He has had an indwelling urinary catheter in place since at least February 2025, with orders to change it every 30 days.
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No resident was documented as having been hurt.
Resident 14 said the portions were "small like what you would feed to a toddler." Resident 4 said portions were small.
The violation fell under the category of nutrition and dietary deficiencies.
The citation, tagged under F0684 and recorded during a complaint inspection on September 29, 2025, affected a small number of residents.
Bed-hold policies tell residents and families how long a facility will keep a room available when someone is hospitalized.
That phrase, "potential for more than minimal harm," is the floor.
On the morning of August 30, one nursing assistant, identified as NA 1, told investigators that a second nursing assistant, NA 2, had helped with the transfer.
One certified nursing assistant at a time.
Not in a drying rack inside the kitchen.
Staff were not completing neuro checks and post-fall evaluations through the facility's electronic health record system, known as PCC, as required.
Inspectors arrived at the facility on the morning of September 29, 2025, and spent less than an hour walking the building before they had seen enough.