Beachwood Post-Acute & Rehab

Inspectors wroteBased on interview and record review, the facility failed to ensure that to adhere to professional standards of practice when the facility staff failed to document services provided to one of four sampled residents (Resident 1) in the resident's chart according to the facility's policy and procedures (P&P) titled Charting and Documentation with revision date of 1/2026. This deficient had resulted in a failure to maintain regulatory compliance and had the potential to result in the delay of the appropriate instructions needed from the physician to prevent decline in Resident 1's health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an alternative accessible call light device was provided to one of three sampled residents (Resident 1), who was unable to operate the button-activated call light device provided. Resident 1 had impairment (is any loss or abnormality of anatomical, physiological, or psychological structure or function) on both sides to the upper extremities (shoulder, elbow, wrist, and hand). This failure resulted in Resident 1 making a lot of noise when calling for help, was unable to utilize the facility's call system, increasing the risk to not meet Resident 1's needs not being met, and placing Resident 1 at an increased risk for falls, injuries, hospitalization and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services by failing to setup the mechanical ventilation (a type of therapy that helps you breathe or breathes for you when you can't breathe on your own) including the alarm settings for two out of four sampled residents (Resident 1 and Resident 2) as indicated in the facility's policy and procedure (P&P), titled, Ventilator Alarm Settings. This deficient practice had the potential to cause complications associated with respiratory treatment.

Inspectors wroteBased on observation, interview, and record review, facility failed to: 1. Ensure one of four sampled residents (Resident 1)'s medications were not left at bedside after administering them according to facility's policy and procedures (P&P) titled, Administering Medications. 2. Ensure that one of four sampled residents (Resident 1 and Resident 2)'s medications were administered in accordance with the physician's orders, including any required time frame according to facility's P&P, titled, Administering MedicationsThis deficient practice increased the risk for accidents, unintended complications from receiving more or less than the required medications dose and jeopardized resident's health and safety by failing to administer necessary medications in accordance with the physician order.

Inspectors wroteBased on interview and record review, the facility failed to initiate and review a resident specific discharge planning during admissions and quarterly reviews for one of three sample residents (Resident 3). This deficient practice resulted in a lack of individualized discharge planning to ensure Resident 3 receive appropriate and timely planning during a transition of care.

Inspectors wroteBased on interview and record review, the facility failed to honor one of the three sampled residents (Resident 2) rights by failing to administer her ordered topical medication Triamcinolone Acetonide External Cream 0.1 % (belongs to the class of medications that are synthetic steroids used to reduce inflammation and itching of the skin. It works by reducing swelling, redness, and itching associated with various skin conditions) to her right elbow. This deficient practice resulted in Resident 2 not being able to make her own decisions regarding her own medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to create an individualized care for one of three sampled residents (Resident 3) with specific goals and interventions for Resident 3's right upper arm and right groin rash. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control policies and procedures (P&P) for one out of three residents (Resident 3) by failing to ensure Resident 3 who had a rash and was ordered a scrape test on 7/10/2025 was placed on contact isolation ( a set of precautions used in health care to prevent the spread of infections that are transmitted through direct or indirect contact with a patient or their environment). This deficient practice potentially increased the risk of infection to other residents and facility staff. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a copy of the records upon request for one of four sampled residents (Resident 1). This deficient practice violated the rights of Resident 1's legal representative to obtain a copy of the medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 3 and Resident 4) who are fed by enteral received appropriate treatment and services by failing to elevate the head of the bed while receiving formula through the gastrostomy tube (GT - a tube inserted through the abdomen that delivers nutrition directly to the stomach). This deficient practice had the potential to cause aspiration (inhalation of foreign materials) and can lead to pneumonia (a lung infection) for Resident 3 and Resident 4.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the facility staff did not refer to residents needing assistnace [NAME] feeding as Feeders for seven of seven sampled residents (37, 97, 94, 95, 165, 188, and 454). This deficient had the potential to result in lowered self esteem for the residents needing assistnace with feeding.

Inspectors wroteBased observation, interview, and record review, the facility failed to: 1. Complete annual performances evaluations and annual skills competencies for eight of eight employees. This deficeint practice had the potential to cause harm to the residents. 2. Licensed nurses did not identify discrepancy (difference) between the medication on hand and what the medical doctor (MD) ordered for Resident 9. 3. Three of Three sampled Licensed Vocational Nurses (LVNs- 9, 11, and 13) were not able to correctly identify basic nursing dosage calculation conversions including the conversions from one ounce (oz - standard unit of weight) to milliliters (ml - a unit of volume) and from a tablespoon (tbsp - a common prescription used to dose liquid medications) to milliliters. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of nine sampled residents (Residents 9, 37, and 157) were free from significant medication errors (an error in medication preparation or administration that can cause the resident discomfort or jeopardizes his or her health and safety) according to professional standards of practice by failing to: 1. Ensure Resident 37's Insulin Lispro (man-made version of human insulin used to manage blood sugar levels in people with diabetes [DM: a chronic condition where the body does not produce or use insulin properly, leading to high blood sugar levels]) Injection Solution 100 Unit/mL (milliliters) Inject 18 units subcutaneously (beneath the skin) before meals for DM 2 Rotate site. [...]

Inspectors wroteBased on observation, interview, and record review, the facility facility failed to ensure the kitchen staff stored food in a sanitary manner to prevent growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food), as well as toxins when: 1. a. Food was not appropraitely stored b. Food was not labeled c. Prepared leftover tuna was not stored in the refrigerator d. Dietary staff did not follow cool down method e. Multiple food items were not labeled with expiration dates f. The ice machine and the kitchen stove were dirty with old, dried food, and debris. g. Clean water pitchers for the residents were stored on a cart with dirty dishes stored on the bottom of the cart. h. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment by failing to implement standard precautions (a set of infection control practices used to prevent the transmission of diseases) in the provision of care for two of two sampled residents (Residents 10 and 131). This deficient practice placed residents at a higher risk of acquiring and transmitting infections to other residents, staff and visitors in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the shared shower room on the 5th floor east in a safe and operating condition This deficient practice had the potential to result in resident injury and/or fall due to pieces of broken safety handles on the left side of the shower wall and a loose safety handle on the right side of the shower wall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was answered in a timely manner for three of three residents (Residents 23, 62, and 92) when the residents needed assistance with care including personal hygiene. This failure resulted in the residents becoming very upset, angry, and embarrassed. This deficient practice also had the potential for falls, injuries, and accidents.

Inspectors wroteBased on observation, interview and record review, the facility's staff failed to ensure for One of one sampled resident (Resident 10): 1. Had a physician's order to self-administer a medical nutritional supplement/tube feeding formula via bolus feeding (a method of enteral tube feeding where a large dose of formula is administered into the stomach or small intestine over a short period of time, typically 15-20 minutes, several times a day) 2. Was assessed, educated and determined to have cognitive and physically demonstrated capability to safely self-administer a bolus feeding. These deficient practice had the potential to result in negative outcomes from food inhalation which could lead to adverse reactions, unnecessary hospitalization and possible poor outcomes for Resident 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to provide a Notice of Medicare Non-Coverage (NOMNC, is a document used in Medicare [a Federal health insurance program] to inform beneficiaries when their Medicare-covered services are ending, and to explain their appeal rights) to one of three sampled resident ' s (Resident 254), representative (responsible party). This failure had the potential to result in Resident 254's representative not being able to exercise their right to file an appeal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one out of one sampled resident (Resident 404) was free from physical restraint by failing to ensure that the physicians order for hand mittens indicated a reason for the use of the mittens in accordance with the facility's policy and policy (P&P) titled Physician Orders with a revised date of 1/2025. This deficient practice had the potential to result in unnecessary restraints and placed the residents at risk of physical harm from impeding the circulation of resident 404's arms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow through with the Preadmission Screening and Resident Review (PASARR- a federally required screening to help identify individuals with possible serious mental illnesses requiring a specialized follow up evaluation) recommendation to obtain a PASRR level II (assessment that determines if resident's mental condition could be met in the nursing facility or if the individual requires specialized services) evaluation for one of two sampled residents (Resident 150). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 150.

Inspectors wroteBased on observation, interview, and record review, the facility failed to refer and provide podiatry service to one of two sampled residents (Resident 62). Resident 62 has not seen a podiatrist since the resident's admission on [DATE] (1 year and 4 months ago). This deficient practice placed Resident 62 at risk for pain or discomfort.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled resident's (Resident 162) urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) was securely anchored (secured to the resident) per the resident's per the resident's physician order. This deficient practice had the potential for the resident to endure pain from potential pulling tractions and dislodgement of the catheter that may result in urethral (a muscular structure that helps keep urine in the bladder until voiding can occur) trauma.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of 5 percent (%-unit of measurement) or less with 25 opportunities, for two of two sampled residents (Residents 9 and 157) during the medication administration, when: 1. Licensed nurses did not identify discrepancy (difference) between the medication on hand and what the medical doctor (MD) ordered for Resident 9. 2. Three of three sampled Licensed Vocational Nurses (LVNs- 9, 11, and 13) were not able to correctly identify basic nursing dosage calculation conversions including the conversions from one ounce (oz - standard unit of weight) to milliliters (ml - a unit of volume) and from a tablespoon (tbsp - a common prescription used to dose liquid medications) to milliliters. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure unopened insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) vials requiring refrigeration were stored in a refrigerator according to the manufacturer's requirements in one of five inspected medication carts (3rd Floor East Medication Cart). This deficient practice of failing to store medication per the manufacturer's requirements had the potential to lead the medication to reduced potency, making the medication less effective or even causing adverse reactions.

Inspectors wroteBased on interview and record review, for one of three sampled residents (Resident 1), the facility failed to: 1. Ensure LVN 3 notified a physician and handed over to a licensed nurse that Resident 1 did not pass urine and urine was not collected for urinalysis (UA- is a medical test that analyzes a urine sample. It involves examining the appearance, chemical composition, and microscopic components of the urine to detect potential health issue) on [DATE] from 7 a.m. to 3 p.m. 2. [...]

Inspectors wroteBased on interview and record review, for one of three sampled residents (Resident 1), the facility failed to: 1. Ensure Augmentin (Amoxicillin-Pot Clavulanate - antibiotic - medication to treat infection) tablet 875-125 mg-unit of measurement) was readily available in the Emergency Kit (Ekit - a kit consisting of drugs, including controlled substances, needed to effectively manage a critical care incident or need of a patient). 2. Ensure Resident 1 received Amoxicillin-Pot Clavulanate tablet 875-125 mg 1 tablet by mouth BID (twice a day) for possible urinary tract infection (UTI- an infection in the bladder/urinary tract) for 10 days according to the physician's order dated 4/2/2025 at 11.14 a.m. 3. Ensure a physician was notified that Resident 1 was not administered Amoxicillin-Pot Clavulanate 875-125 mg according to physician's order dated 4/2/2025 at 11.14 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a notice of bed-hold policy and return form when the resident was transferred to General Acute Care Hospital 1 (GACH 1) for one of two sampled residents (Resident 1). This deficient practice had a potential to result in the resident's responsible party being unaware of the bed hold policy and can lead to a transfer of the resident to another skilled nursing facility not of the resident's or responsible party's preference.

Inspectors wroteBased on interview and record review the facility failed to ensure Resident 1 received quality of care and treatment in accordance with facility ' s policy and procedure titled, Acute Changes, to monitor Resident 1 after she had a change of condition (COC) on 2/23/2025. This deficiency had the potential to result in poor quality of care and delayed response to resident needs after a COC.

Inspectors wroteBased on interview and record review for one of three sampled residents, Resident 1. The facility failed to provide and review discharge care instructions with the resident representative (RR) at the time of discharge. This deficient practice caused the RR to be unsure of the follow up instructions for Resident 1 ' s stage II pressure ulcer (Partial-thickness loss of skin, presenting as a shallow open sore or wound) on the sacrum (lower back) after discharge.

Inspectors wroteBased on interview and record reviews, facility failed to ensure one of four sampled residents, (Resident 2) was notified and informed by failing to: 1. Provide monthly statements for costs and charges of the services that facility provided for Resident 2. 2. Provide information how to dispute and/or appeal Resident 2 ' s share of cost as indicated in the facility ' s policy and procedure (P&P) titled, Medi-Cal Share of Cost. These deficient practices violated resident ' s right to be informed of the services that the facility charged and resident ' s wish to appeal. Findings. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of three sampled residents, (Resident 1) was thoroughly assessed and monitored after Resident 1 was found lying on the floor beside the bed and had an alleged fall which resulted in increased pain and bump on the occipital area (refers to the back of the head, specifically the area covered by the occipital bone). 2. Ensure Resident 1 was monitored and staff immediately documented the interventions to prevent falls after Resident 1 was found lying on the floor such as necessary laboratory test and/or radiology test to ensure resident was stable without any delayed complications. These deficient practices had a potential for Resident 1 ' s fall not properly assessed and investigated and placing resident at risk for further falls or accidents.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure resident received appropriate treatment and services to prevent urinary tract infection (UTI- an infection in the bladder/urinary tract) for one of three sampled residents (Resident 2) by failing to change and monitor Resident 2 ' s incontinent brief promptly when soiled. This deficient practice had the potential to result or resulted in urinary tract infections for the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of five sampled residents, (Resident 1) received treatment and care accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs by failing to ensure the physician ' s order was carried out when physician ordered to check Resident 1 ' s vital signs (VS - measurements of the body's basic functions, including breathing, heart rate, blood pressure, and temperature) every shift for the whole month of January, 2025. This deficient practice resulted to failure in the delivery of necessary care and services for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to assure that residents receive care and services for the provision of hemodialysis (HD-filtering the blood of a person whose kidneys are not working normally) consisted with professional standard of practice by failing to ensure ongoing assessment of the resident's condition and monitoring for complications after hemodialysis treatment was received for two of four sampled residents (Resident 1, Resident 2). This deficient practice had the potential to negatively impact the delivery of care and services provided to Resident 1 and Resident 2.

Inspectors wroteBased on interview and record review the facility failed to inform the Resident Representative (RR) of Residents return from the general acute care hospital (GACH) for one of four sampled residents (Resident 1). This deficient practice caused the resident Representative to not be informed of the resident's care.

Inspectors wroteBased on interview, and record review, facility failed to provide one of three residents (Resident 1) supervision, by failing to ensure that Resident 1 who is a high fall risk was not left unattended in the common area near the nursing station. on 12/18/2024 at 3:30 PM. This deficient practice resulted in Resident 1 had an unwitnessed fall from the wheelchair on 12/18/2024 and sustaining a nasal (nose) fracture.

Inspectors wroteBased on interviews and record reviews the facility failed to provide skin and pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) prevention care per the care plan for one out of four sampled residents (Resident 2) by failing to reposition Resident 2 every 2 hours per the resident ' s care plan. This deficiency had the potential to result in Residents 2 ' s left gluteal (buttocks) pressure ulcer/injury stage 2 (Partial-thickness loss of skin, presenting as a shallow open sore or wound) to worsen.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure one of one sampled residents (Resident 2) received appropriate treatment and services for spontaneous peritonitis (a serious infection of the fluid in the abdomen that occurs when the lining of the abdomen, becomes infected without an obvious cause) by failing to clarify the correct use of Ciprofloxacin 250 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount), one tablet orally daily given after hemodialysis on hemodialysis days, for one out of four sampled residents, Resident 3. This deficiency resulted in a medication error and for Resident 3 to receive the Ciprofloxacin for the correct diagnosis.

Inspectors wroteBased on interview and record review the facility failed to implement fall precautions to prevent falls for one of three sampled residents (Resident 1) by failing to: 1. Provide two-person assist when turning and repositioning for Resident 1 who was identified as high risk for fall. 2. Implement the risk for fall care plan for Resident 1 to provide fall mats (a floor pad designed to help prevent injury should a person fall). As a result, on 11/4/2024 at 6:40 a.m., Resident 1 fell from the bed and hit head on the floor when Certified Nursing Assistant (CNA) 1 was providing care to the resident. Resident 1 was transferred to a general acute care hospital (GACH) and diagnosed with a 1 centimeter (cm-unit of measurement) thick right parietal subdural hematoma (SDH-a collection of blood outside of a blood vessel caused by a broken blood vessel between the brain and the skull). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from significant medication errors (causes the resident discomfort or jeopardizes his or her health and safety) according to professional standards of practice by failing to ensure Licensed Vocational Nurse (LVN1) administered Heparin Sodium Injection (medication to thin the blood) 5000 unit/ml (Heparin Sodium) Inject 0.5ml (ml=milliliters) subcutaneously (fatty tissue layer just beneath the skin) two times a day for DVT (Deep Vein Thrombosis-blood clot) prophylaxis (prevention) as per physician ' s order. As a result, on 11/2/2024 LVN 1 gave Resident 1 a double dose of Heparin. This deficient practice placed Resident 1 at risk for bleeding.

Inspectors wroteBased on interview and record review the facility failed to obtain a physician ' s order for a urine culture and sensitivity (C&S=a lab test that checks for bacteria in the urine and which medications will work) prior to obtaining a urine sample with a straight catheter (a thin flexible hollow tube used to drain urine from the bladder) for one of three sampled residents (Resident 1), who was suspected of having a (UTI, an infection in any part of the urinary system including the kidneys [organs in the body that filter waste materials out of the blood and pass them out of the body as urine, regulates blood pressure and the levels of water, salts, and minerals], and ureters [Tube/s that carry urine from the kidneys to the bladder and urethra]). [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of physical abuse to the state survey agency within 2 hours for one of three sampled residents (Resident 1) in accordance with the facility's policy and procedures (P&P) titled, Abuse Investigation and Reporting, revised 1/24. This deficient practice had the potential to result in a delay of an onsite inspection by the California Department of Public Health (CDPH) to ensure Resident 1's allegation was investigated timely. This deficient practice also had the potential to place Resident 1 at further risk for abuse.

Inspectors wroteBased on observation, interview record review, the facility failed to ensure one out of 3 sampled Residents (Resident 1) received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs by: Failing to timely administer bowel medication timely per doctors on order. This failure caused Resident 1 to experience unnecessary pain and placed the Resident 1 at risk for bowel impaction, bowel perforation, unnecessary hospitalization and even death.

Inspectors wroteBased on interview and record review, the facility failed to investigate and report allegations physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one out of three sampled residents (Resident 1) to the Department of Public Health, Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement in accordance with the facility's policy and procedures (P&P) titled Abuse investigation and Reporting revised 1/2024, by failing to report a resident-to-employee altercation to the State Survey Agency (SSA) within 2 hours after the allegation occurred on 7/16/2024. This deficient practice resulted in delayed onsite investigation by the SSA had the potential to place Resident 1 at increased risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Obtain a physician's order for Out on Pass (OOP) for one of three sampled residents (Resident 1). 2. Ensure staff monitored/supervised Resident 1 while the resident was on unauthorized OOP. 3. Ensure Resident 1 signed out and back in on the OOP log. Facility was aware Resident 1 went on unauthorized OOP three times a week. These deficient practices placed Resident 1 at increased risk for falls, injuries, accidents, hospitalizations, and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: A. 1. Ensure the staff did not leave a hot cup of coffee at Resident 108's bedside table. 2. Ensure Certified Nursing Assistant 7 (CNA7) did not prepare hot liquid in an electric water kettle on the resident's bedside table, serve, and leave a cup of hot coffee unattended and within the resident's reach. 3. Ensure a licensed nurse assessed and measured Resident 108's skin immediately after the resident was burnt with the hot coffee. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure missing narcotics (the controlled medications used to treat moderate to severe pain) were documented and reported per the facility's policy. This deficient practice had the potential for medication loss and diversion, placing the resident at risk not receiving pain medication when needed.

Inspectors wroteBased on observation, interview, and record review the facility failed ensure medications were discarded as per facility policy and procedure titled, Discarding and Destroying Medications dated 2001. By failing to: 1. Check the expiration date, remove, and discard from use, one box of BD Vacutainer Safety-Lok Blood Collection Set (tubing and needle used to collect blood specimens). 2. Remove one box of expired Bisacodyl (laxative- medication that prevents/treats constipation) 10 milligrams. These deficient practices had the potential to cause a mechanical failure of the expired blood collection set during an attempt to collect blood from a resident and affect medication efficacy (the power to produce the desired effect) and reduce the therapeutic (intended to treat diseases or disorders) effects of medications administered.

Inspectors wroteREVIEWED Based on oservation, interview, and record review, the facility failed to ensure safe and sanitary food storage, food labeling practices in accordance with professional standards and facility policy to ensure food service safety and ensure routine maintenance of kitchen pipes was performed. These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses and other toxins) and corrosion to the pipes, safety hazards in 211 of 211 medically compromised residents who received food and have food prepared from the kitchen, staff getting injured due to large puddles of water on the floor, and large industrial fan blowing in kitchen while food is being prepared.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents of one of three residents (Resident 143) to a dignified existence and self- determination by failing to properly dispose a soiled wash towel, cleaning and placing resident's toothbrush clean and secure environment after activities of daily living (ADL) care. This deficient practice had the potential to affect Resident 143's sense of self-worth and self-esteem.

Inspectors wroteBased on observation, and interview, the facility failed to ensure a safe, comfortable, sanitary, and clean homelike environment for three of seven residents (Residents 13, 71, and 328) by failing to: 1. Ensure Resident 328's room temperature was maintained between set at 74 or 75 Farenhiet (F- Unit of measurement). This failure resulted in Resident 328's room temperature was 68 degrees F, and the resident complained of feeling very cold and had the potential for the resident to develop hypothermia (a significant and dangerous drop in the body temperature). 2. Multiple dark spots on the floor in Resident 71 room were removed. 3. Soiled wash towel and toothbrush not left on top of a toilet lid in the bathroom for Residents 143 and 278. These dificient practices resulted in an unsanitary and unhomelike environemnt for Residents 71, 143 and 278.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide oral (mouth) care for one of ten residents (Resident 4). This deficient practice resulted in Resident 4 developing a very dry tongue and lips with the potential for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to turn and reposition five of five residents (Residents 30, 99, 103, and 105) every 2 hours as per physician's order and inaccordance with the facility's policy and procedures titled Prevention of Pressure Ulcers, Prevention of Pressure Ulcers/Injuries, and Repositioning. This failure placed Residents 30, 99, 103, and at increased risk to develop new pressure ulcers and or worsening of existing pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, for one of ten residents (Resident 202) the facility failed to: 1. Monitor Resident 202's urine for signs and symptoms (S/S- something an individual experiences.) of urinary tract infection (UTI- an infection involving any part of the urinary system). Resident 202 had an indwelling catheter (a flexible tube to drain urine). 2. Notify a medical doctor (MD) that Resident 202's urine had sediments in the indwelling catheter. These deficient practices had the potential for Resident 202 to develop UTI.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the hourly water flush volume was administrated as ordered through a percutaneous endoscopic gastrostomy (PEG - surgically placed that allows a person to receive nutrition through the stomach) tube while on enteral feeding (delivery of nutrients through a feeding tube directly into the stomach) for one of two sampled residents (Resident 30). This deficient practice had the potential for Resident 30 to experience dehydration and tube blockage when the hourly water flush through the PEG tube ran less than the calculated amount as prescribed.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure one of ten sampled residents (Resident 64) received tracheostomy (trach- a surgically created hole in your windpipe that provides an alternative airway for breathing) care by leaving his trach unsecured and not applying a dressing around the trach. This deficient practice placed Resident 64 at risk increased for the trach to become dislodged (move out of place) and the potential for respiratory distress and death.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 13 sample residents (Resident 9) was free from significant medication errors. By failing to: 1. Obtain and document a physician's order to keep pain relieving medications (1). Salonpas Lidocaine 4% patch (patch used to reduce itching and relieve pain from certain skin conditions), and (2) Diclofenac Sodium topical gel 1% (medication used to relieve pain and reduce inflammation) at bedside. 2. Allow Resident 9's responisble party (RP) to administer Diclofenac Sodium topical gel 1% and a box with 7 Salonpas Lidocaine 4% patches to Resident 9 without supervision or assessment of competency to administer medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights (device with a button or touch pad a resident uses to set off an alarm that flashes/rings to alert the facility staff the resident needs assistance) were within reach for one of seven sampled residents (Resident 165). This deficient practice had the potential to result in a delay in meeting Resident 165's needs for hydration, toileting, and activities of daily living.

Inspectors wroteBased on interview, and record review the facility failed to ensure a licensed administrator was appointed by the governing body to run the facility. This failure had the potential to affect resident care and management of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 1 was free from injury while being repositioned in bed for one of two sampled residents (Resident 1) by failing to: 1. Ensure Certified Nurse Assistant 1 (CNA 1) had a second staff member present to assist with repositioning Resident 1 as per Physical Therapy (is a healthcare profession, as well as the care provided by physical therapists who promote, maintain, or restore health through patient education, physical intervention, disease prevention, and health promotion) Discharge Summary report. 2. Obtain a Physician's Order to use a low air loss mattress (LALM - is a mattress designed to prevent and treat pressure wounds) for Resident 1. 3. Develop and implement a plan of care with appropriate interventions for the LALM for Resident 1. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their policy regarding reporting of an injury of unknown source and to submit a conclusion report of investigation within five days or in accordance with state or federal law for one of three sampled resident (Resident 1). This deficeint practice resulted in a delay of an onsite inspection by the Department to ensure the safety of the residents and had the potential to place residents at further risk for injuries. Cross Reference F610.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy regarding reporting of an injury of unknown source and to submit a conclusion report of investigation within five days or in accordance with state or federal law for one of three sampled resident (Resident 1). This deficeint practice resulted in a delay of an onsite inspection by the Department to ensure the safety of the residents and had the potential to place residents at further risk for injuries. Cross Reference F609.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of three sampled residents (Resident 2) by failing to develop a comprehensive care plan for physician ' s order of Cefazolin (antibiotic medication used to treat infection) medications. This deficient practice had the potential to result negative impact on residents ' health and safety, as well as the quality of care and services received. Cross Reference F760.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bowel and bladder receives appropriate treatment and services to prevent occurrence of urinary tract infection (UTI - an infection that can occur in any area of the urinary tract, including the ureters, bladder, kidneys, or urethra) for one of five sampled residents (Resident 4) by failing to ensure Resident 4 ' s skin remain clean, dry and free of irritation. This deficient practice had the potential to negatively affect the resident's physical comfort and psychosocial well-being and had the potential for formation of pressure sores (injury to skin and underlying tissue resulting from prolonged pressure on the skin) to the resident.

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure one of three sampled residents (Resident 2) was free from significant medication error by failing to ensure the Cefazolin (antibiotic medication used to treat infection) medications were given on time as ordered by the physician. This deficient practice has the potential to result in Resident 2 in unintended complications related to the management of infection. Cross Reference: F656.

Inspectors wroteBased on interview, and record review the facility failed to implement measures to prevent falls and injuries for one of three sampled residents (Resident 1). For Resident 1, who was confused, was a high fall risk, and attempted to get up without assistance, the facility failed to prevent repeated falls by not: 1. Supervising and monitoring Resident 1. 2. Identify interventions related to Resident 1's specific risks and contributing factors to prevent repeated falls and minimize complications from falling. 3. Ensure Resident 1's care plan interventions were effective and appropriate to the resident's safety needs. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt attempt was made to resolve grievances for one of two sampled resident (Resident 1). This deficient practice violated Resident 1's responsible party (R1 RP ' s) right to have grievance addressed.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary treatment and service to one of three sampled residents (Resident 1) consistent with the resident ' s needs and professional standard of care by failing to ensure Resident 1 ' s low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) was in appropriate setting per facility's policy. This deficient practice can place Resident 1 at risk of poor wound healing of the current pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) and possibly development of a new pressure injury.

Inspectors wroteBased on interview and record review, the facility failed to implement their protocol for Antibiotic (medication that fight bacterial infection) Stewardship by ensuring a process on tracking/monitoring, reporting, and documenting antibiotic use for two of four sampled residents (Residents 1 and 6). This deficient practice had the potential for Resident 1 and 6 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Certified Nursing Assistant 2 (CNA2) was not standing while feeding one of four sampled residents (Resident 5). This deficient practice violated the right to be treated with dignity and respect for Resident 5.

Inspectors wroteBased on interview and record review, the facility failed to provide professional standards of care and practice to one of eight sampled residents (Resident 2) by failing to ensure proper documentation of refusals of showers, appropriate education and care planning was provided to Resident 2. This deficient practice had the potential to negatively impact the delivery of care service provided to Resident 2.

Inspectors wroteBased on interview, and record review, the facility failed to maintain complete and accurate medical record in accordance with accepted professional standards and practices for one of eight sampled residents (Resident 5) by failing to ensure proper documentation of activities of daily living (ADLs) for Resident 5. This deficient practice had the potential for a delay in communication between facility staff which can negatively impact the delivery of service given to Resident 5.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure an interdisciplinary team (IDT-a coordinated group of experts from several healthcare fields that actively coordinate treatment goals for the patient) meeting was done in coordination with two of four sampled residents (Resident 1 and Resident 2 ' s) family or representative per facility policy. 2. Ensure revision of comprehensive care plan for one of four sampled residents (Resident 1) when Resident 1 had multiple episodes of fall. These deficient practices had the potential for Resident 1 and Resident 2 ' s not receiving appropriate care treatment and/or services by the facility.

Inspectors wroteBased on interview and record review, the facility failed to monitor and supervise one of four sampled residents (Resident 1) by failing to ensure Resident 1 did not have any further episodes of falling. Resident 1 had episodes of falling on 10/21/2023, 12/27/2023 and 12/31/2023. This deficient practice had a potential for further episodes of Resident 1 ' s falling and possibly life-threatening conditions such as major injuries and even death.

Inspectors wroteBased on interview and record review, the facility failed to ensure to develop a baseline care plan addressing one of four sampled residents (Resident 2) by failing to ensure care plan for refusals of care was completed for Resident 2. This deficient practice had the potential to negatively affect the provision of care and services provided to Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to implement, a comprehensive person-centered care plan for one of four sampled residents (Resident 2) when Resident 2 ' s left arm was not properly elevated per plan of care. This deficient practice had the potential to negatively affect the provision of care and services provided to Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was informed of/or offered an advance directive (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated [describes a state where a patient is unable to participate in a meaningful way in medical decisions]). This deficient practice violated resident ' s and/or the representative's right to be fully informed of the option to formulate advanced directives and had the potential to cause conflict with health care wishes for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of care and practice for one of three sampled residents (Resident 1) by failing to ensure vital signs were checked and documented at least once every shift and as needed for any change in condition (COC- a change in resident ' s condition nursing documentation). This deficient practice had the potential to negatively impact the delivery of care service provided to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standard of care and practice for one of three sampled residents (Resident 1) by failing to ensure facility did not provide emergency basic life support such as CPR (cardiopulmonary resuscitation-refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased) to Resident 1 who had a physician order of Do Not Resuscitate (DNR-refers to a medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer CPR in the event of cardiac or respiratory arrest). This deficient practice had the potential to negatively impact the delivery of care service provided to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR) for one of five sampled residents (Resident 1). This deficient practice had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug).

Inspectors wroteBased on interview and record review, the facility failed to implement their policy regarding reporting of residents' allegation of abuse and to submit a conclusion report of investigation within five days or in accordance with state or federal law for one of five sampled residents, Resident 2. This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further abuse for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prevention policy by failing to report an allegation of abuse within 2 hours or in accordance with state or federal law for one of five sampled residents (Resident 2). This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further abuse for Resident 2. Cross Reference F609.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of quality of care for one out of five sampled residents, Resident 1 by failing to ensure medications were given on time as ordered by the physician. These deficient practices jeopardized Resident 1,'s health and safety by failing to administer necessary medications in accordance with the physician order.

Inspectors wroteBased on observation, interview and record review, the facility failed to effectively manage a resident's pain by not following physician's medication order for one of five sampled residents (Resident 1). This deficient practice resulted in Resident 1 experienced unnecessary pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control measure and prevention by failing to: A. Ensure the staff wear full personal protective equipment (PPE-mask, gown, eye protection, gloves) before entering one of one sampled resident, Resident 3 ' s room who tested positive for COVID-19 [a deadly respiratory disease transmitted from person to person] infection) per facility policy. B. Ensure that a current physician order for transmission-based precaution for Resident 3 was in placed. These deficient practices had the potential to result in the spread of disease and infection to residents and staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement it's policy titled Laryngectomy [a surgery to remove part or all your larynx [voice box] done to treat laryngeal cancer or severe larynx damage] Site Care, by failing to ensure that one of three sampled resident's stoma was not noted with thick greenish mucous when Resident 1's Familiy Member (FM 1) visited him. This deficiency practice resulted in Resident 1 contracting pneumonia (Infection that inflames air sacs in one or both lungs, which may fill with fluid)

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pertinent intervention to prevent fall for one of three sampled residents (Resident 1) who was identified as a high fall risk by failing to ensure there was no clutter in Resident 1's room. As a result, Resident 1 had a fall on 11/6/2023 and suffered a 1-inch laceration (a deep cut or tear in skin or flesh) above the left eye and was sent to General Acute Care Hospital (GACH) where she received sutures (also known as stitches, are sterile surgical threads used to repair cuts) to the injury.

Inspectors wroteBased on observation, interview and record review the facility failed to follow the physician order and its policy on Enteral Tube Feeding via Continuous Pump (Enteral Tube is also known as gastric tube or g-tube - a flexible plastic tube placed into the stomach to deliver nutrition to those that cannot obtain nutrition though the mouth or cannot swallow safely) for two of four sampled residents (Resident 3 and Resident 6) by failing to ensure: 1. Resident 3's feeding pump (machine used to deliver g-tube feeding formula) was set to the rate ordered by Resident 3's physician. 2. Resident 3 ' s g-tube feeding formula packaging was filled out with the time the feeding was prepared and the rate the feeding was infusing. 3. Resident 6 had the correct g-tube feeding formula and water volume infusing as ordered by Resident 6's physician. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one of three sampled residents (Resident 8), who was admitted to the facility with pressure ulcer / injury (also called bedsores or pressure sores, are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin; usually affect people confined to bed or who sit in a chair or wheelchair for long periods of time) was provided a Low Air Loss Mattress (LALM, an air mattress designed to relieve pressure) as ordered by the physician. This deficient practice placed Resident 8 at risk for poor wound healing and deterioration of his current wounds.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure standard infection control practices (Standard Precautions) were followed for one of three sampled residents (Resident 8) by failing to ensure Licensed Vocational Nurse 5 performed hand hygiene and changed gloves during wound care treatment. This deficient practice placed Resident 8 at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered plan of care with measurable goals and individualized interventions for one of four sampled residents, Resident 1 who was refusing his medications. This deficient practice had the potential to result in a delay in delivery of care and services.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that pain management was provided consistent with professional standards of practice to one of eight sampled residents (Resident 3). The facility failed to provide pain medication as ordered by the physician (MD) when Resident 3 complained of 7/10 pain on the pain scale (Pain Scale -0=no pain, 1-3=mild pain, 4-6=moderate pain, 7-9=severe pain, 10=worst pain). This deficient practice had the potential to negatively affect Resident 3 ' s physical comfort and psychosocial well-being and had the potential to increase the pain level and result in an unmanageable pain level.

Inspectors wrote5. A review of Resident 30's Face Sheet, indicated the facility admitted Resident 30 on 10/16/2020, with diagnoses that included chronic respiratory failure, candidiasis, chronic kidney disease (kidneys are damaged and can't filter blood the way they should), and anxiety disorder (symptoms of intense anxiety or panic that are directly caused by a physical health problem). A review of Resident 30's MDS, dated [DATE], indicated Resident 30 was dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. 7. A review of Resident 54's Face Sheet indicated the facility admitted Resident 54 on 8/4/2019, with diagnoses that included DM, essential hypertension (high blood pressure) and anemia. A review of Resident 54's MDS, dated [DATE], indicated Resident 54 had intact cognition. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure four of four sampled residents (Resident 1, 93, 509 and 511) received care and services when providing parenteral fluids consistent with professional standards of practice by failing to 1. Ensure intravenous (IV - canula being placed inside a vein) site was being monitored for any signs and symptoms of infection for Resident 93, 509 and 511. 2. Ensure IV dressing was changed, with labels and date per facility policy for Resident 1 and 509. 3. Ensure IV site for Resident 1 was removed when IV therapy was discontinued and documented upon removal per facility policy. These deficient practices had the potential to result in Resident 1, 93, 509 and 511's IV sites to develop complication such as infection.

Inspectors wrote2. During an observation on 04/26/2022 at 2:51 p.m., a medication cart in the fourth floor common hallway was observed unlocked. There were staff and residents near the medication cart. During an interview on 04/26/2022 at 2:51 p.m., LVN 11 stated the medication cart was unlocked, and it should be locked. LVN 11 also stated anyone can access the medication cart when the cart is not locked. A review of the facility's P&P titled, Storage of Medications, revised November 2020, indicted, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked compartments . 3. During a concurrent observation and interview with LVN 9 on 4/27/2022 at 3:13 p.m., an opened foil pouch of Xopenex, dated 4/7/2022 was observed in the drawer of the medication cart. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services when: 1) Dietary Aide 2 (DA 2) did not know the required sanitizing contact time (how long a disinfectant needs to stay wet on a surface in order to be effective) while manually washing dishes; and 2) Dietary Aide 3 (DA 3) who oversaw food delivery and labeling did not know when to discard supplement shakes. This failure had the potential to result in unsafe and unsanitary food preparation and production, and a potential for food-borne illness affecting the residents who consumed the food prepared by the facility kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow portion size as written on the menu for residents on pureed diet when 23 residents on pureed diet received inaccurate portion for their food. This deficient practice had the potential for the residents to receive wrong protein and caloric intake, which could result in undernutrition or overnutrition and compromise their health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1) Multiple condiments and a juice box were not labeled properly; 2) Multiple resident foods were not kept per the facility's policy; 3) The concentrations of sanitizing chemical in two sanitizer buckets were measured below 100 parts per million (ppm - Usually describes the concentration of something in water or soil); 4) Interior surfaces of the popcorn machine placed in the dry food storage were rusty; and 5) Multiple environmental defects were observed in Kitchen. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure overripe onions were disposed of in a timely manner to prevent fruit flies. This deficient practice had the potential to result in food-borne illness (any illness resulting from the spoilage of contaminated food, bacteria-germs, viruses, or parasites that contaminate food, as well as toxins [poisons]) and pest entrance or harborage in the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its' Psychotropic Medication Management policy and procedures to ensure the residents and/or responsible party (RP) were informed in advance, of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior) for two of two sampled resident (Residents 192 and 509). This deficient practice violated the residents' right to make informed decision regarding the use of psychoactive medications for Residesst 192 and 509.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its' Activities of Daily Living (ADLs), Supporting policy and procedures (P&P) to ensure the breakfast tray remained inside the food cart and not left at the bedside table for one of one sampled resident (Resident 112). Resident 112 required extensive staff assist with eating food. This deficient practice resulted in Resident 112 waiting for 31 minutes to eat breakfast and had potential for the breakfast to get cold and decrease the resident's appetite and or food intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents identifiable information on discarded tube feeding (TF-the means of providing nutrition via a feeding tube inserted into the gastrointestinal tract) was appropriately destroyed according to facility's Resident Rights policy and procedures (P&P) for one of one sampled resident (Resident 192). This deficient practice violated the resident's right for privacy and had the potential to release/disclose Resident 192's personal information to unauthorized person(s).

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a resident centered comprehensive care plans (documents a resident's needs and interventions to meet those needs) for three of three residents (Residents 72, 93, and 109) by failing to develop and implement: 1) Non-compliance care plan for refusing (RNA- rehabilitation care to help people regain or improve their physical, mental, and emotional health) Restorative Nursing Assistant services for 23 days for Resident 93. 2) Non-compliance care plan for refusing to wear identification wrist band for Resident 72 and Resident 109. These deficient practices had the potential to result in inability to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, facility failed to meet professional standards of quality by not obtaining a physician's order regarding inserting a peripheral intravenous (IV-a small, flexible tube placed into a small vein for intravenous therapy such as medication fluids) on the lower extremities (legs) for one of three sampled residents, Resident 62. This deficient practice has the potential to result in Resident 62's IV site to develop complication such as infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident 93 received oral care. This deficient practice could place the resident at risk for discomfort and possible infection due to lack of oral hygiene care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an environment free of accidents and hazards for one of five sampled residents (Resident 37). This deficient practice had the potential to result in an accident or injury to Resident 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 62), who are fed by enteral means received appropriate treatment and services by ensuring the gastrostomy tube (GT - a tube inserted through the abdomen that delivers nutrition directly to the stomach) was kept clean and dry. This deficient practice has the potential to result in Resident 62's' enteral nutrition therapy to develop an infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper disposition of returning and/or destroying unused medications. This deficient practice had the potential to result in medication error when the discontinued medication was not returned or destroyed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures by failing to: 1. Ensure Certified Nursing Assistant (CNA 4) was using proper Personal Protective Equipment (PPE-such as gloves, gowns, masks and eye protections) while providing care to Resident 35. 2. Cleaning and sanitizing a common resident shower room between resident showers. These deficient practices had the potential to result in the spread of diseases and infection to residents, staffs, and visitors.