Federal inspectors found the violations at South Mountain Post Acute during a December complaint investigation.
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The resident was discovered during a facility-wide search on the evening the incident occurred.
The facility had documented previous altercations involving the same three residents.
Comprehensive abuse prevention policies must address multiple critical areas.
Twenty times across twenty-eight days, spread across early mornings, middays, afternoons, and at least once past midnight.
The resident had developed the new wound on December 4.
Federal inspectors cited the facility following a complaint inspection completed December 31, 2025.
The survey team offered to delay their exit until the next day if administrators felt they had additional information to provide about the case.
The December 30 inspection found the facility failed to serve palatable, attractive food at safe temperatures to residents.
What he couldn't show was that the facility had ever done a formal risk assessment to reach those conclusions.
"They took the call light from me," the woman told federal inspectors on December 30.
The resident, admitted in 2025 with obesity and diabetes, was supposed to receive weekly semaglutide injections starting September 23.