The verbal abuse occurred at La Bella of Woodstock after hospice staff had bathed the resident the previous day.
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Inspectors found handwashing stations without paper towels, open food containers exposed to contamination, and food served below required temperatures.
Advanced Center for Nursing & Rehabilitation botched its response when notified of a positive legionella case, according to a March 31 state inspection.
State inspectors found the expired medical supplies during a March 31 examination of the facility's medication storage practices.
The resident, identified only as Resident 1, fell on November 11, 2025, then again on January 21, 2026, both times between 4 AM and 4:30 AM.
The altercation occurred at Beach Gardens Rehab and Nursing Center while administrators were conducting their morning meeting at 10:15 AM on March 16.
Resident #3, the victim of the assault, sustained a left eyebrow scratch during the fight.
The resident never signed consent forms acknowledging the medication's purpose, benefits, or risks before treatment began.
On April 1, 2026, state inspectors watched the lunch preparation unfold in real time.
The error at Southside Care Center was one of two coding mistakes federal inspectors found during an April review of resident assessment accuracy.
Aventura at Creekside ordered Ceftriaxone injections for Resident 8 in January 2026 to treat what staff called a urinary tract infection.
The violations centered on the facility's handling of high-risk physician orders, particularly those involving anticoagulant therapy.