His doctor ordered neurological checks for 72 hours.
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Residents who had eaten together in that room for months were sent back to their beds and bedside tables, and most of them were never told why.
The Director of Staff Development, when interviewed, confirmed that LN 1 no longer worked at the facility and was unavailable for an interview.
The posted schedule showed "Science Experiment" at 11 a.m., "Parachute Popcorn" at 2 p.m., and "Name that Tune" at 3:30 p.m.
Both falls were tied to the same problem: he needed help getting to the bathroom, he used his call light, and nobody arrived in time.
That is what an inspector found at Valley Vista Nursing and Transitional Care LLC on August 13, 2025.
The resident at the center of the complaint had signed a Durable Power of Attorney back in August 2012, naming a family member as their legal agent.
The incident occurred July 31 when the nurse entered a room where a woman lived with her hospice-status husband.
When inspectors interviewed the administrator on August 11, she explained the facility's reasoning for skipping the required notification.
Resident #1 was lying on their side when the fall occurred.
That finding sits at the center of a complaint inspection conducted at the facility on August 14, 2025, by federal surveyors.
Metoprolol tartrate, a drug used to manage blood pressure and protect the heart, was to be given twice daily.