Inspectors observed the transfers on September 19, 2025, at 10:24 a.m.
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The resident, identified in inspection records only as Resident 1, has dementia, post-traumatic stress syndrome, and diabetes.
The resident had never required assistance getting to the bathroom before.
The inspection was triggered by three separate complaints filed against the facility.
The inspection was tied to three separate complaint intakes filed against the facility.
The fall happened around 6:30 a.m.
That gap is what a federal inspection, completed September 18, 2025, found at the facility.
The first visit came at 5:30 AM.
The inspector stood with the cart and waited.
He has weakness on one side of his body, uses a wheelchair, and needs help getting dressed.
That finding, classified as immediate jeopardy, was not the only one.
The September 2025 inspection, triggered by a complaint, found the facility's 400-hall IV cart stocked with bags that had expired as far back as December 2024.