Resident 24 at South Shore Rehabilitation and Nursing Center was supposed to receive showers twice weekly according to their care plan.
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The 85-year-old woman had been admitted after acute kidney failure and unsteadiness on her feet led to hospitalization.
The resident, identified in inspection records as Resident 32, was harmed.
On some days, just two certified nurse aides covered entire units designed for three.
The inspection at Park Manor Bee Cave, conducted August 18, 2025, centered on a single resident, identified in records only as Resident #1.
Then she hit another resident too.
An inspector walking through the dry storage room at 11:50 AM on August 14 found a pile of small pieces of plaster and wood on the floor in the corner.
Staff would stop what they were doing, try to redirect her, and she would come back.
The number belonged to a document management contact, identified in inspection records as DCTM 2.
The altercation occurred on August 13, 2025.
The posted breakfast menu for August 15 promised hot or cold cereal, breakfast quiche, and milk or juice.
Federal inspectors visited the facility on August 17, 2025, following a complaint.