Multiple nursing assistants told inspectors they understood the proper procedures.
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Resident #1 has diagnoses of aggression and behavioral issues, takes medication for these conditions, and regularly grabs food and drinks from staff members.
The resident told inspectors his breakfast was "lukewarm and almost cold" on December 22.
Resident 1 told inspectors on September 10 that Resident 2 "could hear him yelling and screaming at the staff" from the room across the hall.
The resident, identified only as Resident 1, scored just 3 out of 15 points on a standardized cognitive assessment.
Resident 1 had been admitted for rehabilitation following a hospitalization.
Federal inspectors found six of 30 rooms they examined on December 22 had blinds so damaged that beds could be seen from outside the facility.
Resident 3 was readmitted to the nursing home on October 13, 2025, according to a nursing note written at 6:36 p.m.
The beverages were being served to Resident #16, the facility's only patient requiring thickened liquids due to swallowing difficulties.
The December 12 assault at Double Tree Post Acute Care Center involved two residents with vastly different cognitive abilities.
Her physician had specifically ordered staff to hold those medications if she developed diarrhea.
The November incident left the resident feeling like "nothing and a nobody" to staff, according to federal inspection records.