Chino Valley Health Care Cente

Inspectors wroteBased on interview and record review the facility failed to ensure an adequate number of Licensed Nurses worked in the facility on the NOC shift (overnight shift from 11:00 pm to 7:00 am) on 6/12/2026, in accordance with the facility's Facility Assessment Tool (FAT, facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies). This failure had the potential to result in residents receiving inadequate care and supervision which could have led to falls, elopement, and delayed recognition of residents (in general) significant changes in condition. During a review of the facility's census dated 6/12/2026, the census indicated the facility had a North and South station, with a total of 97 residents in-house (in the facility). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility was free of five percent or greater medication error rate. The facility had three total medication errors in 33 opportunities for errors yielding a total of 9.09 percent error rate during medication pass (process through which medication is administered [the act of giving a treatment, such as a drug, to a patient]) for one of five sampled residents (Resident 43) when: 1. Licensed Vocational Nurse (LVN) 3 did not administer a delayed release (a drug that does not dissolve or release its active ingredient right away when swallowed) aspirin (ASA, a medication used to treat mild to moderate pain) to Resident 43.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in one of one kitchen (Kitchen 1) when the following was observed: On 6/9/2026, an open container, filled with a white flaky powder substance, was unlabeled and undated in Kitchen 1's cooking area. On 6/9/2026, [NAME] (CK) 1 was not wearing a beard cover while preparing food in Kitchen 1. On 6/11/2026, one of two sampled sanitizing solution buckets (Solution Bucket, SB 1) did not have the correct concentration required to effectively kill bacteria (microscopic single-celled organisms some can make people sick) and organisms from kitchen surfaces in accordance with the facility's policy and procedure (P&P) titled, Sanitizing Equipment and Surfaces. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection (the invasion and growth of germs in the body) prevention and control practices by failing to ensure:a. Personal care items found inside the shared restrooms for five of five sampled residents (Residents 37, 2, 107, 48, and 75) were labeled and stored properly.b. The lint screen/trap and base (bottom) for three of three sampled commercial laundry dryers (CLD 1, CLD 2, CLD 3) were free of dense accumulation of lint (a thick, cottony pad [about the thickness of a felt sheet or small quilt] that completely hides the screen).c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 77), was free from abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) when Resident 86, who had a history of sexual inappropriate behavior, touched Resident 77 on the left breast on 5/30/2026. This deficient practice resulted in Resident 77 getting startled, upset, and screaming for help and had the potential to result in psychosocial (relates to how a person's mental health and social environment [relationships, community] affect each other) harm to Resident 77.

Inspectors wroteBased on interview and record review, the facility failed to complete and transmit the Minimum Data Set (MDS, a resident assessment tool) discharge assessment in a timely manner for one of two sampled residents (Resident 14) as indicated in the Centers for Medicare and Medicaid Service's (CMS, a federal agency that manages health care programs in the United States) Resident Assessment Instrument (RAI, a tool used by nursing homes to assess the needs, strengths, and preferences of residents, mandated by CMS) Manual. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) accurately reflected the resident's condition for two (2) of 2 sampled residents (Resident 12 and Resident 79) by:Coding Resident 12 as receiving limb restraints when the resident was not using limb restraints. Coding Resident 79 as not having a serious mental illness when the resident had diagnosis of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar type (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan for one of seven sampled residents (Resident 106) within 48 hours of the resident's admission. This deficient practice had the potential for Resident 106 not receiving necessary care and services. During a review of Resident 106's Face Sheet (FS), the FS indicated Resident 106 was admitted to the facility on [DATE] with diagnoses which included unsteadiness on feet and tobacco use. The FS indicated Resident 106 did not have any other diagnosis. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate interventions to prevent the development or worsening of existing pressure injuries (PI, lesion/wound caused by unrelieved pressure usually over a bony area that results in damage of underlying tissue) for one of two sampled residents (Resident 2) when Resident 2's, who had a PI, low air loss mattress (LALM, special type of mattress used for both the prevention and treatment of PI, prioritizes moisture control and temperature regulation to prevent skin breakdown) was not set to the correct setting. This failure had the potential to result in delayed wound healing, worsening of Resident 2's PI, and the development of new PI's or skin breakdown to Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four residents' (Resident 4) environment remained as free of accident (any unexpected or unintentional incident, which results or may result in injury or illness to a resident) hazards as possible when Resident 4 was observed biting and chewing on a towel. This deficient practice had the potential to cause teeth or gum damage, jaw strain and/or choking to Resident 4 risking Resident 4's overall physical health.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for one of seven sampled residents (Resident 106) when Resident 106's Face Sheet (FS-admission record) did not indicate a complete cumulative diagnosis list (a complete list of a resident's active medical diagnoses). This deficient practice resulted in incomplete documentation for Resident 106 and had the potential to result in Resident 106's medical needs not being addressed.

Inspectors wroteBased on interview and record review, the facility failed to report for one of five sampled residents (Resident 3) to the California Department of Public Health (the Department), to the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and to the local law enforcement a resident-to-resident altercation within two hours in accordance with the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation, dated September 2022. This failure resulted in the delay of notification to the Department and had the potential for Resident 3 to be subjected to abuse while at the facility. A. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (1) of three (3) sampled residents (Resident 11) who was re-admitted to the facility after a surgical procedure had a skin assessment. This failure had the potential for Resident 11 receiving delayed care and treatment for Resident 11's surgical wounds which could lead to infection. During a review of Resident 11's Face Sheet (FS, document that contains a patient's personal and contact information, diagnoses, and medical history), the FS indicated Resident 11 was re-admitted to the facility on [DATE] with diagnoses that included lack of coordination and displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing (patient had surgery on the left thigh bone and is now in the healing phase). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its abuse prevention policy by failing to report one allegation of injury of unknown origin to the state agency (Department of Public Health) and law enforcement within the required reporting time frames for one of five sampled residents (Resident 2). This deficient practice delayed the investigation of abuse and placed Resident 2, and other residents at risk for abuse and feelings of intimidation.

Inspectors wroteBased on observation, interview and record review, the facility staff member failed to notify the responsible party when 1 of 3 sample residents (Resident 1) moved to another room. This failure resulted in lack of timely communication with Resident 1's responsible party regarding changes in Resident 1's Room/environment. During a review of Resident 1's admission Record (AR-Face Sheet), the AR indicated the facility admitted Resident 1 on 2/5/2026, with diagnoses including dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury), and Alzheimer's disease (progressive mental deterioration). During a review of Resident 1's History and Physical (H&P), dated 2/7/2026 the H&P indicated, Resident 1 does not have the mental capacity to make medical decisions. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision for 1 of 3 sampled residents (Resident 1) who required supervision during showers. This failure resulted in Resident 1 being found in the shower area without staff supervision, placing the resident at risk for injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan (individualized document developed to manage a patient's physical, mental, emotional, and social health needs) with interventions (action taken to improve a situation) for three of eight sampled residents (Residents 3, 6 and 7).

Inspectors wroteBased on interview and record review the facility failed to ensure an adequate amount of Certified Nursing Assistants (CNAs) worked in the South Dementia unit (unit designed to meet the specific needs of residents with dementia [a progressive state of decline in mental abilities]) on the NOC shift (overnight shift from 11 pm to 7 am) on 3/8/2026, 3/11/2026 and 3/21/2026, in accordance with the facility's Facility Assessment Tool (FAT - facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies), dated 3/19/2026. This failure had the potential to result in residents receiving inadequate care and supervision which can lead to falls, elopement, and delayed recognition of residents' significant changes in condition.

Inspectors wroteBased on interview and record review the facility failed to complete an SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form for two of eight sampled residents (Resident 3 and Resident 7) in accordance with the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status when:1. There was no SBAR found in Resident 3's medical record regarding Resident 3's skin rash (abnormal changes in skin color or texture and are typically associated with irritation or swelling) on both hands. 2. There was no SBAR found in Resident 7's medical record regarding Resident 7's generalized body rash. These deficient practices placed Resident 3 and Resident 7 at risk of not receiving appropriate care.

Inspectors wroteBased on observation and interview, the facility failed to provide an accessible call light system as indicated in the facility's policy and procedure titled, Call System, Residents, by failing to ensure the call light pull cords were within reach from the floor for ten of 10 sampled residents (Residents 4, 15, 16, 20, 21, 22, 23, 24, 25, and 26) when using Bathroom [ROOM NUMBER] and Bathroom [ROOM NUMBER]. This deficient practice had the potential to delay the provision of care for Residents 4, 15, 16, 20, 21, 22, 23, 24, 25, and 26 and negatively affect the residents' well-being when the residents were unable to call staff for assistance.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse for one of four sampled residents (Resident 15) to the California Department of Public Health (the Department), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and to the local law enforcement within two hours, in accordance with the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 9/2022. This failure resulted in the delay of notification to the Department and had the potential to result in Resident 15 to be subjected to abuse while at the facility.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe and sanitary shower for 1 out of 1 shower room in the facility where a black substance was observed on the tile under the shower handle. This deficient practice had the potential for all residents who used the shower to be placed at risk for respiratory health hazards.

Inspectors wroteBased on observation, interview, and record, the facility failed to maintain safe food handling practices according to the facility's policies and procedures (P&P) titled, Daily Food Temperature Control, and Refrigerator/Freezer Storage, by failing to:1. Ensure the temperatures of freezer 1, freezer 2, refrigerator (fridge) 1, and fridge 2 were checked and logged from 9/3/2025 to 9/18/2025.2. Ensure the temperatures of freezer 2 that stored ice cream, remained below zero (0) degrees Fahrenheit (F- unit of temperature measurement) and fridge 1 that stored milk and dairy products, remained below 40 degrees F.3. Ensure the temperature of the milk in fridge 1 remained below 40 degrees F.4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide privacy during provision of perineal care (cleaning and maintaining the area between the anus and the genitals) and changing of incontinence briefs (disposable diaper) for two of two sampled residents (Resident 1 and Resident 3). This failure had the potential to result in Resident 1 and Resident 3 feeling embarrassed and having loss of self-esteem.a. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/12/2025 with diagnoses which included hypertension (high blood pressure), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure infection control practices were implemented when one of one Certified Nurse Assistant (CNA 1) did not wash or sanitize hands after exiting Resident 1's shower room and before touching Resident 2. This deficient practice had the potential to result in cross contamination (transfer of germs and harmful substance) and spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to identify a skin rash (an area of irritated or swollen skin that can be red, itchy, painful, or bumpy) for one of one sampled resident (Resident 1) when Licensed Vocational Nurse (LVN) 1 discharged Resident 1 without doing a skin check (a visual examination of the skin surface) on 5/29/2025. This failure resulted in delayed treatment for Resident 1's skin rash and had the potential to result in physical decline to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 1) who had an order of X-ray (an imaging test to create detailed pictures of the organs) of the left hand was implemented in a timely manner, as ordered. This failure had the potential for Resident 1 not to receive necessary care and services to immediately meet the resident's medical needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 3), who was cognitively impaired (refers to difficulties with thinking, learning, remembering, and using judgment, among other mental abilities) and was assessed at risk for elopement (the act of leaving a facility unsupervised and without prior authorization) did not elope from the facility's secured unit (specialized healthcare setting that restricts patient/resident movement and access to promote safety with measures such as locked doors and surveillance) on 4/24/2025, at 7: 06 PM by failing to ensure: 1. Certified Nursing Assistant (CNA) 6 closed/locked the door when CNA 6 exited the facility's secured unit and ascertained (make sure of) Resident 3 did not follow CNA 6 out of the secured unit. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy during assistance with personal care and during treatment procedures for two of two sampled residents (Resident 45 and Resident 202). This deficient practice had the potential to affect Resident 45 and Resident 202's feelings of self-worth and self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure Certified Nurse Assistants (CNAs) 8 and 9 know how to recognize verbal abuse and implement the facility's policy on abuse for two of two residents (Residents 23 and 47) on 4/29/2025. These deficient practices had the potential to expose other residents in the facility to abuse and cause distress, fear and nervousness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items in one of one kitchen were stored and distributed in a sanitary manner by failing to: a. Ensure expired dry food items were not kept in storage in one of one kitchen (Kitchen 1). b. Ensure proper ice handling practices by one of one kitchen staff (Dietary Aide 1) during lunch tray line. These deficient practices had the potential to expose 97 of 97 residents to food borne illness (any illness resulting from eating/drinking contaminated foods) and could negatively affect the health of the residents at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure gnats (a group of tiny, winged flies) were not found inside the kitchen area. This deficient practice had the potential for gnats to multiply and fly to other areas of the facility or contaminate food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 47) was free from verbal abuse as indicated by the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program. This deficient practice resulted in verbal abuse to Resident 47 and had the potential to lead to psychosocial harm to Resident 47.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report verbal abuse within two hours that involved one of one sampled resident (Resident 47) as indicated in the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating. This deficient practice prevented timely investigation and implementation of appropriate measures, which could potentially allowed continued abuse to Resident 47.

Inspectors wroteBased on interview and record review, the facility failed to enter a diagnosis of schizophrenia (a serious mental health condition that affects how people think, feel, and behave, characterized by prominent delusions [a belief or altered reality that is persistently held despite evidence or agreement to the contrary], and hallucinations [false perception of objects or events involving the senses]) in the the Minimum Data Set (MDS - a standardized assessment and screening tool) for one of one sampled residents (Resident 15). This deficient practice resulted in Resident 15's MDS not accurately reflecting Resident 15's clinical status, and had the potential to impact care planning, quality measures, and resource allocation for Resident 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the plan of care to prevent aspiration (when something swallowed enters the airway or lungs) and/or choking (blockage of the upper airway by food or other objects) for one of one sampled resident (Resident 32) who was assessed as being at risk for aspiration and choking. This deficient practice had the potential to result in aspiration and/or choking for Resident 32.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 24) who spoke primarily Mandarin had a communication board at bedside. This failure had the potential to result in Resident 24 having unmet needs and emotional distress.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain its infection prevention and control program, for one of two sampled residents (Resident 2), as indicated by the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precautions The facility failed to wear appropriate personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) while providing care and having direct physical contact with Resident 2 who was under Enhanced Barrier Precautions (EBP, an approach that entails the use of PPE to reduce transmission of multidrug-resistant organism [MDRO, bacteria that are resistant to three or more classes of antimicrobial drugs]). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 27 out of 37 resident rooms (Rooms 102, 103, 104, 105, 106, 107, 108, 109, 111, 116, 117, 118, 119, 120, 121, 122, 123, 124, 125, 126, 127, 128, 129, 130, 131, 132 and 133) met the minimum requirement of 80 square feet (sq. ft. - unit of measure) per resident in rooms with more than one resident. Seven rooms had two residents per room and twenty rooms had three beds per room. These deficient practices had the potential to result in the rooms were not having enough space for nursing staff to provide resident hygiene care, or the ability to permit the use of resident care devices.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse for one of three sampled residents (Resident 1) to the California Department of Public Health (the Department), the Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement, within two hours, in accordance with the facility's policy and procedure (P&P), titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised March 2023. This failure resulted in a delay in notification to the Department and had the potential to result in Resident 1 to be subjected to abuse while at the facility.

Inspectors wroteBased on interview and record review, the facility failed ensure two of 13 sampled staff understood the facility's Policies and Procedures (P&P) regarding abuse reporting by failing to: 1. Ensure Certified Nursing Assistant (CNA) 1 knew who the facility's Abuse Coordinator (a designated staff member for overseeing and coordinating the facility's efforts to prevent resident abuse) was. 2. Ensure Registered Nurse (RN) 1 knew which agencies needed to be notified about allegations of resident abuse. RN 1 did not know that all allegations of abuse must be reported to the California Department of Public Health (the Department), the Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement within two hours. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, License, Certification, and Registration of Personnel, and job description (JD) titled, Director of Staffing Development (DSD- a licensed Registered Nurse [RN] or Licensed Vocational Nurse [LVN- a nurse who provides direct nursing care for people who are sick, injured, convalescent, or disabled] who is approved by the Department), for one of 15 sampled staff (previous DSD/office assistant [OA]) by failing to: Ensure that the OA did not work without a license to practice nursing from [DATE] to [DATE] while providing care to nine of nine sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9) and working under the title DSD. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents (Residents 33 and Resident 57) and/or their representatives were provided information regarding the right to formulate an advance directive (AD, legal documents that provided instructions for medical care and only went into effect if a person cannot communicate his/her own wishes). This failure had the potential to result in Resident 33 and Resident 57 and/or their representative to receive unwanted care and treatment and/or unnecessary life-sustaining treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a standardized assessment and care-screening tool) was accurate for two of three sampled residents (Residents 7 and 8) a. Resident 7's MDS did not indicate Resident 7 had the active diagnosis of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). b. Resident 8's MDS did not indicate Resident 8 had active diagnoses of Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and bipolar disorder (a mental illness that causes unusual shifts in a person's mood). These failures had the potential for Residents 7 and 8 not to receive appropriate treatment and/or services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor for side effects of psychotropic medications (medications that affects brain activities associated with mental processes and behavior) for one of five sampled residents (Resident 64) according to the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated July 2022. This failure had the potential for Resident 64 to experience a decline in health and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow safe and proper food storage practices, in one of one kitchen (Kitchen 1), in accordance with professional standards for food service safety and the facility's policy and procedure (P&P) by failing to label/date food items in the kitchen. This deficient practice could result in serious complications from food borne illness (illness caused by the ingestion of contaminated food or beverage) and/or affect the quality and palatability of food to the residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement the facility's policy and procedures (P&P), for food items in one of one refrigerator (Refrigerator 1), that indicated labeling food brought into the facility by family and visitors for residents, with the resident's name, the item, and the use by date when, 1. Staff did not know when to discard food brought in by family and other visitors. 2. Staff did not know who was responsible for checking Refrigerator 1 located in the South Station and determine when foods were to be discarded. These failures had the potential for residents to eat spoiled foods and develop foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of one sampled resident (Resident 59) was treated with dignity by failing to provide privacy while accessing Resident 59's gastrostomy tube (G-tube, a tube inserted through the belly to bring nutrition and/or medications directly to the stomach) during medication administration. This deficient practice resulted in Resident 59's legs and diaper (adult brief) getting exposed and could have resulted in Resident 59 to feel humiliated, embarrassed, and ashamed.

Inspectors wroteBased on interview and record review, the facility failed to revise the care plans for one of one sampled resident (Resident 19). The facility failed to revise Resident 19's care plans for falls regarding the use of bilateral (left and right) floor mats. This deficient practice had the potential for the Resident 19 to not receive proper and consistent care.

Inspectors wroteBased on interview and record review the facility failed to ensure 1 of 3 sampled discharged (when a resident no longer needs to receive services and is sent home or moved to another facility or location) residents (Resident 102) and Resident 102's family were involved in developing Resident 102's post-discharge plan prior to Resident 102's discharge on [DATE]. This failure had the potential for Resident 102 and Resident 102's family to not have the chance to ask questions regarding Resident 102's placement and post-discharge care which could result in a difficult transition to the post-discharge setting.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one staff (Registered Nurse 2, [RN 2]) had specific competencies (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) to communicate with Resident 33, who spoke and communicated in Arabic This deficient practice resulted in RN 2 could not understand Resident 33's needs and had the potential to result in a decline in Resident 33's quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of four sampled residents (Resident 55) observed during medication pass (term used to describe the process through which medication is administered [given] to patients) was free of significant medication errors by failing to ensure Resident 55's routinely scheduled medication, Tramadol (a strong opiod [class of drug used to reduce pain] medication used to treat moderate to severe pain that is not being relieved by other types of pain medicines) was administered. This failure had the potential to cause a decline in Resident 55's physiological well-being related to poor management of Resident 55's pain and the potential for Resident 55 to experience withdrawal (physical and mental symptoms that occur after stopping or reducing intake of a drug) symptoms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 27 out of 37 resident rooms (Rooms 102, 103, 104, 105, 106, 107, 108, 109, 111, 116, 117, 118, 119, 120, 121, 122, 123, 124, 125, 126, 127, 128, 129, 130, 131, 132 and 133) met the minimum requirement of 80 square feet (sq. ft. - unit of measure) per resident in multiple resident rooms. Seven rooms had two residents per room and twenty rooms had three beds per room. This deficient practice had the potential to result in not having enough space for nursing staff to provide resident care, inability to accommodate the resident's functional furniture or care devices, and not enough room for visitors.