Staff A started her 7:00 AM shift on October 19, 2025, and began checking rooms around 7:15 AM when she discovered Resident ID #1 missing from bed.
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Among the citations, the facility failed to ensure residents' right to a safe, clean, and comfortable living environment.
The deficiency was classified at **Scope/Severity Level D**, meaning the violation was isolated in nature.
The violent altercation left the resident with a nasal fracture.
Medical records showed the patient was cognitively intact with a BIMS score of 13 out of 15.
The facility was given a correction timeline and reported the issue was resolved as of **December 18, 2025**.
During three days of inspections in November, investigators discovered the same pattern repeatedly.
Staff only called an ambulance after the granddaughter alerted them around 4:15 PM on September 3 that she was having trouble waking the resident up.
The owner of the independent living facility told inspectors the placement was inappropriate from the start.
The resident suffered a left hip fracture.
The resident, identified as R #24 in inspection records, had been in the dining room since 11:30 AM when inspectors found him at 1:55 PM on November 17.
Resident 175 had $1,915.07 sitting in her personal account when federal inspectors arrived in September.