The resident, identified in inspection records only as Resident 1, was assessed as severely cognitively impaired.
Nursing Home News — Page 86
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The citation, recorded under the federal tag that covers pest control programs, found a pattern of deficiency.
The deficiency was one of five cited during the inspection.
The fall happened on a February evening.
Pressure ulcers, also called bedsores, develop when sustained pressure cuts off blood flow to skin and underlying tissue.
The citation, issued August 15, covered the full arc of how food moves through a nursing home: procurement, storage, preparation, distribution, and service.
The citation, issued August 15, fell under a category covering how facilities procure, store, prepare, and serve food.
The inspection narrative does not identify which residents were affected or describe the specific orders that went unfollowed.
Inspectors classified the deficiency as isolated, with no actual harm documented, but determined there was potential for more than minimal harm to residents.
Inspectors rated the scope as widespread, meaning the problems were not confined to a single room or wing.
The deficiency was one of eight cited during the inspection, conducted on August 15.
Inspectors classified it as a pattern, meaning this wasn't a one-time lapse caught on a single resident's chart.