was fully dependent on staff for transfers and toileting, was alert and aware of everything happening around her.
The nurse had already signed the Treatment Administration Record saying the dressing change was complete.
The camera in the resident's room captured everything.
The tests were never collected.
The inspection, completed October 8, 2025, found the facility failed to provide timely pain medication to a resident on hospice care who was dying.
The elopement came to light not because anyone saw R2 leave, but because staff did a head count and he was gone.
A progress note from the former administrator, dated September 11, documented that R25's power of attorney was called that day to discuss the move.
That was the morning of October 10, when state inspectors were present.