The doctor's order, dated August 25, specified the resident must wear the collar until a follow-up appointment in six weeks.
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The incident occurred on August 29, 2025, when LVN D observed Resident 87 tell Resident 49 "I'm going to hit you" during what she described as an argument.
Resident #1 fell in his room during the overnight shift on August 10.
Resident 1 began experiencing severe right hip pain on August 27, 2025.
Federal inspectors found the resident lying in bed on September 11 with fingernails extending half a centimeter beyond his fingertips.
The family member demanded the resident be moved back to the general population hall during a care planning meeting.
The same resident later escaped the facility and fell into bushes, sustaining head injuries that required police intervention.
The administrator and social worker told inspectors on September 4 that they were unaware of the notification requirement entirely.
The resident at Coleman Healthcare Center told state inspectors on September 9 that he had never seen a privacy bag cover for his catheter.
The patient had been prescribed polyethylene glycol powder mixed with eight ounces of water once daily for bowel management.
Two had also fallen short on their general continuing education requirements.
The resident required substantial assistance with basic care and was dependent on staff for transfers.