Mallard Cove

Based on observation, staff interview, record review, and review of job descriptions, the facility failed to ensure an effective administration was in place to provide necessary oversight to ensure the needs of the residents were met to include having a smoking policy in place and smoking assessments for the residents who smoked were completed. This affected all 194 residents who resided in the facility. The facility census was 94.

Findings include:

1) Review of medical record for Resident #194 revealed an admission date of 10/22/24. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD), tobacco use, hypertension, bradycardia, presence of cardiac pacemaker, muscle spasms, and bipolar disorder.

Review of the Resident Agreement signed by Resident #194 on 10/21/24, revealed the community was non- smoking and smoking was not permitted on community campus, except in designated areas outside and away from the entrance. Smoking in non-designated areas posed a health and safety risk to other residents, staff members, and guests. The residents would be required to pay for all property damage caused by smoking in unauthorized areas. The resident agreed to hold harmless and indemnify the community for any personal injuries to the resident and other person or property caused by such smoking. Failure to comply with the community smoking policy may result in termination of residency.

Review of the most recent Functional Assessment for Resident #194 dated 01/23/25, revealed the resident was alert and oriented to person, place, time and situation, and was independent with all activities of daily living (ADL). Resident #194 required oxygen therapy and had not smoked in the last two months; however, he had a long history of smoking. Resident #194 did not have cigarettes and reported he had no interest in smoking.

Review of the service plan for Resident #194 dated 01/23/25, revealed the resident was on two liters per minute (LPM) of continuous oxygen via nasal cannula and was independent in smoking but the resident reported he had not smoked in over six weeks and had no desire to smoke.

Review of the Smoking Safety Evaluation for Resident #194 dated 09/22/25, revealed the resident smoked only in the designated area, safely lit smoking material, held smoking material safely, disposed of ashes in the ash tray, removed oxygen tubing, and oxygen was not brought into the smoking area. The smoking safety evaluation indicated Resident #194 understood that smoking paraphernalia was not to be kept in his apartment.

Review of the EMS report dated 02/27/26, revealed the EMS unit was dispatched at 6:01 P.M. related to a burned patient from a structure fire. EMS arrived at the facility when the Fire Department staff were carrying Resident #194 from the building and placed the resident on the staged EMS stretcher. An assessment revealed Resident #194 was found to be alert and oriented, had burns/charring to anterior areas, abrasions on back, burn/charring to face, burn, blistering, redness and charring to left palm and left wrist, burn, blistering redness to both knees and abrasions on right hip. Resident #194 had a wet cough, singed facial, chest and arm hair and partial thickness burn to the left palmar hand and wrist and bilateral knees. Resident #194 stated his new oxygen machine caught on fire and he was not wearing the nasal cannula as it was coiled on the floor at the time of the fire. Resident #194 attempted to put the fire out with his hands and only fanned the flames further. Resident #194 reported he called for help and tried to crawl out of his apartment. Eventually, the resident was dragged out by his feet by a staff person on the scene. Resident #194's clothing was removed for full assessment and approximately seven percent (%) body surface area (BSA) had second degree burns. There was soot (fine, black or brown powdery residue produced by the incomplete combustion of materials like wood, plastic, or fuel during a fire) noted throughout face, chest and arms and the patient denied any shortness of breath (SOB). The resident was administered Fentanyl (narcotic pain medication used to treat severe pain) and was transported the level one trauma center.

Review of the Fire Department Incident Report dated 02/27/26, revealed crews were dispatched to the facility for a fire alarm at 5:53 P.M. with smoke showing. The Fire Department advised there was light smoke on the third floor of building four and one resident (Resident #194) was burned from smoking with oxygen on. The sprinkler system controlled the fire and the fire was out. The resident was found lying on the floor in the hallway with a nurse who stated the resident had been burned. The nurse stated the resident smoked with oxygen on. The Fire Department staff carried the resident from the building to the area outside where EMS was waiting. The employee that discovered the fire stated he smelled smoke in the hallway and heard someone screaming inside the room. When the employee opened the door, he was met with pitch black smoke and observed six-foot-tall flames in the bedroom to the left. The employee crawled into the living room and pulled the resident into the hallway by his leg. The fire investigator indicated the cause of the fire was determined to be a result of using smoking materials while using oxygen. There was a distinct burn pattern on the plastic oxygen tubing and carpet from the damaged recliner to the oxygen concentrator in a separate room. There were smoking materials present throughout the scene and the resident was known by staff to smoke while on his continuous oxygen. The oxygen concentrator was still operating when the investigation was initiated, and it was switched to the off position.

Review of medical record for Resident #194 from 02/27/26 to 03/05/26, revealed no documentation related to the fire incident in Resident #194's room on 02/27/26 or the resident being sent to the hospital related to the injuries he sustained from the fire.

Review of the facility's SRIs created on 03/03/26 at 9:42 A.M. for neglect/mistreatment, revealed Resident #194 was smoking in his room on 02/27/26 at 8:30 P.M. Resident #194 was smoking in his room which is against the community's policies and the resident had an oxygen concentrator in his apartment. The resident's apartment caught fire and the facility's fire suppression system was immediately activated. Resident #194 was sent to the hospital and was in stable condition. The facility was in the process of evicting Resident #194, and the resident would not be returning to the facility. The building sustained significant water damage from the fire suppression system. The facility administration and the local Fire Department responded swiftly and immediately moved four residents to other apartments due to the water damage. All families were notified directly after the incident and all residents and staff are safe. The facility was working with local and state fire officials to restore and maintain the facility's fire system. The fire system in building four was down until 03/02/26 at approximately 9:00 A.M. The facility was in the process of cleanup and restoration. The SRI was completed on 03/03/26 at 10:18 A.M. and unsubstantiated.

Review of the State of Ohio Fire Marshall report dated 03/04/26 at 3:12 P.M., revealed the ED created the report on 03/04/26 at 3:12 P.M. The report stated a fire occurred in the facility on 02/27/26 at 6:30 P.M. inside Resident #194's apartment. Resident #194 was sitting in his living room recliner smoking with oxygen. The oxygen tubing caught on fire which was hooked up to a concentrator in the bedroom, and it caught on fire. The facility's fire suppression system immediately activated, and the sprinkler system ran for about thirty minutes. Only one resident (Resident #194) was injured.

Observation of Resident #194's room on 03/05/26 at 8:15 A.M., revealed there was a recliner in the living room that was broken apart with the recliner's foam exposed and partially charred. There were black burn marks on the lower wooden frame of the recliner and a white substance on the fabric of the recliner. There was distinct burn mark on the carpeted floor with pieces of oxygen tubing near it which led from the side of the recliner to the bedroom where an oxygen concentrator was sitting. The blue oxygen concentrator was partially melted, and the entire left side of the concentrator was charred. There were large burn marks that went up the wall near the oxygen concentrator and across the ceiling. The window blinds across the bedroom room were melted. There were lighters scattered throughout the resident's room. There was a wooden table next to the recliner with packs of cigarettes, lighters, a container (ash tray) full of cigarette butts and one cigarette on the side container that the resident appeared to be smoking at the time of the incident along with various melted items. Resident #194 also had a sign on the outside of his door that had a no smoking symbol and stated oxygen in use.

During an interview on 03/05/26 at 8:17 A.M., Resident #56 stated he was in his room on 02/27/26 when there was a fire in Resident #194's room. Resident #56 stated he smelled smoke and heard the smoke detector going off. Resident #56 reported the sprinklers went off and he saw staff running and pulling Resident #194 out of his apartment. Resident #56 stated he regularly smoked cigarettes in his room and on the balcony.

During an interview on 03/05/26 at 8:22 A.M., Caregiver #241 stated she had observed Resident #194 smoking in his room with oxygen in use but could not remember any dates. Caregiver #241 stated she had reported Resident #194 smoking with oxygen in use to Licensed Practical Nurse (LPN) #239.

During an interview on 03/05/26 at 8:35 A.M., ED verified Resident #194 had a fire in his room on 02/27/26. The ED verified Resident #194 smoked in his room with continuous oxygen in use and caught his room on fire. The ED verified there were burn marks where Resident #194's oxygen tubing went from his recliner to the oxygen concentrator in the bedroom which was burnt and melted. The ED verified there were cigarettes on Resident #194's table next to his recliner and lighters in his room. The ED verified Resident #194 was sent to the hospital on 02/27/26 because of injuries he sustained from the fire in his room, and he remained in the hospital. The ED stated she was not aware of Resident #194's condition. The ED stated residents were not permitted to smoke in their rooms and not with oxygen in use.

During an interview on 03/05/26 at 8:40 A.M., Resident #38 stated he often smelled cigarette smoke in the hallways and in the laundry room. Resident #38 stated the staff reported the fire in Resident #194's room was caused by smoking with oxygen in use. Resident #38 reported he was in his room on 02/27/26 when the fire alarms went off. Resident #38 stated he saw smoke in the hallway, and the sprinklers went off prior to the fire doors slamming shut.

Observation of Resident #55's room on 03/05/26 at 8:43 A.M., with the ED, revealed the resident had a pack of cigarettes on his table beside his bed. Resident #55's room smelled like cigarette smoke.

During an interview on 03/05/26 at 8:43 A.M., the ED verified Resident #55 had a pack of cigarettes on his table beside his bed and the room smelled like cigarette smoke. Interview with Resident #55 at the same time, revealed he smoked; however, would not disclose where he smoked.

During an interview on 03/05/26 at 10:34 A.M., State Fire Marshall (SFM) #600 stated the facility had a fire incident on 02/27/26 and he went to the facility on 03/04/26 because the facility did not send the mandatory report about the fire to the State Fire Marshal. State Fire Marshall #600 stated the local Fire Department Battalion Chief (FDBC) #400 informed the State Fire Marshal of the fire at the facility on 02/27/26 after the Fire Department responded to the fire at the facility. State Fire Marshall #600 stated he checked the fire alarms and the sprinklers on 03/04/26 but the State Fire Marshal did not investigate the fire or origination of the fire.

During an interview on 03/05/26 at 11:19 A.M., Resident #21 stated she regularly smoked in her room or on her lower-level patio. Resident #21 stated that everyone smoked in their rooms and the facility had told them to stop smoking in their rooms. Resident #21 reported the facility never did anything about the residents smoking in their rooms, so she and the other residents continued to smoke in their rooms and on their patios.

Observation of Resident #01's room on 03/05/26 at 11:21 A.M. with the ED, revealed Resident #01 had a pack of cigarettes and a lighter on his table in his living room. Interview with the ED at the same time verified the findings.

During an interview on 03/05/26 at 11:22 A.M., Resident #01 stated he regularly smoked in his room until 03/04/26 when he was told to stop smoking by the ED.

During an interview on 03/05/26 at 11:25 A.M., Resident #50 stated he regularly smoked on his second story balcony.

During an interview on 03/05/26 at 11:29 A.M., Resident #26 stated she occasionally smoked on lower-level patio. Resident #26 stated that she was aware of where the smoking area was located but she could not walk that far. Resident #26 stated that she had resided at the facility for 10 years and she had been smoking on her patio for 10 years with no issues. Observation at the same time, revealed two portable cup style ash trays with ashes in them sitting on a table on Resident #26's patio.

During an interview on 03/05/26 at 11:29 A.M. the ED verified there were two portable cup style ash trays with ashes in them sitting on a table on Resident #26's patio.

During an interview on 03/05/26 at 11:33 A.M., Resident #32 stated he smoked on the second story balcony and in his room.

During an interview on 03/05/26 at 11:47 A.M., Resident #63 stated he regularly smoked on the second story balcony of his room.

Observation of Resident #63's room on 03/05/26 at 11:48 A.M. with the ED, revealed there was a portable cup style ash tray with ashes in it sitting on a table in Resident #63's living room. Resident #63's room smelled like cigarette smoke. Interview with the ED at the same time verified the findings.

During an interview on 03/05/26 at 12:12 P.M., LPN #230 stated she heard the fire alarm going off and went to the area where the fire alarm showed and observed smoke coming from Resident #194's room. LPN #230 reported Resident #194 could be heard yelling help and get him out of the room. LPN #230 opened the door, and a bunch of smoke came out of the room. LPN #230 shut the door and called LPN #232 for assistance. LPN #232 arrived at the room, opened Resident #194's room door and then closed it again. LPN #230 called 911 while LPN #232 opened the door and was able to get Resident #194 out of the room. LPN #230 stated Resident #194 had some abrasions to his knees, but he did not appear to have any additional injuries. LPN #230 reported the facility did not do an assessment on Resident #194 because of the smoke, but EMS arrived and took Resident #194 to the hospital. LPN #230 stated she had smelled smoke in Resident #194's room in the past.

During a telephone interview on 03/05/26 at 1:10 P.M., Local Fire Marshall (LFM) #500 stated the Fire Department was dispatched for a fire alarm going off in the facility on 02/27/26 at 5:53 P.M. and when a Fire Department member arrived, they observed smoke in the hallway and upgraded the fire response to a structure fire. LFM #500 stated Resident #194 was already in the hallway with the facility staff when the Fire Department staff arrived. LFM #500 reported the staff informed the Fire Department staff that they heard the fire alarms going off and got in the elevator to go up to the third floor where the fire alarm system was showing. LFM #500 stated when the staff members got off the elevator, there was smoke in the hallway, and a staff member was able to reach into Resident #194's room and drag Resident #194 into the hallway. LFM #500 reported FDBC #400 was tasked with completing the fire investigation. LFM #500 stated FDBC #400 was able to follow the oxygen nasal cannula route from the recliner in the living room to the oxygen concentrator in the bedroom and FDBC #400 identified the cause of the fire as Resident #194 was smoking while utilizing oxygen.

During a telephone interview on 03/05/26 at 1:43 P.M., Assistant Fire Chief (AFC) #300 on 03/05/26 at 1:43 P.M. revealed a neighboring Fire Department transported Resident #194 to the hospital on 02/27/26. AFC #300 stated Resident #194 sustained burns to his hands, wrists and knees related to the fire.

During an interview on 03/05/26 at 1:56 P.M., the ED verified Resident #194's medical record did not have any documentation or progress notes related to the fire incident on 02/27/26. The ED verified the resident was transported to the hospital related to the injuries he sustained in the fire and there was no documentation in the medical record.

During an interview via telephone on 03/05/26 at 2:16 P.M., LPN #232 stated LPN #230 called him and reported there was smoke on the third floor and LPN #230 was requesting LPN #232's assistance. LPN #232 arrived at Resident #194's room and there was black smoke in the hallway and thick black smoke when he opened Resident #194's door. LPN #232 stated he could hear Resident #194 screaming for help. LPN #232 tried to use his phone flashlight but could not see anything due to the smoke. LPN #232 then crouched down and got a couple of feet into the room and was able to grab Resident #194's leg and pull him out of the room. LPN #232 stated he saw flames shooting up the wall in the bedroom from Resident #194's concentrator. LPN #232 stated Resident #194 was only wearing an incontinence brief at the time of the incident, and he was wet from the sprinklers. LPN #232 reported LPN #232 did not do an assessment on Resident #194 prior to him being sent to the hospital by EMS. LPN #232 stated he had seen cigarettes and ashes in the trash in Resident #194's room in the past. LPN #232 also stated all the residents had been smoking in their rooms since they moved in there and it was not a secret to anyone.

During an interview via telephone on 03/05/26 at 3:15 P.M., FDBC #400 stated he investigated the fire incident that occurred at the facility on 02/27/26. FDBC #400 stated Resident #194's room had burn patterns that started at the recliner in the living room. FDBC #400 reported there was a black line across the carpet from the living room to the bedroom where the oxygen concentrator was located. FDBC #400 stated the black line in the carpet was the fire following the oxygen tubing back to the source or the oxygen concentrator. FDBC #400 stated the cause of the fire was Resident #194 smoking in his room with oxygen in use.

During an interview via telephone on 03/09/26 at 10:39 A.M., ED #210 and Vice President of Clinical Operations (VPCO) #700 verified Resident #194's Smoking Safety Evaluation dated 09/22/25 indicated Resident #194 smoked only in designated smoking areas and Resident #194 would remove oxygen tubing and oxygen would not be brought into the smoking area. Resident #194 was noted as understanding smoking paraphernalia would not be kept in his apartment. VPCO #700 stated the company just took over operations at the facility and the facility was in the process of doing smoking assessments on all residents. VPCO #700 stated the facility did not have a smoking policy during the time of the incident; however, the facility created one on 02/28/26. VPCO #700 reported she was not aware of the prior smoking policy. VPCO #700 verified Resident #194 did not have a physician order for oxygen; however, verified Resident #194 was smoking while using oxygen at the time of the fire on 02/27/26. VPCO #700 and the ED stated they were not aware of where Resident #194's smoking materials were to be stored since the smoking safety evaluation dated 09/22/25 stated he was not to keep smoking paraphernalia in his room.

2) Review of the medical record for Resident #55 revealed an admission date of 01/31/20. Diagnoses included hypertension, type two diabetes mellitus, insomnia, and schizophrenia.

Review of the medical record for Resident #55's from 01/31/20 to 03/09/26, revealed Resident #55 did not have a smoking assessment on file at the facility.

During an interview on 03/09/26 at 10:39 A.M., the ED and Vice President of Clinical Operations (VPCO) #700 verified Resident #55 smoked and did not have a smoking assessment on file at the facility. VPCO #700 stated that Resident #55 refused his smoking assessment on 03/04/26 and the facility did not have any smoking assessments on file for Resident #55 prior to 03/04/26. The ED and VPCO #700 stated Resident #55 had a history of non-compliance with the smoking policy.

3) Review of the medical record for Resident #56 revealed an admission date on 10/05/21. Diagnoses included atrial fibrillation, depression, chronic obstructive pulmonary disease, alcoholic cirrhosis, hypertension, hyperlipidemia, and psoriasis.

Review of the medical record for Resident #56's from 10/05/21 to 03/09/26, revealed Resident #56 did not have a smoking assessment on file at the facility.

During an interview on 03/09/26 at 10:39 A.M., the ED and VPCO #700 verified the facility did not have a smoking policy in place until after the fire incident on 02/27/26. The ED stated the prior company took all their policies and procedures with them when they vacated the building in December 2025. The ED verified Resident #56 smoked and did not have a smoking assessment on file at the facility. VPCO #700 stated that Resident #56 refused his smoking assessment on 03/04/26 and the facility did not have any smoking assessments on file for Resident #56. The ED and VPCO #700 stated Resident #56 had a history of non-compliance with the smoking. The ED verified 13 Residents (#01, #12, #21, #26, #30, #31, #32, #46, #47, #55, #56, #63, and #78) were identified as being smokers and verified they did not have any smoking assessments completed prior to the fire incident on 02/27/26.

Review of the facility's undated Oxygen Use and Storage Policy. revealed oxygen significantly increased the risk of fire. Smoking while using oxygen is strictly prohibited. Residents using oxygen must be at least ten feet from any open flame or smoking material. Oxygen must be turned off and removed before a resident enters the designated smoking area. Residents must wait several minutes after oxygen has been turned off before smoking to allow oxygen saturation in the clothing and hair to dissipate. Smoking materials must never be near oxygen tanks, concentrators or tubing.

Review of the facility's smoking policy dated 02/28/26 revealed smoking was only permitted in a designated outdoor smoking area approved by the community. Smoking inside resident rooms, on room balconies or in any indoor area of the building was strictly prohibited. To ensure resident safety, a smoking safety assessment would be completed upon admission, with any significant change of condition, and quarterly. The evaluation would evaluate the physical ability to safely handle smoking materials, risks of burns or fire hazards, a history of unsafe smoking behaviors and oxygen use. Smoking was strictly prohibited while using oxygen.

Based on staff interview, and record review, the facility failed to ensure residents had functional assessments completed annually. This affected three Residents (#55, #56 and #194) out of three residents reviewed for annual health assessments. The facility census was 94.

Findings include:

1) Review of medical record for Resident #194 revealed an admission date of 10/22/24. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD), tobacco use, hypertension, bradycardia, presence of cardiac pacemaker, muscle spasms, and bipolar disorder.

Review of the most recent Functional Assessment for Resident #194 dated 01/23/25, revealed the resident was alert and oriented to person, place, time and situation, and was independent with all activities of daily living (ADL). Resident #194 required oxygen therapy and had not smoked in the last two months; however, he had a long history of smoking. Resident #194 did not have cigarettes and reported he had no interest in smoking.

2) Review of the medical record for Resident #55 revealed an admission date of 01/31/20. Diagnoses included hypertension, type two diabetes mellitus, insomnia, and schizophrenia.

Review of the most recent Functional Assessment for Resident #55 dated 06/01/23, revealed the resident was occasionally forgetful as to place and time. Resident #55 was independent with ADL.

3. Review of the medical record for Resident #56 revealed an admission date on 10/05/21. Diagnoses included atrial fibrillation, depression, chronic obstructive pulmonary disease, alcoholic cirrhosis, hypertension, hyperlipidemia, and psoriasis.

Review of the most recent Functional Assessment for Resident #55 dated 06/01/23, revealed the resident was alert and oriented to place and time. Resident #56 was independent with ADL.

During an interview on 03/09/26 at 10:39 A.M., Executive Director (ED) and Vice President of Clinical Operations (VPCO) #700 (via telephone), verified Resident #194's last Functional Assessment was completed on 01/23/25. VPCO #700 verified Resident #55 and Resident #56's last functional assessment was completed 06/01/23.

Review of the facility's assessments and individualized service plan policy dated 10/30/25 revealed the facility will perform a complete and ongoing assessment of each resident's physical, mental, emotional, and social needs.

Based on observation, staff interview, record review, and policy review, the facility failed to ensure a resident had a physician's order for continuous oxygen being used at the facility. This affected one (Resident #194) out of three residents reviewed for physician orders. The facility census was 94.

Findings include:

Review of medical record for Resident #194 revealed an admission date of 10/22/24. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD), tobacco use, hypertension, bradycardia, presence of cardiac pacemaker, muscle spasms, and bipolar disorder.

Review of the physician orders for Resident #194 from 10/22/24 to 03/05/26, revealed no documented physician order for the resident to utilize continuous oxygen.

Review of the most recent Functional Assessment for Resident #194 dated 01/23/25, revealed the resident was alert and oriented to person, place, time and situation, and was independent with all activities of daily living (ADL). Resident #194 required oxygen therapy and had not smoked in the last two months; however, he had a long history of smoking. Resident #194 did not have cigarettes and reported he had no interest in smoking.

Review of the service plan for Resident #194 dated 01/23/25, revealed the resident was on two liters per minute (LPM) of continuous oxygen via nasal cannula and was independent in smoking but the resident reported he had not smoked in over six weeks and had no desire to smoke.

Review of the Smoking Safety Evaluation for Resident #194 dated 09/22/25, revealed the resident smoked only in the designated area, safely lit smoking material, held smoking material safely, disposed of ashes in the ash tray, removed oxygen tubing, and oxygen was not brought into the smoking area. The smoking safety evaluation indicated Resident #194 understood that smoking paraphernalia was not to be kept in his apartment.

Review of the Fire Department Incident Report dated 02/27/26, revealed crews were dispatched to the facility for a fire alarm at 5:53 P.M. with smoke showing. The Fire Department advised there was light smoke on the third floor of building four and one resident (Resident #194) was burned from smoking with oxygen on. The nurse stated the resident smoked with oxygen on. When the employee opened the door, he was met with pitch black smoke and observed six-foot-tall flames in the bedroom to the left. The fire investigator indicated the cause of the fire was determined to be a result of using smoking materials while using oxygen. There was a distinct burn pattern on the plastic oxygen tubing and carpet from the damaged recliner to the oxygen concentrator in a separate room. There were smoking materials present throughout the scene and the resident was known by staff to smoke while on his continuous oxygen. The oxygen concentrator was still operating when the investigation was initiated, and it was switched to the off position.

Review of the State of Ohio Fire Marshall report dated 03/04/26 at 3:12 P.M., revealed the ED created the report on 03/04/26 at 3:12 P.M. The report stated a fire occurred in the facility on 02/27/26 at 6:30 P.M. inside Resident #194's apartment. Resident #194 was sitting in his living room recliner smoking with oxygen.

Observation of Resident #194's room on 03/05/26 at 8:15 A.M., revealed there was a recliner in the living room that was broken apart with the recliner's foam exposed and partially charred. There were black burn marks on the lower wooden frame of the recliner and a white substance on the fabric of the recliner. There was distinct burn mark on the carpeted floor with pieces of oxygen tubing near it which led from the side of the recliner to the bedroom where an oxygen concentrator was sitting. The blue oxygen concentrator was partially melted, and the entire left side of the concentrator was charred. There were large burn marks that went up the wall near the oxygen concentrator and across the ceiling. The window blinds across the bedroom room were melted. There were lighters scattered throughout the resident's room. There was a wooden table next to the recliner with packs of cigarettes, lighters, a container (ash tray) full of cigarette butts and one cigarette on the side container that the resident appeared to be smoking at the time of the incident along with various melted items. Resident #194 also had a sign on the outside of his door that had a no smoking symbol and stated oxygen in use.

During an interview on 03/05/26 at 8:22 A.M., Caregiver #241 stated she had observed Resident #194 smoking in his room with oxygen in use but could not remember any dates. Caregiver #241 stated she had reported Resident #194 smoking with oxygen in use to Licensed Practical Nurse (LPN) #239.

During an interview on 03/05/26 at 8:35 A.M., Executive Director (ED) verified Resident #194 smoked in his room with continuous oxygen in use and caught his room on fire. The ED verified there were no active orders for oxygen and stated residents were not permitted to smoke in their rooms and not with oxygen in use.

Telephone interview with Local Fire Marshall (LFM) #500 on 03/05/26 at 1:10 P.M., revealed the Fire Department was notified of a fire alarm going off in the facility on 02/27/26 at 5:53 P.M. and the Fire Department observed smoke in the hallway upon arrival. LFM #500 stated the fire investigator was able to follow the oxygen nasal cannula route from the recliner in the living room to the oxygen concentrator in the bedroom and FDBC #400 identified the cause of the fire as Resident #194 smoking with oxygen.

During an interview via telephone on 03/05/26 at 3:15 P.M., Fire Department Battalion Chief (FDBC) #400 stated he investigated the fire incident that occurred at the facility on 02/27/26. FDBC #400 stated Resident #194's room had burn patterns that started at the recliner in the living room. FDBC #400 reported there was a black line across the carpet from the living room to the bedroom where the oxygen concentrator was located. FDBC #400 stated the black line in the carpet was the fire following the oxygen tubing back to the source or the oxygen concentrator. FDBC #400 stated the cause of the fire was Resident #194 smoking in his room with oxygen in use.

During an interview on 03/09/26 at 10:39 A.M., the ED and Vice President of Clinical Operations (VPCO) #700 verified Resident #194 was using oxygen in his room at the time of the fire incident on 02/27/26. VPCO #700 verified Resident #194 had no active physician order for continuous oxygen. VPCO #700 and the ED stated they were not aware of Resident #194's smoking materials being kept in his room.

Review of the facility's undated Medication Administration Policy, revealed the facility would ensure all medications were administered per physician orders. All medications required a valid physician order to specify the resident, drug, dose, route, frequency and duration.

Review of the facility's undated Oxygen Use and Storage Policy, revealed oxygen significantly increases the risk of fire and smoking while using oxygen is strictly prohibited. Residents using oxygen must be at least ten feet from any open flame or smoking material. Oxygen must be turned off and removed before a resident enters the designated smoking area. Residents must wait several minutes after oxygen has been turned off before smoking to allow oxygen saturation in the clothing and hair to dissipate. Smoking materials must never be near oxygen tanks, concentrators or tubing.

Review of the facility's Smoking Policy created on 02/28/26, revealed smoking was only permitted in designated outdoor smoking areas approved by the community. Smoking inside resident rooms, on room balconies or in any indoor area of the building was strictly prohibited. To ensure resident safety, a smoking safety assessment would be completed upon admission, with any significant change of condition, and quarterly. The evaluation would evaluate the physical ability to safely handle smoking materials, risks of burns or fire hazards, a history of unsafe smoking behaviors and oxygen use. Smoking was strictly prohibited while using oxygen.

Based on observation and staff interview, the facility failed to maintain the building to meet the minimum requirements of the Ohio Fire Code. This affected 94 out of 94 residents that resided in the facility.

Findings include:

During record review on 03/05/26, the following violations were identified:

1) The fire alarm inspection documentation dated 05/20/25 noted several deficiencies with the fire alarm system and no documentation that these deficiencies had been corrected.

2) There was no documentation of a semi-annual visual inspection as required by code.

3) There was no documentation that the facility's fire alarm devices had been sensitivity tested as required by code.

4) There were only two documented sprinkler inspections completed in the past 12 months. Documentation provided was dated 12/20/25 and 09/25/25. No other documentation was provided during the survey.

Observation during the tour of the facility on 03/05/26 at 1:37 P.M., revealed there was a trouble signal on the fire alarm panel. The trouble signal was reading GRD FAULT ACTIVE (alert on a fire alarm panel that indicates that an electrical conductor in the system is unintentionally touching a grounded surface, such as a metal conduit, junction box, or the panel enclosure. This creates a leakage path for electricity and must be addressed immediately as it can compromise the system's ability to detect or report a fire).

During an interview on 03/10/26 at 9:37 A.M., Director of Plant Operations (DPO) #207 verified there was a trouble signal on the fire alarm panel. DPO #207 verified the fire alarm inspection dated 05/20/25 did not have any documentation that the deficiencies were corrected and the facility had no documentation of no semi- annual visual inspections as required by code. DPO #207 also verified the facility had no documentation of fire alarm sensitivity testing as required by code. DPO #207 confirmed that the facility only had two documented sprinkler inspections in the past 12 months.

Based on observation, medical record review, staff interview, State Fire Marshall interview, local Fire Department interviews, review of the facility's self-reported incidents (SRI), review of emergency medical services (EMS) reports, review of fire department reports and policy review, the facility failed to ensure a fire incident at the facility was reported to the State Fire Marshal and to the State Surveying Agency within 24 hours. This affected 94 out of 94 residents that resided at the facility. The facility census was 94.

Findings include:

Review of medical record for Resident #194 revealed an admission date of 10/22/24. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD), tobacco use, hypertension, bradycardia, presence of cardiac pacemaker, muscle spasms, and bipolar disorder.

Review of the most recent Functional Assessment for Resident #194 dated 01/23/25, revealed the resident was alert and oriented to person, place, time and situation, and was independent with all activities of daily living (ADL). Resident #194 required oxygen therapy and had not smoked in the last two months; however, he had a long history of smoking. Resident #194 did not have cigarettes and reported he had no interest in smoking.

Review of the EMS report dated 02/27/26, revealed EMS was dispatched at 6:01 P.M. related to a burned patient from a structure fire. Resident #194 stated his new oxygen machine caught fire. Resident #194 attempted to put the fire out with his hands and only fanned the flames further. Resident #194 reported he called for help and tried to crawl out of his apartment. Eventually, the resident was dragged out by his feet by a staff person on the scene. Resident #194's clothing was removed for full assessment and approximately seven percent (%) body surface area (BSA) had second degree burns. There was soot (fine, black or brown powdery residue produced by the incomplete combustion of materials like wood, plastic, or fuel during a fire) noted throughout face, chest and arms and the patient denied any shortness of breath (SOB). The resident was transported to the nearest level one trauma center for burns and smoke inhalation.

Review of the Fire Department Incident Report dated 02/27/26, revealed crews were dispatched to the facility for a fire alarm at 5:53 P.M. with smoke showing. The Fire Department advised there was light smoke on the third floor of building four and one resident (Resident #194) was burned from smoking with oxygen on. The sprinkler system controlled the fire and the fire was out. The resident was found lying on the floor in the hallway with a nurse who stated the resident had been burned. The nurse stated the resident smoked with oxygen on. The Fire Department staff carried the resident from the building to the area outside where EMS was waiting. The employee that discovered the fire stated he smelled smoke in the hallway and heard someone screaming inside the room. When the employee opened the door, he was met with pitch black smoke and observed six-foot-tall flames in the bedroom to the left. The employee crawled into the living room and pulled the resident into the hallway by his leg. The fire investigator indicated the cause of the fire was determined to be a result of using smoking materials while using oxygen. There was a distinct burn pattern on the plastic oxygen tubing and carpet from the damaged recliner to the oxygen concentrator in a separate room. There were smoking materials present throughout the scene and the resident was known by staff to smoke while on his continuous oxygen. The oxygen concentrator was still operating when the investigation was initiated, and it was switched to the off position.

Review of the medical record for Resident #194 from 02/27/26 to 03/05/26, revealed no documentation related to the fire incident in Resident #194's room on 02/27/26 or the resident being sent to the hospital related to the injuries he sustained from the fire.

Review of the facility's SRIs created on 03/03/26 at 9:42 A.M. for neglect/mistreatment, revealed Resident #194 was smoking in his room on 02/27/26 at 8:30 P.M. Resident #194 was smoking in his room which is against the community's policies and the resident had an oxygen concentrator in his apartment. The resident's apartment caught fire and the facility's fire suppression system was immediately activated. Resident #194 was sent to the hospital and was in stable condition. The facility was in the process of evicting Resident #194, and the resident would not be returning to the facility. The building sustained significant water damage from the fire suppression system. The facility administration and the local Fire Department responded swiftly and immediately moved four residents to other apartments due to the water damage. All families were notified directly after the incident and all residents and staff are safe. The facility was working with local and state fire officials to restore and maintain the facility's fire system. The fire system in building four was down until 03/02/26 at approximately 9:00 A.M. The facility was in the process of cleanup and restoration. The SRI was completed on 03/03/26 at 10:18 A.M. and unsubstantiated.

Review of the State of Ohio Fire Marshall report dated 03/04/26 at 3:12 P.M., revealed the ED created the report on 03/04/26 at 3:12 P.M. The report stated a fire occurred in the facility on 02/27/26 at 6:30 P.M. inside Resident #194's apartment. Resident #194 was sitting in his living room recliner smoking with oxygen. The oxygen tubing caught on fire which was hooked up to a concentrator in the bedroom, and it caught on fire. The facility's fire suppression system immediately activated, and the sprinkler system ran for about thirty minutes. Only one resident (Resident #194) was injured.

Observation of Resident #194's room on 03/05/26 at 8:15 A.M., revealed there was a recliner in the living room that was broken apart with the recliner's foam exposed and partially charred. There were black burn marks on the lower wooden frame of the recliner and a white substance on the fabric of the recliner. There was distinct burn mark on the carpeted floor with pieces of oxygen tubing near it which led from the side of the recliner to the bedroom where an oxygen concentrator was sitting. The blue oxygen concentrator was partially melted, and the entire left side of the concentrator was charred. There were large burn marks that went up the wall near the oxygen concentrator and across the ceiling. The window blinds across the bedroom room were melted. There were lighters scattered throughout the resident's room. There was a wooden table next to the recliner with packs of cigarettes, lighters, a container (ash tray) full of cigarette butts and one cigarette on the side container that the resident appeared to be smoking at the time of the incident along with various melted items. Resident #194 also had a sign on the outside of his door that had a no smoking symbol and stated oxygen in use.

During an interview on 03/05/26 at 8:17 A.M., Resident #56 stated he was in his room on 02/27/26 when there was a fire in Resident #194's room. Resident #56 stated he smelled smoke and heard the smoke detector going off. Resident #56 reported the sprinklers went off and he saw staff running and pulling Resident #194 out of his apartment.

During an interview on 03/05/26 at 8:35 A.M., ED verified Resident #194 had a fire in his room on 02/27/26. The ED verified Resident #194 smoked in his room with continuous oxygen in use and caught his room on fire. The ED verified there were burn marks where Resident #194's oxygen tubing went from his recliner to the oxygen concentrator in the bedroom which was burnt and melted. The ED verified there were cigarettes on Resident #194's table next to his recliner and lighters in his room. The ED verified Resident #194 was sent to the hospital on 02/27/26 because of injuries he sustained from the fire in his room, and he remained in the hospital. The ED stated she was not aware of Resident #194's condition. The ED stated residents were not permitted to smoke in their rooms and not with oxygen in use.

During an interview on 03/05/26 at 8:40 A.M., Resident #38 reported he was in his room on 02/27/26 when the fire alarms went off. Resident #38 stated he saw smoke in the hallway, and the sprinklers went off prior to the fire doors slamming shut.

During an interview on 03/05/26 at 10:34 A.M., State Fire Marshall SFM #600 stated the facility had a fire incident on 02/27/26 and he went to the facility on 03/04/26 because the facility did not send the mandatory report about the fire to the State Fire Marshal. State Fire Marshall #600 stated the local Fire Department Battalion Chief (FDBC) #400 informed the State Fire Marshal of the fire at the facility on 02/27/26 after the Fire Department responded to the fire at the facility. State Fire Marshall #600 stated he checked the fire alarms and the sprinklers on 03/04/26 but the State Fire Marshal did not investigate the fire or origination of the fire.

During an interview on 03/05/26 at 12:12 P.M., LPN #230 stated she heard the fire alarm going off and went to the area where the fire alarm showed and observed smoke coming from Resident #194's room. LPN #230 reported Resident #194 could be heard yelling help and get him out of the room. LPN #230 opened the door, and a bunch of smoke came out of the room. LPN #230 shut the door and called LPN #232 for assistance. LPN #232 arrived at the room, opened Resident #194's room door and then closed it again. LPN #230 called 911 while LPN #232 opened the door and was able to get Resident #194 out of the room. LPN #230 stated Resident #194 had some abrasions to his knees, but he did not appear to have any additional injuries. LPN #230 reported the facility did not do an assessment on Resident #194 because of the smoke, but EMS arrived and took Resident #194 to the hospital.

During a telephone interview on 03/05/26 at 1:10 P.M., Local Fire Marshall (LFM) #500 stated the Fire Department was dispatched for a fire alarm going off in the facility on 02/27/26 at 5:53 P.M. and when a Fire Department member arrived, they observed smoke in the hallway and upgraded the fire response to a structure fire. LFM #500 reported FDBC #400 was tasked with completing the fire investigation. LFM #500 stated FDBC #400 was able to follow the oxygen nasal cannula route from the recliner in the living room to the oxygen concentrator in the bedroom and FDBC #400 identified the cause of the fire as Resident #194 was smoking while utilizing oxygen.

During a telephone interview on 03/05/26 at 1:43 P.M., Assistant Fire Chief (AFC) #300 on 03/05/26 at 1:43 P.M. revealed a neighboring Fire Department transported Resident #194 to the hospital on 02/27/26. AFC #300 stated Resident #194 sustained burns to his hands, wrists and knees related to the fire.

During an interview via telephone on 03/05/26 at 3:15 P.M., FDBC #400 stated he investigated the fire incident that occurred at the facility on 02/27/26. FDBC #400 stated Resident #194's room had burn patterns that started at the recliner in the living room. FDBC #400 reported there was a black line across the carpet from the living room to the bedroom where the oxygen concentrator was located. FDBC #400 stated the black line in the carpet was the fire following the oxygen tubing back to the source or the oxygen concentrator. FDBC #400 stated the cause of the fire was Resident #194 smoking in his room with oxygen in use.

During an interview via telephone on 03/10/26 at 9:50 A.M., the ED verified the facility did not report the fire incident on 02/27/26 to the State Fire Marshal and to the State Surveying Agency within 24 hours.

Review of the facility's resident incident reporting policy dated 11/03/25 revealed incidents must be reported to the State Surveying Agency in accordance with the state's regulations.

Based on observation, record review, staff interview, State Fire Marshall interview, local Fire Department interviews, review of the facility's self-reported incidents (SRI), review of emergency medical services (EMS) reports, review of fire department reports and policy review, the facility failed to ensure residents did not smoke in rooms while oxygen was in use. This resulted in Real and Present Danger and Actual Harm when on 02/27/26, Resident #194 was smoking in his room while oxygen was in use. The oxygen concentrator was on and running; the oxygen tubing was laying on the floor. The oxygen tubing caught fire, and the fire ran backwards through the oxygen tubing, caught the oxygen concentrator on fire and caught the resident's recliner on fire. Resident #194 attempted to extinguish the fire himself which resulted in second degree burns and smoke inhalation. The facility's sprinkler system activated due to the fire. Resident #194 had to be physically removed from his room by staff. Resident #194 was transported to a Level One Trauma Center where he was admitted for injuries related to the fire. This affected one (Resident #194) of three residents reviewed for smoking in the facility. The facility census was 94.

On 03/05/26 at 11:05 A.M., the Executive Director (ED) was notified Real and Present Danger began on 02/27/26 at approximately 5:53 P.M. when Resident #194, who was known by staff to smoke inside his room with continuous oxygen in use, was smoking with oxygen running via a nasal cannula inside his room. The oxygen tubing caught on fire causing the resident's recliner he was sitting in to catch fire, then the fire traveled back through the oxygen tubing and caught the oxygen concentrator on fire. Resident #194 was transported to a Level One Trauma Center for treatment and admitted for second degree burns and smoke inhalation.

The Real and Present Danger was removed on 03/13/26 when the facility implemented the following corrective actions:

On 02/28/26, the facility implemented a smoking policy. There was no smoking policy in place prior to 02/28/26.

On 03/02/26 from 9:00 A.M. to 10:00 A.M., the facility smoking policy was hand-delivered to all residents by Concierge #203, Director of Life Enrichment and Memory Support (DLEMS) #211, Director of Marketing and Community Relations (DMCR) #208. The policy was also posted on the community and staff communication page by the ED.

On 03/02/26 at 10:30 A.M., the ED had a conversation with a social worker at the Veterans Administration (VA) explaining that Resident #194 was non-complaint with the facility's smoking policy. Therefore, the resident was not appropriate to return to their community. Resident #194 would not be returning to their community following a community assessment determining he was non-compliant with the facility's smoking policy.

On 03/03/26 at approximately 9:00 A.M., the facility's leadership team identified 13 current and former smokers within the community. Each resident received one-on-one education regarding the facility's new smoking policy which included the location of the designated smoking area, safety expectations and consequences for policy violations. All residents verbalized understanding of the policy. Smoking assessments were conducted on the 13 residents. Residents #55 and #63 refused to allow staff to conduct smoking assessments and both residents were given 30-day discharge notices due to non-compliance with the smoking policy.

On 03/09/26 at 10:30 A.M., a voicemail was left inviting the Ombudsman to visit the community to discuss the process for discharging residents who were not compliant with the community's smoking policy.

On 03/10/26 from 11:00 A.M. to 12:00 P.M., interviews were conducted with Dietary Aide #703, Caregiver #228, Caregiver #256, Caregiver #704, LPN #231 and Housekeeper #219 and all staff verified they were educated on the smoking policy and procedures and to report residents in violation of the smoking policy to management immediately.

On 03/10/26 at 6:30 P.M., Vice President of Operations (VPO) #702 and the ED conducted a one-on-one conversation with Resident #12, who was identified as being a smoker and recently returned from the hospital. The resident was provided with a copy of the smoking policy and the staff verbally explained that any future non-compliance with the policy would result in eviction.

On 03/11/26 at 10:30 A.M., the ED created a new Resident Smoking Safety Plan to ensure the safety of all residents, staff and properly. Topics included: Storage of smoking materials, scheduled smoke times, smoking time limit, failure to return smoking materials, residents with cognitive impairment, room safety checks and fire safety compliance.

On 03/11/26 at 3:00 P.M., all employee education was completed in person by the ED and via the online communication system in Paylocity on the community's Smoking Policy and the education was verified by the ED. As part of staff education, employees were instructed by the ED that if they witness a resident violating the smoking policy, they must immediately report the incident to leadership. The community staff would notify leadership and the floor nurses if any items were found in resident's room that went against the smoking policy and the items would immediately be removed by a floor nurse or the leadership team. The ongoing education would occur during daily huddles and monthly inservices. All policies were uploaded into the on-line Paylocity Communication System where employees read and signed them, and this was verified by the ED. The Smoking Policy was also added into the curriculum of new hire orientation beginning on 03/13/26. All staff members signed documentation acknowledging that they read and understood the policy.

On 03/11/26 at 3:00 P.M., Director of Plant Operations (DPO) #207 purchased two lock boxes with four keys to each box. These boxes would hold the residents smoking materials. These boxes were placed in the East Nurses Station, closest to the designated smoking area outside. All residents are required to go to this nurse's station to obtain their smoking materials. Designated smoking times were given to each resident and were posted outside of the East Nurse's Station.

On 03/11/26 at 5:00 P.M., all 96 residents had a smoking assessment completed by DMCR #208, and DLEMS #211. No additional concerns were identified.

On 03/11/26 at 5:00 P.M., the community team (Concierge #204, Concierge #203, Caregiver #241, Caregiver #251, Caregiver #285, DLEMS #211, DMCR #208, and Maintenance Assistant #221) completed a sweep of all smokers' rooms and removed all items that were against the community's smoking policy. These items were placed in the lock boxes.

Starting on 03/11/26, to ensure ongoing compliance, the residents found to be non-compliant with the community's smoking policy would receive a 30-day eviction notice. As of 03/12/26, two Residents (#55 and #56) had been issued 30-day eviction notices by VPO #702 and the ED due to failing to adhere to the smoking policy.

On 03/12/26 at 10:00 A.M., after leadership discussed what a proper discharge notice was with the Ombudsman's Office, revised eviction notices were personally given to Residents #194, #55, #63, #56, and #32.

Starting on 03/13/26, to ensure ongoing compliance, random room safety checks will be conducted to ensure smoking materials are not being stored in the residents' rooms. The staff who observe residents smoking in unauthorized areas would immediately report the incident to leadership. Once the staff reports an issue, the ED would go speak to the resident(s) and issue a 30-day notice. If the ED is not available, a designated manager would speak to the resident and issue a 30-day notice. The ED, Concierge #203, Concierge #204, DLEMS #211, DPO #207, DMCR #208 and ADON #350 would document any non-compliance and address it according to community policy, including issuing warnings or eviction notices when necessary. This will occur daily until 04/01/26; weekly until 05/01/26; and then monthly for six months and the results will be evaluated by the Ed and VP #702.

Starting on 03/13/26, to ensure ongoing compliance with the Smoking Policy and the Resident Smoking Safety Plan, the leadership team (the ED, Concierge #203, Concierge #204, DLEMS #211, DPO #207, DMCR #208, and Assistant Director of Nursing [ADON] #350) will conduct routine rounds in the facility throughout the day to monitor for compliance with the Smoking Policy. This will occur daily until 04/01/26; weekly until 05/01/26; then monthly for six months and the results will be evaluated by the Ed and VP #702.

Starting on 03/13/26, to ensure ongoing compliance, the nursing staff (Licensed Practical Nurses and Caregivers on a rotating schedule) will be at the nurse's station to pass out the residents smoking materials. The independent residents could go out by themselves and bring the items back during the designated time frame. If an independent resident does not bring the smoking items back during the time frames, the nursing staff will locate the resident and retrieve the items. The residents who do not smoke independently and need assistance will be escorted to the smoking area by the nursing staff. The nursing staff will stay with the residents who need assistance the entire time during the smoking period. The nursing staff would help those residents who need assisting (i.e., applying a smoking apron, lighting the cigarette, etc.).

Although the Real and Present Danger was abated on 03/13/26, the violation remained as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance.

Findings include:

Record review revealed Resident #194 was admitted to the facility on 10/22/24. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD), tobacco use, hypertension, bradycardia, presence of cardiac pacemaker, muscle spasms, and bipolar disorder.

Review of the Resident Agreement, signed by Resident #194 on 10/21/24, revealed the community was non- smoking and smoking was not permitted on community campus, except in designated areas outside and away from the entrance. Smoking in non-designated areas posed a health and safety risk to other residents, staff members, and guests. The residents would be required to pay for all property damage caused by smoking in unauthorized areas. The resident agreed to hold harmless and indemnify the community for any personal injuries to the resident and other person or property caused by such smoking. Failure to comply with the community smoking policy may result in termination of residency.

Review of the most recent Functional Assessment for Resident #194 dated 01/23/25, revealed the resident was alert and oriented to person, place, time and situation, and was independent with all activities of daily living (ADL). Resident #194 required oxygen therapy and had not smoked in the last two months; however, he had a long history of smoking. Resident #194 did not have cigarettes and reported he had no interest in smoking.

Review of the service plan for Resident #194 dated 01/23/25, revealed he was on oxygen, two liters per minute (LPM) via nasal cannula and was independent in smoking but the resident reported he had not smoked in over six weeks and had no desire to smoke.

Review of the Smoking Safety Evaluation for Resident #194 dated 09/22/25, revealed the resident smoked only in the designated area, safely lit smoking material, held smoking material safely, disposed of ashes in the ash tray, removed oxygen tubing, and oxygen was not brought into the smoking area. The smoking safety evaluation indicated Resident #194 understood that smoking paraphernalia was not to be kept in his apartment.

Review of the Fire Department Incident Report dated 02/27/26, revealed crews were dispatched to the facility for a fire alarm at 5:53 P.M. with smoke showing. The Fire Department advised there was light smoke on the third floor of building four and one resident (Resident #194) was burned from smoking with oxygen on. The sprinkler system controlled the fire and the fire was out. The resident was found lying on the floor in the hallway with a nurse who stated the resident had been burned. The nurse stated the resident smoked with oxygen on. The Fire Department staff carried the resident from the building to the area outside where EMS was waiting. The employee that discovered the fire stated he smelled smoke in the hallway and heard someone screaming inside the room. When the employee opened the door, he was met with pitch black smoke and observed six-foot-tall flames in the bedroom to the left. The employee crawled into the living room and pulled the resident into the hallway by his leg. The fire investigator indicated the cause of the fire was determined to be a result of using smoking materials while using oxygen. There was a distinct burn pattern on the plastic oxygen tubing and carpet from the damaged recliner to the oxygen concentrator in a separate room. There were smoking materials present throughout the scene and the resident was known by staff to smoke while on his continuous oxygen. The oxygen concentrator was still operating when the investigation was initiated, and it was switched to the off position.

Review of the EMS report dated 02/27/26, revealed the EMS unit was dispatched at 6:01 P.M. related to a burned patient from a structure fire. EMS arrived at the facility when the Fire Department staff were carrying Resident #194 from the building and placed the resident on the staged EMS stretcher. An assessment revealed Resident #194 was alert and oriented, had burns/charring to anterior areas, abrasions on back, burn/charring to face, burn, blistering, redness and charring to left palm and left wrist, burn, blistering redness to both knees and abrasions on right hip. Resident #194 had a wet cough, singed facial, chest and arm hair and partial thickness burn to the left palmar hand and wrist and bilateral knees. Resident #194 stated his new oxygen machine caught on fire and he was not wearing the nasal cannula as it was coiled on the floor at the time of the fire. Resident #194 attempted to put the fire out with his hands and only fanned the flames further. Resident #194 reported he called for help and tried to crawl out of his apartment. Eventually, the resident was dragged out by his feet by a staff person on the scene. Resident #194's clothing was removed for full assessment and approximately seven percent body surface area (BSA) had second degree burns. There was soot (fine, black or brown powdery residue produced by the incomplete combustion of materials like wood, plastic, or fuel during a fire) noted throughout face, chest and arms and the patient denied any shortness of breath (SOB). The resident was administered Fentanyl (narcotic pain medication used to treat severe pain) and was transported the level one trauma center.

Review of medical record for Resident #194 from 02/27/26 to 03/05/26, revealed no documentation related to the fire incident in Resident #194's room on 02/27/26 or the resident being sent to the hospital related to the injuries he sustained from the fire.

Review of the facility's SRIs created on 03/03/26 at 9:42 A.M. for neglect/mistreatment, revealed Resident #194 was smoking in his room on 02/27/26 at 8:30 P.M. Resident #194 was smoking in his room which is against the community's policies and the resident had an oxygen concentrator in his apartment. The resident's apartment caught fire and the facility's fire suppression system was immediately activated. Resident #194 was sent to the hospital and was in stable condition. The facility was in the process of evicting Resident #194, and the resident would not be returning to the facility. The building sustained significant water damage from the fire suppression system. The facility administration and the local Fire Department responded swiftly and immediately moved four residents to other apartments due to the water damage. All families were notified directly after the incident and all residents and staff are safe. The facility was working with local and state fire officials to restore and maintain the facility's fire system. The fire system in building four was down until 03/02/26 at approximately 9:00 A.M. The facility was in the process of cleanup and restoration. The SRI was completed on 03/03/26 at 10:18 A.M. and no neglect was substantiated.

Review of the State of Ohio Fire Marshall report dated 03/04/26 at 3:12 P.M., revealed the ED created the report on 03/04/26 at 3:12 P.M. The report stated a fire occurred in the facility on 02/27/26 at 6:30 P.M. inside Resident #194's apartment. Resident #194 was sitting in his living room recliner smoking with oxygen. The oxygen tubing caught on fire which was hooked up to a concentrator in the bedroom, and it caught on fire. The facility's fire suppression system immediately activated, and the sprinkler system ran for about thirty minutes. Only one resident (Resident #194) was injured.

Observation of Resident #194's room on 03/05/26 at 8:15 A.M., revealed there was a recliner in the living room that was broken apart with the recliner's foam exposed and partially charred. There were black burn marks on the lower wooden frame of the recliner and a white substance on the fabric of the recliner. There was distinct burn mark on the carpeted floor with pieces of oxygen tubing near it which led from the side of the recliner to the bedroom where an oxygen concentrator was sitting. The blue oxygen concentrator was partially melted, and the entire left side of the concentrator was charred. There were large burn marks that went up the wall near the oxygen concentrator and across the ceiling. The window blinds across the bedroom room were melted. There were lighters scattered throughout the resident's room. There was a wooden table next to the recliner with packs of cigarettes, lighters, an ash tray full of cigarette butts, various melted items and one cigarette in the ashtray that was partially smoked. Resident #194 also had a sign on the outside of his door that had a no smoking symbol and stated oxygen in use.

During an interview on 03/05/26 at 8:17 A.M., Resident #56 stated he was in his room on 02/27/26 when there was a fire in Resident #194's room. Resident #56 stated he smelled smoke and heard the smoke detector going off. Resident #56 reported the sprinklers went off and he saw staff running and pulling Resident #194 out of his apartment. Resident #56 stated he regularly smoked cigarettes in his room and on the balcony.

During an interview on 03/05/26 at 8:22 A.M., Caregiver #241 stated she had observed Resident #194 smoking in his room with oxygen in use but could not remember any dates. Caregiver #241 stated she had reported Resident #194 smoking with oxygen in use to Licensed Practical Nurse (LPN) #239.

During an interview on 03/05/26 at 8:35 A.M., the ED verified Resident #194 had a fire in his room on 02/27/26. Resident #194 smoked in his room with continuous oxygen in use and caught his room on fire. There were burn marks where Resident #194's oxygen tubing went from his recliner to the oxygen concentrator in the bedroom which was burnt and melted and there were cigarettes on Resident #194's table next to his recliner and lighters in his room. The ED verified Resident #194 was sent to the hospital on 02/27/26 because of injuries he sustained from the fire in his room, and he remained in the hospital. The ED stated she was not aware of Resident #194's condition. The ED stated residents were not permitted to smoke in their rooms and not with oxygen in use.

During an interview on 03/05/26 at 8:40 A.M., Resident #38 stated he often smelled cigarette smoke in the hallways and in the laundry room. Resident #38 stated the staff reported the fire in Resident #194's room was caused by smoking with oxygen in use. Resident #38 stated he was in his room on 02/27/26 when the fire alarms went off. Resident #38 stated he saw smoke in the hallway, and the sprinklers went off prior to the fire doors slamming shut.

Observation of Resident #55's room on 03/05/26 at 8:43 A.M., with the ED, revealed the resident had a pack of cigarettes on his table beside his bed. Resident #55's room smelled like cigarette smoke.

During an interview on 03/05/26 at 8:43 A.M., the ED verified Resident #55 had a pack of cigarettes on his table beside his bed and the room smelled like cigarette smoke. Interview with Resident #55 at the same time, revealed he smoked; however, would not disclose where he smoked.

During an interview on 03/05/26 at 10:34 A.M., State Fire Marshall SFM #600 stated the facility had a fire incident on 02/27/26 and he went to the facility on 03/04/26 because the facility did not send the mandatory report about the fire to the State Fire Marshal. State Fire Marshall #600 stated the local Fire Department Battalion Chief (FDBC) #400 informed the State Fire Marshal of the fire at the facility on 02/27/26 after the Fire Department responded to the fire at the facility. State Fire Marshall #600 stated he checked the fire alarms and the sprinklers on 03/04/26 but the State Fire Marshal did not investigate the fire or origination of the fire.

During an interview on 03/05/26 at 11:19 A.M., Resident #21 stated she regularly smoked in her room or on her lower-level patio. Resident #21 stated that everyone smoked in their rooms and the facility had told them to stop smoking in their rooms. Resident #21 reported the facility never did anything about the residents smoking in their rooms, so she and the other residents continued to smoke in their rooms and on their patios.

Observation of Resident #01's room on 03/05/26 at 11:21 A.M. with the ED, revealed Resident #01 had a pack of cigarettes and a lighter on his table in his living room. Interview with the ED at that time verified the findings.

During an interview on 03/05/26 at 11:22 A.M., Resident #01 stated he regularly smoked in his room until 03/04/26 when he was told to stop smoking by the ED.

During an interview on 03/05/26 at 11:25 A.M., Resident #50 stated he regularly smoked on his second story balcony.

During an interview on 03/05/26 at 11:29 A.M., Resident #26 stated she occasionally smoked on lower-level patio. Resident #26 stated that she was aware of where the smoking area was located but she could not walk that far. Resident #26 stated that she had resided at the facility for 10 years and she had been smoking on her patio for 10 years with no issues.

During an interview on 03/05/26 at 11:33 A.M., Resident #32 stated he smoked on the second story balcony and in his room.

Observation of Resident #26's patio on 03/05/26 at 11:45 A.M. with the ED, revealed there were two portable cup style ash trays with ashes in them sitting on a table on Resident #26's patio. Interview with the ED at that time verified the findings.

Observation of Resident #63's room on 03/05/26 at 11:48 A.M. with the ED, revealed there was a portable cup style ash tray with ashes in it sitting on a table in Resident #63's living room. Resident #63's room smelled like cigarette smoke. Interview with the ED at that time verified the findings.

During an interview on 03/05/26 at 11:47 A.M., Resident #63 stated he regularly smoked on the second story balcony of his room.

During an interview on 03/05/26 at 12:12 P.M., LPN #230 stated she heard the fire alarm going off and went to the area where the fire alarm showed and observed smoke coming from Resident #194's room. LPN #230 reported Resident #194 could be heard yelling help and get him out of the room. LPN #230 opened the door, and a bunch of smoke came out of the room. LPN #230 shut the door and called LPN #232 for assistance. LPN #232 arrived at the room, opened Resident #194's room door and then closed it again. LPN #230 called 911 while LPN #232 opened the door and was able to get Resident #194 out of the room. LPN #230 stated Resident #194 had some abrasions to his knees, but he did not appear to have any additional injuries. LPN #230 stated the facility did not do a physical assessment on Resident #194 at that time because of the smoke, but EMS arrived and took Resident #194 to the hospital. LPN #230 stated she had smelled smoke in Resident #194's room in the past.

During a telephone interview on 03/05/26 at 1:10 P.M., Local Fire Marshall (LFM) #500 stated the Fire Department was dispatched for a fire alarm going off in the facility on 02/27/26 at 5:53 P.M. and when a Fire Department member arrived, they observed smoke in the hallway and upgraded the fire response to a structure fire. LFM #500 stated Resident #194 was already in the hallway with the facility staff when the Fire Department staff arrived. LFM #500 reported the staff informed the Fire Department staff that they heard the fire alarms going off and got in the elevator to go up to the third floor where the fire alarm system was showing. LFM #500 stated when the staff members got off the elevator, there was smoke in the hallway, and a staff member was able to reach into Resident #194's room and drag Resident #194 into the hallway. LFM #500 reported FDBC #400 was tasked with completing the fire investigation. LFM #500 stated FDBC #400 was able to follow the oxygen nasal cannula route from the recliner in the living room to the oxygen concentrator in the bedroom and FDBC #400 identified the cause of the fire as Resident #194 was smoking while utilizing oxygen.

During a telephone interview on 03/05/26 at 1:43 P.M., Assistant Fire Chief (AFC) #300 on 03/05/26 at 1:43 P.M. revealed a neighboring Fire Department transported Resident #194 to the hospital on 02/27/26. AFC #300 stated Resident #194 sustained burns to his hands, wrists and knees related to the fire.

During an interview on 03/05/26 at 1:56 P.M., the ED verified Resident #194's medical record did not have any documentation or progress notes related to the fire incident on 02/27/26. The ED verified the resident was transported to the hospital related to the injuries he sustained in the fire and there was no documentation in the medical record.

During an interview via telephone on 03/05/26 at 2:16 P.M., LPN #232 stated LPN #230 called him and reported there was smoke on the third floor and LPN #230 was requesting LPN #232's assistance. LPN #232 arrived at Resident #194's room and there was black smoke in the hallway and thick black smoke when he opened Resident #194's door. LPN #232 stated he could hear Resident #194 screaming for help. LPN #232 tried to use his phone flashlight but could not see anything due to the smoke. LPN #232 then crouched down and got a couple of feet into the room and was able to grab Resident #194's leg and pull him out of the room. LPN #232 stated he saw flames shooting up the wall in the bedroom from Resident #194's concentrator. LPN #232 stated Resident #194 was only wearing an incontinence brief at the time of the incident, and he was wet from the sprinklers. LPN #232 reported LPN #232 did not do an assessment on Resident #194 prior to him being sent to the hospital by EMS. LPN #232 stated he had seen cigarettes and ashes in the trash in Resident #194's room in the past. LPN #232 also stated all the residents had been smoking in their rooms since they moved in there and it was not a secret to anyone.

During an interview via telephone on 03/05/26 at 3:15 P.M., FDBC #400 stated he investigated the fire incident that occurred at the facility on 02/27/26. FDBC #400 stated Resident #194's room had burn patterns that started at the recliner in the living room. FDBC #400 reported there was a black line across the carpet from the living room to the bedroom where the oxygen concentrator was located. FDBC #400 stated the black line in the carpet was the fire following the oxygen tubing back to the source or the oxygen concentrator. FDBC #400 stated the cause of the fire was Resident #194 smoking in his room with oxygen in use.

During an interview via telephone on 03/09/26 at 10:39 A.M., ED #210 and Vice President of Clinical Operations (VPCO) #700 verified Resident #194's Smoking Safety Evaluation dated 09/22/25 indicated Resident #194 smoked only in designated smoking areas and Resident #194 would remove oxygen tubing and oxygen would not be brought into the smoking area. Resident #194 was noted as understanding smoking paraphernalia would not be kept in his apartment. VPCO #700 stated the company just took over operations at the facility and the facility was in the process of doing smoking assessments on all residents. VPCO #700 stated the facility did not have a smoking policy during the time of the incident; however, the facility created one on 02/28/26. VPCO #700 reported she was not aware of the prior smoking policy. VPCO #700 verified Resident #194 did not have a physician order for oxygen; however, verified Resident #194 was smoking while using oxygen at the time of the fire on 02/27/26. VPCO #700 and the ED stated they were not aware of where Resident #194's smoking materials were to be stored since the smoking safety evaluation dated 09/22/25 stated he was not to keep smoking paraphernalia in his room.

Review of the undated facility's policy titled Oxygen Use and Storage Policy, revealed oxygen significantly increases the risk of fire. Smoking while using oxygen is strictly prohibited. Residents using oxygen must be at least ten feet from any open flame or smoking material and oxygen must be turned off and removed before a resident enters the designated smoking area. Residents must wait several minutes after oxygen has been turned off before smoking to allow oxygen saturation in the clothing and hair to dissipate. Smoking materials must never be near oxygen tanks, concentrators or tubing.

This violation represents non-compliance investigated under Complaint Number OH00169956.

Based on observation, medical record review, staff interview, State Fire Marshall interview, local Fire Department interviews, review of the facility's self-reported incidents (SRI), review of emergency medical services (EMS) reports, review of fire department reports and policy review, the facility failed to ensure a resident's record was complete and accurate. This affected one (Resident #194) out of three residents reviewed for complete and accurate medical records. The facility census was 94.

Findings include:

Review of medical record for Resident #194 revealed an admission date of 10/22/24. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD), tobacco use, hypertension, bradycardia, presence of cardiac pacemaker, muscle spasms, and bipolar disorder.

Review of the most recent Functional Assessment for Resident #194 dated 01/23/25, revealed the resident was alert and oriented to person, place, time and situation, and was independent with all activities of daily living (ADL). Resident #194 required oxygen therapy and had not smoked in the last two months; however, he had a long history of smoking. Resident #194 did not have cigarettes and reported he had no interest in smoking.

Review of the Fire Department Incident Report dated 02/27/26, revealed crews were dispatched to the facility for a fire alarm at 5:53 P.M. with smoke showing. The Fire Department advised there was light smoke on the third floor of building four and one resident (Resident #194) was burned from smoking with oxygen on. The resident was found lying on the floor in the hallway with a nurse who stated the resident had been burned. The nurse stated the resident smoked with oxygen on. The Fire Department staff carried the resident from the building to the area outside where EMS was waiting. The employee that discovered the fire stated he smelled smoke in the hallway and heard someone screaming inside the room. When the employee opened the door, he was met with pitch black smoke and observed six-foot-tall flames in the bedroom to the left. The employee crawled into the living room and pulled the resident into the hallway by his leg. The fire investigator indicated the cause of the fire was determined to be a result of using smoking materials while using oxygen.

Review of the EMS report dated 02/27/26, revealed the EMS unit was dispatched at 6:01 P.M. related to a burned patient from a structure fire. EMS arrived at the facility when the Fire Department staff were carrying Resident #194 from the building and placed the resident on the staged EMS stretcher. An assessment revealed Resident #194 was found to be alert and oriented, had burns/charring to anterior areas, abrasions on back, burn/charring to face, burn, blistering, redness and charring to left palm and left wrist, burn, blistering redness to both knees and abrasions on right hip. Resident #194 had a wet cough, singed facial, chest and arm hair and partial thickness burn to the left palmar hand and wrist and bilateral knees. Resident #194 stated his new oxygen machine caught on fire and he was not wearing the nasal cannula as it was coiled on the floor at the time of the fire. Resident #194 attempted to put the fire out with his hands and only fanned the flames further. Resident #194 reported he called for help and tried to crawl out of his apartment. Eventually, the resident was dragged out by his feet by a staff person on the scene. Resident #194's clothing was removed for full assessment and approximately seven percent (%) body surface area (BSA) had second degree burns. There was soot (fine, black or brown powdery residue produced by the incomplete combustion of materials like wood, plastic, or fuel during a fire) noted throughout face, chest and arms and the patient denied any shortness of breath (SOB). The resident was administered Fentanyl (narcotic pain medication used to treat severe pain) and was transported the level one trauma center.

Review of the medical record for Resident #194 from 02/27/26 to 03/05/26, revealed no documentation related to the fire incident in Resident #194's room on 02/27/26 or the resident being sent to the hospital related to the injuries he sustained from the fire.

Review of the facility's SRIs created on 03/03/26 at 9:42 A.M. for neglect/mistreatment, revealed Resident #194 was smoking in his room on 02/27/26 at 8:30 P.M. Resident #194 was smoking in his room which is against the community's policies and the resident had an oxygen concentrator in his apartment. The resident's apartment caught fire and the facility's fire suppression system was immediately activated. Resident #194 was sent to the hospital and was in stable condition. The facility was in the process of evicting Resident #194, and the resident would not be returning to the facility. The building sustained significant water damage from the fire suppression system. The facility administration and the local Fire Department responded swiftly and immediately moved four residents to other apartments due to the water damage. All families were notified directly after the incident and all residents and staff are safe. The facility was working with local and state fire officials to restore and maintain the facility's fire system. The fire system in building four was down until 03/02/26 at approximately 9:00 A.M. The facility was in the process of cleanup and restoration. The SRI was completed on 03/03/26 at 10:18 A.M. and unsubstantiated.

Review of the State of Ohio Fire Marshall report dated 03/04/26 at 3:12 P.M., revealed the ED created the report on 03/04/26 at 3:12 P.M. The report stated a fire occurred in the facility on 02/27/26 at 6:30 P.M. inside Resident #194's apartment. Resident #194 was sitting in his living room recliner smoking with oxygen. The oxygen tubing caught on fire which was hooked up to a concentrator in the bedroom, and it caught on fire. The facility's fire suppression system immediately activated, and the sprinkler system ran for about thirty minutes. Only one resident (Resident #194) was injured.

Observation of Resident #194's room on 03/05/26 at 8:15 A.M., revealed there was a recliner in the living room that was broken apart with the recliner's foam exposed and partially charred. There were black burn marks on the lower wooden frame of the recliner and a white substance on the fabric of the recliner. There was distinct burn mark on the carpeted floor with pieces of oxygen tubing near it which led from the side of the recliner to the bedroom where an oxygen concentrator was sitting. The blue oxygen concentrator was partially melted, and the entire left side of the concentrator was charred. There were large burn marks that went up the wall near the oxygen concentrator and across the ceiling. The window blinds across the bedroom room were melted. There were lighters scattered throughout the resident's room. There was a wooden table next to the recliner with packs of cigarettes, lighters, a container (ash tray) full of cigarette butts and one cigarette on the side container that the resident appeared to be smoking at the time of the incident along with various melted items. Resident #194 also had a sign on the outside of his door that had a no smoking symbol and stated oxygen in use.

During an interview on 03/05/26 at 8:35 A.M., ED verified Resident #194 had a fire in his room on 02/27/26. The ED verified Resident #194 was sent to the hospital on 02/27/26 because of injuries he sustained from the fire in his room, and he remained in the hospital.

During an interview on 03/05/26 at 10:34 A.M., State Fire Marshall (SFM) #600 stated the facility had a fire incident on 02/27/26 and he went to the facility on 03/04/26 because the facility did not send the mandatory report about the fire to the State Fire Marshal.

During an interview on 03/05/26 at 12:12 P.M., LPN #230 stated she heard the fire alarm going off and went to the area where the fire alarm showed and observed smoke coming from Resident #194's room. LPN #230 reported Resident #194 could be heard yelling help and get him out of the room. LPN #230 opened the door, and a bunch of smoke came out of the room. LPN #230 shut the door and called LPN #232 for assistance. LPN #232 arrived at the room, opened Resident #194's room door and then closed it again. LPN #230 called 911 while LPN #232 opened the door and was able to get Resident #194 out of the room. LPN #230 stated Resident #194 had some abrasions to his knees, but he did not appear to have any additional injuries. LPN #230 reported that the nursing staff did not do an assessment on Resident #194 because of the smoke, but EMS arrived and took Resident #194 to the hospital. LPN #230 verified there was no documentation in Resident #194's medical record related to the fire incident on 02/27/26.

During a telephone interview on 03/05/26 at 1:10 P.M., Local Fire Marshall (LFM) #500 stated the Fire Department was dispatched for a fire alarm going off in the facility on 02/27/26 at 5:53 P.M. LFM #500 stated Resident #194 was already in the hallway with the facility staff when the Fire Department staff arrived. LFM #500 reported that the staff informed the Fire Department staff that they heard the fire alarms going off and got in the elevator to go up to the third floor where the fire alarm system was showing. LFM #500 stated when the staff members got off the elevator, there was smoke in the hallway, and a staff member was able to reach into Resident #194's room and drag Resident #194 into the hallway.

During a telephone interview on 03/05/26 at 1:43 P.M., Assistant Fire Chief (AFC) #300 on 03/05/26 at 1:43 P.M. revealed a neighboring Fire Department transported Resident #194 to the hospital on 02/27/26. AFC #300 stated Resident #194 sustained burns to his hands, wrists and knees related to the fire.

During an interview on 03/05/26 at 1:56 P.M., the ED verified Resident #194's medical record did not have any documentation or progress notes related to the fire incident on 02/27/26. The ED verified the resident was transported to the hospital related to the injuries he sustained in the fire and there was no documentation in the medical record.

During an interview via telephone on 03/05/26 at 2:16 P.M., LPN #232 stated LPN #230 called him and reported there was smoke on the third floor and LPN #230 was requesting LPN #232's assistance. LPN #232 arrived at Resident #194's room and there was black smoke in the hallway and thick black smoke when he opened Resident #194's door. LPN #232 stated he could hear Resident #194 screaming for help. LPN #232 tried to use his phone flashlight but could not see anything due to the smoke. LPN #232 then crouched down and got a couple of feet into the room and was able to grab Resident #194's leg and pull him out of the room. LPN #232 stated he saw flames shooting up the wall in the bedroom from Resident #194's concentrator. LPN #232 stated Resident #194 was only wearing an incontinence brief at the time of the incident, and he was wet from the sprinklers. LPN #232 reported LPN #232 did not do an assessment on Resident #194 prior to him being sent to the hospital by EMS. LPN #232 verified there was no documentation in Resident #194's medical record related to the fire incident on 02/27/26.

Review of the facility's nursing documentation policy dated 11/03/25 revealed all licensed nurses and nursing staff are responsible for documenting resident care in a clear, accurate and timely manner.

Based on medical record review, review of Activities of Daily Living (ADL) Care Tracking Sheets, review of Emergency Call-Pendant Response Reports, staff interviews, resident interviews and policy review, the facility failed to ensure residents received personal care as needed. This affected one (#02) of the three residents reviewed for personal care. The facility census was 132. Findings include: Review of the medical record revealed Resident #02 was admitted to the facility on 07/18/25 with diagnoses of dementia, metabolic encephalopathy, sacral fracture, congestive heart failure, pulmonary hypertension and hypertensive heart disease with heart failure. The resident was transferred to the hospital on 08/01/25 at 11:14 A.M. and did not return to the facility. Review of the Functional Assessment dated 07/19/25 revealed Resident #02 was oriented to person and situation and required assistance for mobility with a manual wheelchair. The resident was independent for eating and required physical assistance for personal hygiene, toileting, bathing, dressing, mobility and transfers. Review of the ADL Care Tracking Sheet for Resident #02 from 07/19/25 to 07/31/25, revealed Resident #02 was not assisted with denture care during the 7:00 A.M. to 3:00 P.M. shift on 07/22/25, 07/23/24, 07/25/25, 07/27/25, 07/28/25, 07/29/25, and on 07/31/25. Review of the ADL Care Tracking Sheet for Resident #02 from 07/19/25 to 07/31/25 revealed Resident #02 was not assisted with toileting during the 7:00 A.M. to 3:00 P.M. shift on 07/22/25, 07/23/25, 07/24/25 to 07/25/25, 07/27/25, 07/28/25, 07/29/25, and 07/31/25; and during the 11:00 P.M. to 7:00 A.M. shift on 07/19/25, 07/20/25, 07/22/25, 07/24/25, and 07/26/25, 07/27/25, 07/28/25, 07/29/25, 07/30/25 and 07/31/25. Review of Excessive Response Report for the emergency call-pendant from 07/19/25 to 08/01/25 revealed Resident #02 activated the emergency pendant a total of 28 times with an average response time of 60.71 minutes. Review of the Excessive Response Report for the emergency call-pendant from 07/01/25 to 10/06/25 revealed an average response time of 88 minutes. Review of the Excessive Response Report for the emergency call-pendant from 09/01/25 to 10/02/25 revealed an average response time of 73 minutes. Observation on 10/06/25 at 8:48 A.M. revealed Resident #95 activated her emergency call-pendant and Care Givers (CG) #500 and #505 responded at 9:14 A.M. for a response time of 26 minutes. Interviews on 10/06/25 between 8:30 A.M. and 9:22 A.M. with Licensed Practical Nurse (LPN) #405 and CGs #500 and #505, revealed because of the size of the facility and the care needs of the residents, there was not enough staff to adequately care for the residents in a timely manner. Interviews on 10/06/25 between 8:30 A.M. and 9:22 A.M. with Residents #02, #16 and #95, revealed concerns with the number of staff available and the response times to their emergency call-pendant alerts. Interview on 10/06/25 at 1:54 P.M. with the Executive Director (ED), who stated the expectation for an emergency call-pendant response time by staff should not exceed 15 minutes. The ED verified the response times for Resident #02. The ED also verified the times on the Excessive Response Reports of 60.71 minutes, 88 minutes and 73 minutes. Interview on 10/07/25 at 3:52 P.M. with the Health and Wellness Director (HWD) #300 who stated care not documented, was considered care not provided. HWD #300 verified the missing personal care for Resident #02 on the dates and times listed above. HWD #300 stated at times, there were not enough staff in the facility to provide adequate care for the residents. Review of the policy titled, Resident Emergency Call SystemBased on medical record review, review of Activities of Daily Living (ADL) Care Tracking Sheets, review of Emergency Call-Pendant Response Reports, staff interviews, resident interviews and policy review, the facility failed to ensure residents received personal care as needed. This affected one (#02) of the three residents reviewed for personal care. The facility census was 132.

Findings include:

Review of the medical record revealed Resident #02 was admitted to the facility on 07/18/25 with diagnoses of dementia, metabolic encephalopathy, sacral fracture, congestive heart failure, pulmonary hypertension and hypertensive heart disease with heart failure. The resident was transferred to the hospital on 08/01/25 at 11:14 A.M. and did not return to the facility.

Review of the Functional Assessment dated 07/19/25 revealed Resident #02 was oriented to person and situation and required assistance for mobility with a manual wheelchair. The resident was independent for eating and required physical assistance for personal hygiene, toileting, bathing, dressing, mobility and transfers.

Review of the ADL Care Tracking Sheet for Resident #02 from 07/19/25 to 07/31/25, revealed Resident #02 was not assisted with denture care during the 7:00 A.M. to 3:00 P.M. shift on 07/22/25, 07/23/24, 07/25/25, 07/27/25, 07/28/25, 07/29/25, and on 07/31/25.

Review of the ADL Care Tracking Sheet for Resident #02 from 07/19/25 to 07/31/25 revealed Resident #02 was not assisted with toileting during the 7:00 A.M. to 3:00 P.M. shift on 07/22/25, 07/23/25, 07/24/25 to 07/25/25, 07/27/25, 07/28/25, 07/29/25, and 07/31/25; and during the 11:00 P.M. to 7:00 A.M. shift on 07/19/25, 07/20/25, 07/22/25, 07/24/25, and 07/26/25, 07/27/25, 07/28/25, 07/29/25, 07/30/25 and 07/31/25.

Review of Excessive Response Report for the emergency call-pendant from 07/19/25 to 08/01/25 revealed Resident #02 activated the emergency pendant a total of 28 times with an average response time of 60.71 minutes.

Review of the Excessive Response Report for the emergency call-pendant from 07/01/25 to 10/06/25 revealed an average response time of 88 minutes.

Review of the Excessive Response Report for the emergency call-pendant from 09/01/25 to 10/02/25 revealed an average response time of 73 minutes.

Observation on 10/06/25 at 8:48 A.M. revealed Resident #95 activated her emergency call-pendant and Care Givers (CG) #500 and #505 responded at 9:14 A.M. for a response time of 26 minutes.

Interviews on 10/06/25 between 8:30 A.M. and 9:22 A.M. with Licensed Practical Nurse (LPN) #405 and CGs #500 and #505, revealed because of the size of the facility and the care needs of the residents, there was not enough staff to adequately care for the residents in a timely manner.

Interviews on 10/06/25 between 8:30 A.M. and 9:22 A.M. with Residents #02, #16 and #95, revealed concerns with the number of staff available and the response times to their emergency call-pendant alerts.

Interview on 10/06/25 at 1:54 P.M. with the Executive Director (ED), who stated the expectation for an emergency call-pendant response time by staff should not exceed 15 minutes. The ED verified the response times for Resident #02. The ED also verified the times on the Excessive Response Reports of 60.71 minutes, 88 minutes and 73 minutes.

Interview on 10/07/25 at 3:52 P.M. with the Health and Wellness Director (HWD) #300 who stated care not documented, was considered care not provided. HWD #300 verified the missing personal care for Resident #02 on the dates and times listed above. HWD #300 stated at times, there were not enough staff in the facility to provide adequate care for the residents.

Review of the policy titled, Resident Emergency Call System

Based on observations, staff interview, record review, and policy review, the facility failed to procure, store, prepare, distribute, and serve all food in a manner that protects it against contamination and spoilage. This had the potential to affect all residents as the facility identified all residents receive food from the kitchen. The facility census was 132. Findings include: Observation of the kitchen on 10/01/25 at 9:26 A.M. with the Dietary Manager (DM) #600 revealed three trash cans in the kitchen did not have lids on them. DM #600 verified the findings at the time of the observation. Continued observation of the kitchen on 10/01/25 at 9:28 A.M. with the DM #600, revealed the dry storage area had one- half bag of pasta labeled with an open date but not beyond use date; one gallon bottle of white vinegar that expired on 08/29/25; two one gallon bottles of red wine vinegar with expiration dates of 09/19/25 and 01/21/25. The walk in refrigerator revealed scalloped potatoes on a tray, labeled with a date of 09/27/25; seven pieces of pie uncovered and not dated; four one gallon containers of milk that expired on 09/30/25; one five pound container of small curd cottage cheese that expired on 09/08/25; two bins of two ounce salad dressing cups not dated or labeled; half of a container of cherry filling not dated or labeled; five small two ounce containers of chocolate cake not dated or labeled. DM #600 verified all of these expired, unlabeled and undated food items at the time of the observations. Review of the policy titled, Principles of Safe Food HandlingBased on observations, staff interview, record review, and policy review, the facility failed to procure, store, prepare, distribute, and serve all food in a manner that protects it against contamination and spoilage. This had the potential to affect all residents as the facility identified all residents receive food from the kitchen. The facility census was 132.

Findings include:

Observation of the kitchen on 10/01/25 at 9:26 A.M. with the Dietary Manager (DM) #600 revealed three trash cans in the kitchen did not have lids on them. DM #600 verified the findings at the time of the observation.

Continued observation of the kitchen on 10/01/25 at 9:28 A.M. with the DM #600, revealed the dry storage area had one- half bag of pasta labeled with an open date but not beyond use date; one gallon bottle of white vinegar that expired on 08/29/25; two one gallon bottles of red wine vinegar with expiration dates of 09/19/25 and 01/21/25. The walk in refrigerator revealed scalloped potatoes on a tray, labeled with a date of 09/27/25; seven pieces of pie uncovered and not dated; four one gallon containers of milk that expired on 09/30/25; one five pound container of small curd cottage cheese that expired on 09/08/25; two bins of two ounce salad dressing cups not dated or labeled; half of a container of cherry filling not dated or labeled; five small two ounce containers of chocolate cake not dated or labeled. DM #600 verified all of these expired, unlabeled and undated food items at the time of the observations.

Review of the policy titled, Principles of Safe Food Handling

Based on observations, record reviews, staff interviews, resident interviews and policy review, the facility failed to take reasonable precautions to ensure the safety of all residents when permitting residents to smoke. This affected one (#16) of the one resident identified by the facility as smoked. This had the potential to affect all 132 residents residing in the facility.

Findings include:

Review of the medical record revealed Resident #16 was admitted to the facility on 07/01/25 with diagnoses of diabetes, hypertension, moderate Alzheimer's and tobacco abuse.

Review of the initial Functional Assessment dated 07/01/25 revealed Resident #16 was oriented to person, place and situation. Resident #16 was able to ambulate independently and did not require assistance with activities of daily living (ADLs). Resident #16 had to smoke safely and a smoking evaluation needed completed. There was no documented smoking evaluation for Resident #16 completed.

Interview with the Health and Wellness Director (HWD) #300 on 10/01/25 at 11:37 A.M. who stated residents who smoke, have rooms with an outdoor patio area to smoke on. HWD #300 verified the facility did not have a designated smoking area. Observation of an outdoor area off of the main dining room, revealed cigarette butts in the two flower planters next to door. Both flower planters were full of cigarette butts. The patio outside of the dining area had a small bucket with paper products and cigarette butts. HWD #300 confirmed that these items should not be there.

Interview on 10/06/25 at 9:45 A.M. with HWD #300 who stated the facility was a smoke free facility.

Interview on 10/06/25 at 10:02 A.M. with the Dietary Manager (DM) #600 who stated residents smoke on the patio directly outside of the dining area on a daily basis.

Observation on 10/06/25 at 10:09 A.M. revealed Resident #16 was smoking on her patio and inside her apartment. There were cigarettes and a lighter on a table tray in front of her couch along with a plastic cup half-filled with black water, ashes and cigarette butts.

Interview with the Executive Director (ED) on 10/06/25 at 10:24 A.M. who stated residents were permitted to smoke on their balconies and patios. The ED additionally confirmed the policy stated that residents could not smoke on their patios or balconies. The ED confirmed the plastic cup half-filled with black water, ashes and cigarette butts on Resident #16's tray table in front of her couch inside her apartment.

Interview with HWD #300 on 10/06/25 at 1:23 P.M. verified Resident #16 did not have a Smoking Safety Evaluation done.

Review of the policy titled, Assisted Living and Memory Care Smoking. dated May 2021, revealed, smoking by residents, staff and visitors shall be allowed only in designated outdoor spaces according to state and local regulations. These spaces shall not be located at entry ways. The resident agrees to follow all the rules as outlined in the smoking policy to include no smoking in the apartments, in the community or on their patios.

Based on record review, observation, staff interview review of Material Safety Data Sheets (MSDS) and policy review, the facility store poisonous and hazardous materials safely. This had the ability to affect 25 of the 26 residents residing in the Memory Care Unit who were identified by the facility as being independently mobile with ambulation. The facility census was 132. Findings include: Interview on 10/01/25 at 11:30 A.M. with the Health and Wellness Director (HWD) #300 who stated there were 26 residents who resided in the Memory Care Unit and 25 were independent with ambulation. Observation of the Memory Care Unit on 10/01/25 at 1:43 P.M. with the Health and Wellness Coordinator (HWC) #150 revealed a one quart plastic container of Clorox Bleach in an unsecured cabinet below the countertop. HWC #150 verified the findings at the time of the observation. Review of the MSDS sheet for Clorox clean up cleaner and bleach dated 05/27/16 revealed the chemical was considered hazardous by the 2012 Occupational Safety and Health Administration (OSHA) Hazard Communication Standard (29 CFR 1910.1200). Avoid contact with skin and eyes due to skin corrosion/irritation and serious eye damage/irritation to eyes. Can cause severe burns and damage to skin and eyes. Review of the policy titled, Memory Care Securing the EnvironmentBased on record review, observation, staff interview review of Material Safety Data Sheets (MSDS) and policy review, the facility store poisonous and hazardous materials safely. This had the ability to affect 25 of the 26 residents residing in the Memory Care Unit who were identified by the facility as being independently mobile with ambulation. The facility census was 132.

Findings include:

Interview on 10/01/25 at 11:30 A.M. with the Health and Wellness Director (HWD) #300 who stated there were 26 residents who resided in the Memory Care Unit and 25 were independent with ambulation.

Observation of the Memory Care Unit on 10/01/25 at 1:43 P.M. with the Health and Wellness Coordinator (HWC) #150 revealed a one quart plastic container of Clorox Bleach in an unsecured cabinet below the countertop. HWC #150 verified the findings at the time of the observation.

Review of the MSDS sheet for Clorox clean up cleaner and bleach dated 05/27/16 revealed the chemical was considered hazardous by the 2012 Occupational Safety and Health Administration (OSHA) Hazard Communication Standard (29 CFR 1910.1200). Avoid contact with skin and eyes due to skin corrosion/irritation and serious eye damage/irritation to eyes. Can cause severe burns and damage to skin and eyes.

Review of the policy titled, Memory Care Securing the Environment

Based on medical record review, observation, staff interviews and policy review, the facility failed to ensure a safe environment for residents in the memory care unit (MCU). This had the potential to affect 25 of the 26 residents residing in the MCU identified by the facility as being independent with ambulation. The facility census was 132. Findings include: 1) Review of the medical record revealed Resident #127 was admitted to the facility on 06/25/25 with diagnoses of dementia, adrenal insufficiency, anemia and hyperlipidemia. Review of the Initial Assessment dated 06/27/25 revealed Resident #127 was cognitively impaired and was able to ambulate independently without any assistive device. 2) Review of the medical record revealed Resident #115 was admitted to the facility on 07/01/22 with diagnoses of Alzheimer's dementia, hypertension and gastro-esophageal reflux disease. Review of the Reassessment dated 10/03/24 revealed Resident #115 was cognitively impaired and was able to ambulate independently without any assistive device. 3) Review of the medical record revealed Resident #123 was admitted to the facility on 11/01/24 with diagnoses of dementia without behavioral disturbances, coronary artery disease, alcohol abuse and malignant neoplasm of prostate. Review of the Initial assessment dated 11/01/24 revealed Resident #123 was cognitively impaired and was able to ambulate independently without any assistive device.. 4) Review of the medical record revealed Resident #128 was admitted to the facility on 05/17/21 with diagnoses of short-term memory loss, hypertension, diabetes mellitus type II and macular degeneration. Review of the annual assessment dated 04/09/25 revealed Resident #128 was cognitively impaired and was able to ambulate independently without any assistive device. Observation of the MCU on 10/01/25 at 10:59 A.M. with the Executive Director (ED) revealed a wide doorway, with no door, open to a kitchen area that included a steam table built into a granite countertop and a residential-type stove with an oven. The kitchen area was located between the main corridor and the dining room. The large kitchen entrance from the main corridor had no door and the entrance from the dining room had a Dutch style door that was propped open. The kitchen area was being utilized as a walk-through by residents and staff to enter the dining room. There was another entrance to the dining room from the main corridor that did not involve going through the kitchen area. The ED stated the door had been broken, and they did not currently have a replacement door. The ED stated the staff were using a large table in the kitchen that they push in front of the door opening to keep the residents out of the kitchen area at times. Interview with the Health and Wellness director (HWD) #300 on 10/01/25 at 11:30 A.M. revealed 25 of the 26 residents in m MCU was independent with ambulation. Observation of the MCU on 10/01/25 at 12:32 P.M. revealed Resident #127 walked into open kitchen area with hot foods and a steam table on the island and very close to the edge of the countertop and within reach of the steam table with no staff in the area. Continuous observations of the MCU revealed Residents #115, #123, and #128 walked through the open MCU kitchen area with no staff present in the area. Interview on 10/01/25 at 12:38 P.M. with the Memory Care Coordinator (MCD) # 205 who stated she had been at the facility for three years and there had never been a door on the large entrance to the memory care kitchen. MCD #205 verified the safety risks to the residents with the kitchen area being unsecured. Interview on 10/01/25 at 12:40 P.M. with Dining Server #700 who stated the steam table was only located approximately 12 inches from the edge of the countertop and within the resident's reach. Dining Server #700 took the temperature of the steam table, and it measured 183 degrees Fahrenheit, and the food temperature was 160 degrees Fahrenheit. Dining Server #700 confirmed the doors to the kitchen remained open during dining hours. Review of the policy titled, Memory Care Securing the EnvironmentBased on medical record review, observation, staff interviews and policy review, the facility failed to ensure a safe environment for residents in the memory care unit (MCU). This had the potential to affect 25 of the 26 residents residing in the MCU identified by the facility as being independent with ambulation. The facility census was 132.

Findings include:

1) Review of the medical record revealed Resident #127 was admitted to the facility on 06/25/25 with diagnoses of dementia, adrenal insufficiency, anemia and hyperlipidemia.

Review of the Initial Assessment dated 06/27/25 revealed Resident #127 was cognitively impaired and was able to ambulate independently without any assistive device.

2) Review of the medical record revealed Resident #115 was admitted to the facility on 07/01/22 with diagnoses of Alzheimer's dementia, hypertension and gastro-esophageal reflux disease.

Review of the Reassessment dated 10/03/24 revealed Resident #115 was cognitively impaired and was able to ambulate independently without any assistive device.

3) Review of the medical record revealed Resident #123 was admitted to the facility on 11/01/24 with diagnoses of dementia without behavioral disturbances, coronary artery disease, alcohol abuse and malignant neoplasm of prostate.

Review of the Initial assessment dated 11/01/24 revealed Resident #123 was cognitively impaired and was able to ambulate independently without any assistive device..

4) Review of the medical record revealed Resident #128 was admitted to the facility on 05/17/21 with diagnoses of short-term memory loss, hypertension, diabetes mellitus type II and macular degeneration.

Review of the annual assessment dated 04/09/25 revealed Resident #128 was cognitively impaired and was able to ambulate independently without any assistive device.

Observation of the MCU on 10/01/25 at 10:59 A.M. with the Executive Director (ED) revealed a wide doorway, with no door, open to a kitchen area that included a steam table built into a granite countertop and a residential-type stove with an oven. The kitchen area was located between the main corridor and the dining room. The large kitchen entrance from the main corridor had no door and the entrance from the dining room had a Dutch style door that was propped open. The kitchen area was being utilized as a walk-through by residents and staff to enter the dining room. There was another entrance to the dining room from the main corridor that did not involve going through the kitchen area. The ED stated the door had been broken, and they did not currently have a replacement door. The ED stated the staff were using a large table in the kitchen that they push in front of the door opening to keep the residents out of the kitchen area at times.

Interview with the Health and Wellness director (HWD) #300 on 10/01/25 at 11:30 A.M. revealed 25 of the 26 residents in m MCU was independent with ambulation.

Observation of the MCU on 10/01/25 at 12:32 P.M. revealed Resident #127 walked into open kitchen area with hot foods and a steam table on the island and very close to the edge of the countertop and within reach of the steam table with no staff in the area. Continuous observations of the MCU revealed Residents #115, #123, and #128 walked through the open MCU kitchen area with no staff present in the area.

Interview on 10/01/25 at 12:38 P.M. with the Memory Care Coordinator (MCD) # 205 who stated she had been at the facility for three years and there had never been a door on the large entrance to the memory care kitchen. MCD #205 verified the safety risks to the residents with the kitchen area being unsecured.

Interview on 10/01/25 at 12:40 P.M. with Dining Server #700 who stated the steam table was only located approximately 12 inches from the edge of the countertop and within the resident's reach. Dining Server #700 took the temperature of the steam table, and it measured 183 degrees Fahrenheit, and the food temperature was 160 degrees Fahrenheit. Dining Server #700 confirmed the doors to the kitchen remained open during dining hours.

Review of the policy titled, Memory Care Securing the Environment

Based on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure medications were administered and documented as ordered. This affected four (#05, #65, #97, and #107) of five residents reviewed for medication administration. The facility identified six residents (#17, #73, #75, #79, #80, and #93) who self-administered their medications. The facility census was 116. Findings include: 1) Review of the medical record of Resident #107 revealed an admission date of 01/15/20. Diagnoses included cerebral infarction, hypertension, type 2 diabetes mellitus, and hyperlipidemia. Review of the Evaluation and Service Plan dated 01/09/25 for Resident #107, revealed the resident was alert and oriented to person, place, time, and situation. The resident was dependent on staff for medication administration. Review of August 2025 active physician orders for Resident #107, revealed the resident was ordered to received the following: Aspirin (nonsteroidal anti-inflammatory drug (NSAID) 81 milligrams (mg) by mouth once daily at 8:00 A.M., baclofen (muscle relaxer) 10 mg tablet three times daily at 8:00 A.M., 2:00 P.M., and 8:00 P.M., diclofenac (NSAID) sodium one percent (%) gel-apply two grams (gm) topically to hamstring and patellar tendon twice daily at 8:00 A.M. and 8:00 P.M., escitalopram (anti-depressant) 20 mg tablet daily at 8:00 A.M., ferrous sulfate (supplement) 325 mg daily at 8:00 A.M., hydrochlorothiazide (diuretic) 25 mg every morning at 8:00 A.M., losartan potassium (for hypertension) 100 mg daily at 8:00 A.M., Metoprolol Succinate (for blood pressure/beta blocker) extended release (ER) 50 mg daily at 8:00 A.M., senexon (stool softener) 50-8.6 mg tablet-two tablets daily at 8:00 A.M., vitamin B-12 (supplement) 25 microgram (mcg) tablet daily at 8:00 A.M., and vitamin D (supplement) 25 mcg table daily at 8:00 A.M. Review of the August 2025 medication administration record (MAR) for Resident #107, revealed there were dashes recorded under the 08/09/25 administration for the aspirin at 8:00 A.M., baclofen at 8:00 A.M. and 2:00 P.M., diclofenac sodium at 8:00 A.M., escitalopram at 8:00 A.M., ferrous sulfate at 8:00 A.M., hydrochlorothiazide at 8:00 A.M. losartan potassium at 8:00 A.M., Metoprolol Succinate at 8:00 A.M., senexon at 8:00 A.M., vitamin B-12 at 8:00 A.M., and vitamin D at 8:00 A.M. The key for the MAR indicated a dash representing the medication was not recorded. Interview on 08/13/25 at 12:41 P.M., Health and Wellness Coordinator (HWC) #305, verified Resident #107's MAR indicated she did not receive her medications as ordered on 08/09/25. 2) Review of the medical record of Resident #05, revealed an admission date of 12/26/24. Diagnosis included Parkinson's disease. Review of the Evaluation and Service Plan dated 04/30/25 for Resident #05, revealed the resident was alert and oriented to person, place, and time. The resident required medication administration for two medication passes daily. Interview on 08/12/25 at 12:21 P.M., Resident #05 stated he was not given his fluoxetine a few days prior. Resident #05 stated he pressed his call light several times and was told by staff that they would get to it. Review of the physician orders dated 04/28/25 for Resident #05, revealed the resident was ordered fluoxetine (antidepressant) 30 mg once a day at 8:00 A.M. The physician order dated 06/03/25 revealed the resident was ordered vitamin B-12-1000 mcg once a day at 8:00 A.M. Review of the August 2025 MAR for Resident #05, revealed there was a dash recorded under the administration for fluoxetine and vitamin B12 on 08/09/25. The key for the MAR indicated a dash representing the medication was not recorded. Interview on 08/13/25 at 12:41 P.M., HWC #305, verified Resident #05's MAR indicated he did not receive his medications as ordered on 08/09/25. 3) Review of the medical record of Resident #97, revealed an admission date of 10/24/24. Diagnoses included congestive heart failure, type 2 diabetes mellitus, pulmonary hypertension, atrial fibrillation, and hypertension. Review of the Evaluation and Service Plan dated 01/21/25 for Resident #97, revealed the resident was alert and oriented to person, place, time, and situation. The resident was dependent on staff for all medications administered by mouth and was able to self-administer eye drops. Review of August 2025 current physician orders for Resident #97, revealed the resident was ordered the following: Acetaminophen (pain reliever) 500 mg caplet-take two caplets by mouth every 8 hours at 12:00 A.M., 8:00 A.M., and 4:00 P.M., amiodarone (controls heart rhythms) 200 mg once daily at 8:00 A.M., aspirin 81 mg by mouth daily at 8:00 A.M., buspirone (anti-anxiety) 10 mg tablet three times per day at 8:00 A.M., 2:00 P.M., and 8:00 P.M., cetirizine (antihistamine) 10 mg tablet daily at 8:00 A.M., Eliquis (anti-coagulant) five mg tablet twice daily at 8:00 A.M., and 5:00 P.M., escitalopram (anti-depressant) 10 mg daily at 8:00 A.M., famotidine (gastro-esophageal reflux) 20 mg tablet twice daily at 8:00 A.M. and 5:00 P.M., furosemide (diuretic) 20 mg daily at 8:00 A.M., Metoprolol Succinate extended release 50 mg daily at 8:00 A.M., pantoprazole (GERD) 40 mg daily at 8:00 A.M., vitamin B-12 1000 mcg tablet daily at 8:00 A.M., vitamin D 25 mcg daily at 8:00 A.M. Review of the August 2025 MAR for Resident #97, revealed dashes were recorded under the 08/09/25 administration of acetaminophen at 8:00 A.M. and 4:00 P.M., amiodarone at 8:00 A.M. aspirin at 8:00 A.M., buspirone at 8:00 A.M. and 2:00 P.M., cetirizine at 8:00 A.M., Eliquis at 8:00 A.M. and 5:00 P.M., escitalopram at 8:00 A.M., famotidine at 8:00 A.M. and 5:00 P.M., furosemide at 8:00 A.M., Metoprolol at 8:00 A.M., pantoprazole at 8:00 A.M., vitamin B-12 at 8:00 A.M., and vitamin D at 8:00 A.M. The key for the MAR indicated a dash representing the medication was not recorded. Interview on 08/13/25 at 11:35 A.M., Resident #97 stated she did not receive any of her daytime medications on 08/09/25. Interview on 08/13/25 at 12:41 P.M., HWC #305, verified Resident #97's MAR indicated she did not receive her medications as ordered on 08/09/25. Interview on 08/13/25 at 2:31 P.M., HWC #305 stated Resident #97 was able to self-administer eye drops and was dependent on staff for all other medications. 4) Review of the medical record of Resident #65, revealed an admission date of 06/06/23. Diagnoses included type 2 diabetes mellitus. Review of the Evaluation and Service Plan dated 06/25/25 for Resident #65, revealed the resident was alert and oriented to person, place, time, and situation. The resident was dependent on staff for medication administration. Interview on 08/12/25 at 12:16 P.M., Resident #65 stated there was one day over the past weekend where she did not receive her medications. Review of August 2025 current physician orders for Resident #65, revealed the resident was ordered to receive Lantus (long acting insulin) 15 units daily at 9:00 P.M. Review of the August 2025 MAR for Resident #65, revealed a dash was recorded under the 08/09/25 administration of Lantus 15 units at 9:00 P.M. The key for the MAR indicated a dash representing the medication was not recorded. Interview on 08/13/25 at 12:41 P.M., HWC #305, verified Resident #65's MAR indicated she did not receive her Lantus as ordered on 08/09/25. HWC #305 stated she personally gave her the medication but must not have signed it off as given. HWC #305 further verified all medications given should be signed off on the MAR. Review of the facility policy titled, Medication AdministrationBased on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure medications were administered and documented as ordered. This affected four (#05, #65, #97, and #107) of five residents reviewed for medication administration. The facility identified six residents (#17, #73, #75, #79, #80, and #93) who self-administered their medications. The facility census was 116.

Findings include:

1) Review of the medical record of Resident #107 revealed an admission date of 01/15/20. Diagnoses included cerebral infarction, hypertension, type 2 diabetes mellitus, and hyperlipidemia.

Review of the Evaluation and Service Plan dated 01/09/25 for Resident #107, revealed the resident was alert and oriented to person, place, time, and situation. The resident was dependent on staff for medication administration.

Review of August 2025 active physician orders for Resident #107, revealed the resident was ordered to received the following: Aspirin (nonsteroidal anti-inflammatory drug (NSAID) 81 milligrams (mg) by mouth once daily at 8:00 A.M., baclofen (muscle relaxer) 10 mg tablet three times daily at 8:00 A.M., 2:00 P.M., and 8:00 P.M., diclofenac (NSAID) sodium one percent (%) gel-apply two grams (gm) topically to hamstring and patellar tendon twice daily at 8:00 A.M. and 8:00 P.M., escitalopram (anti-depressant) 20 mg tablet daily at 8:00 A.M., ferrous sulfate (supplement) 325 mg daily at 8:00 A.M., hydrochlorothiazide (diuretic) 25 mg every morning at 8:00 A.M., losartan potassium (for hypertension) 100 mg daily at 8:00 A.M., Metoprolol Succinate (for blood pressure/beta blocker) extended release (ER) 50 mg daily at 8:00 A.M., senexon (stool softener) 50-8.6 mg tablet-two tablets daily at 8:00 A.M., vitamin B-12 (supplement) 25 microgram (mcg) tablet daily at 8:00 A.M., and vitamin D (supplement) 25 mcg table daily at 8:00 A.M.

Review of the August 2025 medication administration record (MAR) for Resident #107, revealed there were dashes recorded under the 08/09/25 administration for the aspirin at 8:00 A.M., baclofen at 8:00 A.M. and 2:00 P.M., diclofenac sodium at 8:00 A.M., escitalopram at 8:00 A.M., ferrous sulfate at 8:00 A.M., hydrochlorothiazide at 8:00 A.M. losartan potassium at 8:00 A.M., Metoprolol Succinate at 8:00 A.M., senexon at 8:00 A.M., vitamin B-12 at 8:00 A.M., and vitamin D at 8:00 A.M. The key for the MAR indicated a dash representing the medication was not recorded.

Interview on 08/13/25 at 12:41 P.M., Health and Wellness Coordinator (HWC) #305, verified Resident #107's MAR indicated she did not receive her medications as ordered on 08/09/25.

2) Review of the medical record of Resident #05, revealed an admission date of 12/26/24. Diagnosis included Parkinson's disease.

Review of the Evaluation and Service Plan dated 04/30/25 for Resident #05, revealed the resident was alert and oriented to person, place, and time. The resident required medication administration for two medication passes daily.

Interview on 08/12/25 at 12:21 P.M., Resident #05 stated he was not given his fluoxetine a few days prior. Resident #05 stated he pressed his call light several times and was told by staff that they would get to it.

Review of the physician orders dated 04/28/25 for Resident #05, revealed the resident was ordered fluoxetine (antidepressant) 30 mg once a day at 8:00 A.M. The physician order dated 06/03/25 revealed the resident was ordered vitamin B-12-1000 mcg once a day at 8:00 A.M.

Review of the August 2025 MAR for Resident #05, revealed there was a dash recorded under the administration for fluoxetine and vitamin B12 on 08/09/25. The key for the MAR indicated a dash representing the medication was not recorded.

Interview on 08/13/25 at 12:41 P.M., HWC #305, verified Resident #05's MAR indicated he did not receive his medications as ordered on 08/09/25.

3) Review of the medical record of Resident #97, revealed an admission date of 10/24/24. Diagnoses included congestive heart failure, type 2 diabetes mellitus, pulmonary hypertension, atrial fibrillation, and hypertension.

Review of the Evaluation and Service Plan dated 01/21/25 for Resident #97, revealed the resident was alert and oriented to person, place, time, and situation. The resident was dependent on staff for all medications administered by mouth and was able to self-administer eye drops.

Review of August 2025 current physician orders for Resident #97, revealed the resident was ordered the following: Acetaminophen (pain reliever) 500 mg caplet-take two caplets by mouth every 8 hours at 12:00 A.M., 8:00 A.M., and 4:00 P.M., amiodarone (controls heart rhythms) 200 mg once daily at 8:00 A.M., aspirin 81 mg by mouth daily at 8:00 A.M., buspirone (anti-anxiety) 10 mg tablet three times per day at 8:00 A.M., 2:00 P.M., and 8:00 P.M., cetirizine (antihistamine) 10 mg tablet daily at 8:00 A.M., Eliquis (anti-coagulant) five mg tablet twice daily at 8:00 A.M., and 5:00 P.M., escitalopram (anti-depressant) 10 mg daily at 8:00 A.M., famotidine (gastro-esophageal reflux) 20 mg tablet twice daily at 8:00 A.M. and 5:00 P.M., furosemide (diuretic) 20 mg daily at 8:00 A.M., Metoprolol Succinate extended release 50 mg daily at 8:00 A.M., pantoprazole (GERD) 40 mg daily at 8:00 A.M., vitamin B-12 1000 mcg tablet daily at 8:00 A.M., vitamin D 25 mcg daily at 8:00 A.M.

Review of the August 2025 MAR for Resident #97, revealed dashes were recorded under the 08/09/25 administration of acetaminophen at 8:00 A.M. and 4:00 P.M., amiodarone at 8:00 A.M. aspirin at 8:00 A.M., buspirone at 8:00 A.M. and 2:00 P.M., cetirizine at 8:00 A.M., Eliquis at 8:00 A.M. and 5:00 P.M., escitalopram at 8:00 A.M., famotidine at 8:00 A.M. and 5:00 P.M., furosemide at 8:00 A.M., Metoprolol at 8:00 A.M., pantoprazole at 8:00 A.M., vitamin B-12 at 8:00 A.M., and vitamin D at 8:00 A.M. The key for the MAR indicated a dash representing the medication was not recorded.

Interview on 08/13/25 at 11:35 A.M., Resident #97 stated she did not receive any of her daytime medications on 08/09/25.

Interview on 08/13/25 at 12:41 P.M., HWC #305, verified Resident #97's MAR indicated she did not receive her medications as ordered on 08/09/25.

Interview on 08/13/25 at 2:31 P.M., HWC #305 stated Resident #97 was able to self-administer eye drops and was dependent on staff for all other medications.

4) Review of the medical record of Resident #65, revealed an admission date of 06/06/23. Diagnoses included type 2 diabetes mellitus.

Review of the Evaluation and Service Plan dated 06/25/25 for Resident #65, revealed the resident was alert and oriented to person, place, time, and situation. The resident was dependent on staff for medication administration.

Interview on 08/12/25 at 12:16 P.M., Resident #65 stated there was one day over the past weekend where she did not receive her medications.

Review of August 2025 current physician orders for Resident #65, revealed the resident was ordered to receive Lantus (long acting insulin) 15 units daily at 9:00 P.M.

Review of the August 2025 MAR for Resident #65, revealed a dash was recorded under the 08/09/25 administration of Lantus 15 units at 9:00 P.M. The key for the MAR indicated a dash representing the medication was not recorded.

Interview on 08/13/25 at 12:41 P.M., HWC #305, verified Resident #65's MAR indicated she did not receive her Lantus as ordered on 08/09/25. HWC #305 stated she personally gave her the medication but must not have signed it off as given. HWC #305 further verified all medications given should be signed off on the MAR.

Review of the facility policy titled, Medication Administration

Based on medical record review, staff interview, and policy review, the facility failed to complete a fall investigation following a fall. This affected one (#114) of two residents reviewed for falls. The facility census was 116. Findings include: Review of the medical record of Resident #114 revealed an admission date of 11/02/22. Diagnoses included aortic stenosis, mild dementia, hypertension, atrial fibrillation, elevated lipids, and obstructive sleep apnea. Review of the Evaluation and Service Plan dated 04/28/25, revealed Resident #114 was alert and oriented to person, place, time, and situation. The resident was assessed at a low fall risk. The resident required physical assistance with dressing, standby assistance for bathing, and was independent with ambulation, transfers, eating. The resident required safety checks twice per shift. Review of a progress note dated 07/20/25 at 9:00 A.M. for Resident #114 revealed the resident was observed sitting on the floor of her bedroom by the bed. The resident stated she had slid off the recliner in her bedroom onto the floor and could not get herself up. The resident had no complaints of pain, and no injuries were visible at that time. The resident denied hitting her head. The resident was observed walking with her walker in the apartment without difficulty. All responsible parties, including the resident's primary care provider, Nurse Practitioner (NP) #500 were notified. Interview on 08/13/25 at 12:34 P.M., the Health and Wellness Coordinator (HWC) #305 stated there was no fall investigation for Resident #114's fall on 07/20/25. HWC #305 stated the former Health and Wellness Director would have been responsible for ensuring the investigation was completed and she did not have any evidence of it being completed. Review of the facility policy titled, Fall PreventionBased on medical record review, staff interview, and policy review, the facility failed to complete a fall investigation following a fall. This affected one (#114) of two residents reviewed for falls. The facility census was 116.

Findings include:

Review of the medical record of Resident #114 revealed an admission date of 11/02/22. Diagnoses included aortic stenosis, mild dementia, hypertension, atrial fibrillation, elevated lipids, and obstructive sleep apnea.

Review of the Evaluation and Service Plan dated 04/28/25, revealed Resident #114 was alert and oriented to person, place, time, and situation. The resident was assessed at a low fall risk. The resident required physical assistance with dressing, standby assistance for bathing, and was independent with ambulation, transfers, eating. The resident required safety checks twice per shift.

Review of a progress note dated 07/20/25 at 9:00 A.M. for Resident #114 revealed the resident was observed sitting on the floor of her bedroom by the bed. The resident stated she had slid off the recliner in her bedroom onto the floor and could not get herself up. The resident had no complaints of pain, and no injuries were visible at that time. The resident denied hitting her head. The resident was observed walking with her walker in the apartment without difficulty. All responsible parties, including the resident's primary care provider, Nurse Practitioner (NP) #500 were notified.

Interview on 08/13/25 at 12:34 P.M., the Health and Wellness Coordinator (HWC) #305 stated there was no fall investigation for Resident #114's fall on 07/20/25. HWC #305 stated the former Health and Wellness Director would have been responsible for ensuring the investigation was completed and she did not have any evidence of it being completed.

Review of the facility policy titled, Fall Prevention

Based on medical record review, staff interview, resident interview, review of facility call light reports, and policy review, the facility failed to ensure all residents were free from neglect. This affected one (#114) of three residents reviewed for call light response. The facility census was 116. Findings include: Review of the medical record of Resident #114 revealed an admission date of 11/02/22. Diagnoses included aortic stenosis, mild dementia, hypertension, atrial fibrillation, elevated lipids, and obstructive sleep apnea. Review of the Evaluation and Service Plan dated 04/28/25, revealed Resident#114 was alert and oriented to person, place, time, and situation. The resident was assessed at a low fall risk. The resident required physical assistance with dressing, standby assistance for bathing, and was independent with ambulation, transfers, eating. The resident required safety checks twice per shift. Review of a progress note dated 07/20/25 at 9:00 A.M. revealed Resident #114 was observed sitting on the floor of her bedroom by the bed. The resident stated she had slid off the recliner in her bedroom onto the floor and could not get herself up. The resident had no complaints of pain, and no injuries were visible at that time. The resident denied hitting her head. The resident was observed walking with her walker in the apartment without difficulty. All responsible parties, including the resident's primary care provider, Nurse Practitioner (NP) #500 were notified. Review of the facility call light report, dated 07/18/25 through 08/12/25 revealed, on 07/20/25 at 3:08 A.M., Resident #114 activated her call light. The report indicated it took 4 hours and 49 minutes for the call light to be addressed. Interview on 08/12/25 at 12:40 P.M., Resident #114 affirmed she had recently fallen. Resident #114 stated she was sitting in her chair in her bedroom and fell asleep and fell to the floor. Resident #114 stated she woke up when she fell, at approximately 4:00 A.M., activated her call pendant, and nobody came to help her until 9:00 A.M. Interview on 08/12/25 at 2:39 P.M., Licensed Practical Nurse (LPN) #300 stated, on 07/20/25 at approximately 9:00 A.M., she entered Resident #114's room to give her medications and Resident #114 was laying on the floor. LPN #300 stated she saw the call light was activated at the time she entered Resident #114's room with the medications. Interview on 08/13/25 at 9:05 A.M., Executive Director (ED) #360, verified the call light response time for Resident #114 on 07/20/25 was 4 hours and 49 minutes. ED #360 stated the expectation was for call lights to be answered in a timely manner and verified a response time of 4 hours and 49 minutes was not timely. Interview on 08/13/25 at 9:55 A.M., Caregiver #350 affirmed she worked the night of 07/20/25 and did not receive any alert of Resident #114's call light being activated. Caregiver #350 stated she normally checks her residents at least twice per shift, however stated she did not check on Resident #114 at any point during her shift because she did not know she needed to be checked on. Interview on 08/13/25 at 1:00 P.M., ED #360 stated, on 07/20/25, Caregiver #355 came on shift and found Resident #114's light was on and went to answer it and found Resident #114 on the floor. ED #360 stated she spoke with Caregiver #350 about the call light and Caregiver #350 stated she did not know the light was going off. ED #360 stated Caregiver #350 told her she was checking the call light system regularly and did not see the alert; however, ED #360 stated she knew that was a lie because Caregiver #355 was able to tell the call light was on when she started her shift that morning. Interview on 08/13/25 at 1:12 P.M., Caregiver #355 stated, when she came on shift on 07/20/25, she could tell there were at least five call lights on. Caregiver #355 stated she started checking on the residents who had their lights on and got to Resident #114 at approximately 8:00 A.M. and observed her on the floor. Caregiver #355 stated Resident #114 was awake and talking and said she had pressed her call light at approximately 3:00 A.M. Review of the facility policy titled, Resident Emergency Call SystemBased on medical record review, staff interview, resident interview, review of facility call light reports, and policy review, the facility failed to ensure all residents were free from neglect. This affected one (#114) of three residents reviewed for call light response. The facility census was 116.

Findings include:

Review of the medical record of Resident #114 revealed an admission date of 11/02/22. Diagnoses included aortic stenosis, mild dementia, hypertension, atrial fibrillation, elevated lipids, and obstructive sleep apnea.

Review of the Evaluation and Service Plan dated 04/28/25, revealed Resident#114 was alert and oriented to person, place, time, and situation. The resident was assessed at a low fall risk. The resident required physical assistance with dressing, standby assistance for bathing, and was independent with ambulation, transfers, eating. The resident required safety checks twice per shift.

Review of a progress note dated 07/20/25 at 9:00 A.M. revealed Resident #114 was observed sitting on the floor of her bedroom by the bed. The resident stated she had slid off the recliner in her bedroom onto the floor and could not get herself up. The resident had no complaints of pain, and no injuries were visible at that time. The resident denied hitting her head. The resident was observed walking with her walker in the apartment without difficulty. All responsible parties, including the resident's primary care provider, Nurse Practitioner (NP) #500 were notified.

Review of the facility call light report, dated 07/18/25 through 08/12/25 revealed, on 07/20/25 at 3:08 A.M., Resident #114 activated her call light. The report indicated it took 4 hours and 49 minutes for the call light to be addressed.

Interview on 08/12/25 at 12:40 P.M., Resident #114 affirmed she had recently fallen. Resident #114 stated she was sitting in her chair in her bedroom and fell asleep and fell to the floor. Resident #114 stated she woke up when she fell, at approximately 4:00 A.M., activated her call pendant, and nobody came to help her until 9:00 A.M.

Interview on 08/12/25 at 2:39 P.M., Licensed Practical Nurse (LPN) #300 stated, on 07/20/25 at approximately 9:00 A.M., she entered Resident #114's room to give her medications and Resident #114 was laying on the floor. LPN #300 stated she saw the call light was activated at the time she entered Resident #114's room with the medications.

Interview on 08/13/25 at 9:05 A.M., Executive Director (ED) #360, verified the call light response time for Resident #114 on 07/20/25 was 4 hours and 49 minutes. ED #360 stated the expectation was for call lights to be answered in a timely manner and verified a response time of 4 hours and 49 minutes was not timely.

Interview on 08/13/25 at 9:55 A.M., Caregiver #350 affirmed she worked the night of 07/20/25 and did not receive any alert of Resident #114's call light being activated. Caregiver #350 stated she normally checks her residents at least twice per shift, however stated she did not check on Resident #114 at any point during her shift because she did not know she needed to be checked on.

Interview on 08/13/25 at 1:00 P.M., ED #360 stated, on 07/20/25, Caregiver #355 came on shift and found Resident #114's light was on and went to answer it and found Resident #114 on the floor. ED #360 stated she spoke with Caregiver #350 about the call light and Caregiver #350 stated she did not know the light was going off. ED #360 stated Caregiver #350 told her she was checking the call light system regularly and did not see the alert; however, ED #360 stated she knew that was a lie because Caregiver #355 was able to tell the call light was on when she started her shift that morning.

Interview on 08/13/25 at 1:12 P.M., Caregiver #355 stated, when she came on shift on 07/20/25, she could tell there were at least five call lights on. Caregiver #355 stated she started checking on the residents who had their lights on and got to Resident #114 at approximately 8:00 A.M. and observed her on the floor. Caregiver #355 stated Resident #114 was awake and talking and said she had pressed her call light at approximately 3:00 A.M.

Review of the facility policy titled, Resident Emergency Call System