The resident has moderate cognitive impairment and legal blindness following a stroke.
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The resident, identified as Resident #14, had been given a urinalysis on July 29, 2024.
The June 6 incident at Woodbury Health Care Center left the resident hospitalized for three days with fractured tibia and fibula bones.
The victim didn't speak to administrators about the incident until the next day.
The facility violated the same resident right during their previous inspection.
The February 21 inspection found staff weren't monitoring visits involving residents with open Adult Protective Services cases.
Staff found redness on the victim's face.
The January 29 complaint inspection revealed systemic breakdowns in safety protocols that put residents at immediate risk.
The resident, who has severe cognitive impairment and depends on kidney dialysis, was also taking three other blood pressure medications.
The maintenance department told kitchen staff the steam table couldn't be repaired and would need replacement, but no timeline was provided.
Resident 2 had been admitted to Cedarwood Rehabilitation & Healthcare Center on April 4, just days after hip fracture surgery from a fall at home.
Federal inspectors found the facility failed to ensure staff called for help when residents showed signs of distress.