The residents who spoke to the director of nursing or her designee on April 15 were direct about what they had experienced.
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The inspection, triggered by a complaint, was completed September 17, 2025.
The resident, identified in the report as R3, required supervision and cueing during meals.
The person at the center of both findings was staff #103, listed on the facility's own staff roster as the Assistant Administrator.
A federal inspection on September 12, 2025, caught it in real time.
The citation had actually begun nearly a year earlier, on September 30, 2024.
That was one bathroom, on one floor, on one morning.
The resident, identified in inspection records as R705, last saw a psychiatric practitioner on December 5, 2024.
The warning had come one day too early to matter.
The aide, identified in inspection records only as CMA JJ, said she reported what she saw to a nurse, who told her they would take care of it.
The inspection was completed September 16, 2025, following a complaint.
The refrigerators held milk, juice, chocolate milk, and bags of salad.