The incident involved Resident 7, who was left alone while suspended in the lift as both nursing assistants exited the room.
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R1 was "always in pain and complained when being turned and repositioned," according to a certified nursing assistant who cared for the resident.
The resident, identified only as Resident 3, had worn the wedding ring during a family visit in July 2025.
Resident #101 was supposed to receive blood sugar checks three times weekly under a doctor's order that began September 13, 2024.
The incident occurred on August 19 at 8:30 a.m.
The August 1, 2025 assault occurred when the victim walked out of their room and passed by their attacker in the dining area.
"Resident #2 reported CNA #1 groped them while assisting them with a shower," inspectors wrote in their complaint investigation findings.
The 10/13/25 fall proved fatal.
None of the spoiled items were labeled or dated.
Federal inspectors cited the facility on December 1, 2025, following a complaint investigation.
A separate citation under **F-Tag 725** addressed the insufficient staffing levels that drove those care failures.
The facility, located at 5943 Telegraph Road, was also cited for wound care documentation failures and gaps in tuberculosis screening for employees.