North Ridge Health and Rehab never conducted a trauma assessment for the 81-year-old woman who had been living at the facility since 2015.
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The nurse administered the resident's 9 AM blood pressure medication at 12:19 PM, more than three hours late.
Resident #105 called Resident #141 the "N-word" and said he didn't want to hear "N***** music" on January 7, sending the victim to tears.
On July 31, 2024, inspectors observed the resident lying in bed without her prescribed hand splint.
His care plan required one to two person assistance during transfers and bed mobility.
Resident 301 arrived at the facility in December 2024 with a medical history that included type 2 diabetes, hemiplegia, and Alzheimer's disease.
Resident 51 suffered the most dramatic consequences.
Inspectors found the facility's administrator and director of nursing failed to effectively manage compliance with federal quality of care requirements.
The most dangerous temperature — 126 degrees Fahrenheit — was recorded in a resident room sink and the shower room serving Wing 1's 20 residents.
During an August 7 interview with federal inspectors, the nurse explained his reasoning.
Federal inspectors found the facility failed to protect her from physical abuse by staff.
The cuffs were never cleaned between uses.