Green Acres Healthcare Center

Inspectors wroteBased on interview, observation, and record review, the facility failed to maintain and promote a homelike environment in accordance with the facility's policy and procedure (P&P), titled Homelike environment for one of three sampled residents (Resident 1), who was placed in a resident room with chipped and peeling paint, visible profanity writing on the inside entrance door written by previous resident and locker door with chipped paint on top and bottom of the door. This deficient practice had the potential to affect Resident 1's quality of life by residing in a non-homelike environment.

Inspectors wroteBased on interviews and record reviews, the facility failed to obtain a complete informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to administration psychotropic medications (medications that affects mood and behavior) for three of three sampled residents (Residents 10, 72, and 82) and keep the consent in the resident's clinical record by failing to ensure: 1. Resident 10's consent for Divalproex Sodium (medication used to stabilize mood) and Olanzapine (a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought]) was signed and dated by the physician who obtained the consent. 2a. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that accurate and current nurse staffing data [total number and actual hours worked by licensed (Registered Nurses [RNs], License Vocational Nurses [LVNs]) and unlicensed nurses (Certified Nursing Assistant [CNAs])] were posted daily at the beginning of each shift (11 PM - 7 AM, 7 AM - 3 PM, and 3 PM - 11 PM). This deficient practice had the potential to delay recognition of inadequate staffing levels, which may lead to delayed response times, unmet resident needs, and decreased supervision, especially for residents requiring assistance with activities of daily living or safety monitoring. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure foods were properly stored and sealed in accordance with the facility's Policy and Procedure titled Food Receiving and Storage. This deficient practice had the potential to result in food contamination and the growth of microorganisms that could cause foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure advanced directives (ADs-written statements of a person's wishes regarding medical treatment, intended to guide care when the individual is unable to communicate) were obtained and accessible in the residents' medical records for two of two sampled residents (Residents 19 and 30). 1. Resident 19 and Resident 30's signed Advance Directive acknowledgment forms were not located in the residents' medical records. 2. Resident 30's Physician Orders for Life-Sustaining Treatment (POLST-medical order forms that direct medical staff regarding treatment preferences during a medical emergency when the individual cannot speak for themselves) were not completed in accordance with the facility's policy. [...]

Inspectors wroteBased on interview and closed record review, the facility failed to ensure the required Notice of Proposed Transfer/Discharge (a written notification to the resident or responsible party (RP) that included the reason for the transfer or discharge) was sent to the Long Term Care Ombudsman ( an state agency that advocates for the residents) for one of two sampled residents (Resident 91). The facility did not inform or email the Ombudsman office when Resident 91 was discharged from the facility, This deficient practice violated the resident's rights to have the Long-Term Care Ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities) to advocate for Resident 91's transfer or discharge home.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sample residents (Resident 90) was provided with care and treatment in accordance with professional standards of practice by failing to: 1. Implement the Discharge Summary instructions from the General Acute Care Hospital (GACH) 1, dated 12/25/2025 to follow up with the outpatient cardiology to consider resuming beta blocker (medications that decrease heart rate and blood pressure) given Resident 90 had episodes of bradycardia (slow heart rate less than 60 beats per minute) and for placement of Zio Patch monitor (a water-resistant monitor applied to the upper left chest allowing continuous heart rhythm [heart electrical activity measuring the heart rate and any abnormal activity] monitoring with optional symptom logging monitor) 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a medication error rate less than five (5) percent (%) during medication pass by committing two (2) medication errors on one of five sampled residents (Resident 8) during medication observation with 29 medication opportunities that resulted in a 6.9% medication error rate. This deficient practice had the potential to result in adverse reactions (undesired effect of a drug or other type of treatment), ineffective treatment, worsening of the resident's condition, or potentially serious harm, injury, or death. Exceeding the acceptable error rate indicates a systemic issue in safe medication administration.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure medications were not expired prior to administration for 1 out of 3 sampled residents (Resident 83). An observation of the locked medication refrigerator revealed an expired ABH gel (a compounded topical medication containing Ativan [medication for anxiety], Benadryl [antihistamine], and Haldol [antipsychotic medication]) 1mg-25mg-1mg/1ml with an expiration date of 2/25/2026. Record review indicated the expired medication was administered to Resident 83 seven times over a five day period. This deficient practice had the potential to affect Resident 83 and other residents receiving medications from improperly monitored storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of the two refrigerators (located in the temporary food storage room at nearby facility) temperatures were monitored and documented before and between meal service activities for stable temperatures. This deficient practice placed the facility residents at risk for foodborne illness an (illness that comes from eating contaminated food) due to inconsistent refrigerator temperature monitoring and documentation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, treatment and treatment alternatives or treatment options for four of four sampled residents (Residents 37, 12, 69 and 14) by failing to: 1. Obtain an informed consent for psychotropic/psychotherapeutic (any drug that affects behavior, mood, thoughts, or perception) medications for Resident 37, who was prescribed Quetiapine (medication used to treat a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) for schizophrenia, and Divalproex Sodium (medication used to treat mental/mood conditions) for mood disorder. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality of two of four sampled residents (Resident 3 and Resident 226) when: 1. Resident 3's suprapubic catheter (a tube that drains urine from your bladder by being inserted through a small incision made in your lower abdomen, just above your pubic bone) urinary bag (urine drainage bag to collect urine) was observed without a urinary catheter bag cover. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure on Advance Directive (AD, a legal document indicating resident preference on end-of-life treatment decisions) by failing to ensure the Advance Directive was offered and explained and the signed AD was in the chart for two of four sampled residents (Residents 14 and 39). This deficient practice has the potential to omit the residents ' medical decisions if they become incapacitated (unable to make decision for self) leading to unnecessary or unwanted treatments due to lack of clear instructions regarding their end-of-life care.

Inspectors wrote2. During a review of Resident 226 ' s admission Record indicated Resident 226 was admitted to the facility on [DATE], with diagnoses that included Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control, dementia (a progressive state of decline in mental abilities), Unspecified abnormalities of Gait and Mobility (changes to the way a person walks or moves due to injuries, medical conditions, or other reasons.) During a review of Resident 226 ' s Minimum Data Set (MDS - a resident assessment tool) dated 10/1/24, indicated Resident 226 was severely cognitively impaired (a condition that makes it very difficult for a person to think, learn, and remember). The MDS also indicated Resident 226 had moderate difficulty in hearing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received proper assistive devices to maintain hearing abilities for one of 3 sampled residents (Resident 226) who was not assisted by the facility in arranging a referral for audiologist (a physician specialized in hearing loss) consult. This deficient practice resulted in a delay of services and Resident 226 not being able to hear adequately while communicating with staffs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) received appropriate treatment and services to prevent urinary tract infection (UTI-when bacteria gets into your urine and travels up to your bladder), in accordance with the facility's policy and procedures (P&P) on Infection Prevention and Control Program. 1. On 2/4/2025, Resident 3 was observed while sitting on his wheelchair, Resident 3's suprapubic catheter (a tube that drains urine from your bladder by being inserted through a small incision made in your lower abdomen, just above your pubic bone) drainage bag (urine drainage bag to collect urine) was hanging on the wheelchair ' s left arm rest (positioned higher than Resident 3's bladder). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure on behavioral health services by failing to provide one of two sampled residents (Resident 9) a referal to psychiatrist (a physician specialized in mental and behavioral health) consultation evaluation for aggressive behavior towards the staff and residents to attain the resident's highest practicable physical, mental, and psychosocial well-being. This deficient practice had the potential to worsen the mental health symptoms of the resident, increase risk of relapse, decrease quality of life, and increase the likelihood of needing more intensive interventions like hospitalization in the future.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five (5) percent (%) during medication pass by committing four (4) medication errors on one of six sampled residents (Resident 15) during medication observation with 29 medication opportunity that resulted to a 13.79% medication error rate. This deficient practice had the potential to result in adverse reaction) undesired effect of a drug or other type of treatment) to the medications that could jeopardize the safety of the residents that could lead to serious harm, injury, or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy and procedure on how to properly and safely store medications and biologicals by failing to separately store Hydrogen Peroxide Topical Solution (an external [outside the body] medication with mild antiseptic used on the skin to prevent infection of minor cuts, scrapes, and burns) on the same shelf with oral (medications given by mouth) medications such as stool softeners and vitamins. This deficient practice had the potential to cause medication errors and expose residents to adverse reactions (an undesired harmful effect) that could lead to serious harm or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a system in preventing, controlling infections and communicable diseases were in place, when one of two sampled residents (Resident 3) according to the facility's Infection Prevention and Control Program. Resident 3 who was on an enhance barrier precaution (EBP) (taking extra steps to prevent the spread of serious infections, like using gowns and gloves) due to a suprapubic catheter (a tube that drains urine from your bladder by being inserted through a small incision made in your lower abdomen, just above your pubic bone) was observed receiving high contact care (fixing Resident 3 ' s suprapubic catheter tubing and urine drainage bag) from Licensed Vocational Nurse (LVN) 1 and Certified Nurse Assistant (CNA) 1). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 40 resident rooms (Rooms 6, 15. and 26) did not accommodate more than four residents per room. This deficient practice had the potential to affect the health and safety of the residents in the room due to inadequate space for resident care, mobility, and privacy of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident ' s bedrooms measure at least 100 square feet (sq. ft) per resident in a single resident room or measure at least 80 sq. ft. In multiple resident's room for four of 12 single rooms (Rooms 4, 5, 16 and 17). This deficient practice had the potential to affect the quality of care, health and safety of the residents in the room due to inadequate space for resident care, mobility, and privacy of the resident.

Inspectors wroteBased on observation. interview, and record review the facility failed to ensure four of 40 resident's bedrooms (Rooms 4, 5, 16, and 17) had direct access to the exit corridor without passing through another resident's bedroom. This deficient practice had the potential to affect the privacy, health and safety of the residents in the room due lack of direct access to an exit during an emergency.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills as staff were not following the manufacturer ' s guidelines when checking the concentration of the dish machine chlorine (a chemical used for disinfection) solution. This failure had a potential to result to potential cross-contamination (a transfer of bacteria from one object to another), ineffective dish machine, and unsanitized dishes that could lead to food borne illness (an illness caused by contaminated food and beverages) in 82 of 82 medically compromised residents who received food and ice from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the correct texture for puree and soft mechanical diets when: a. Five (5) of 5 residents on soft mechanical diet did not receive ground sausage links and sausage was dry. b. Six (6) of 6 residents on puree diet received oatmeal that was not pureed in texture and consistency. This deficient practice had the potential to cause difficulty in eating, chewing, and swallowing causing a decrease food intake resulting to weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, functional, and sanitary condition to ensure safe and sanitary food preparation and storage practices in Facility 1 ' s kitchen by failing to: 1. Ensure Facility 1 ' s Kitchen was maintained to prevent the subfloor from being completely rotten, and tile from disrepair due to having an old rotten floor, the dishwasher left rusted, and the wooden entrance door frames throughout the kitchen worn out and deteriorating as reported by the local Health Department on 12/14/2023. As a result, Facility 1 was required to start construction renovation to their kitchen on 1/29/2024. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe environment for 11 out of 81 residents (Residents 12, 15, 20, 28, 30, 39, 42, 47, 63, 69 and 71), who were assessed at being at risk for falling, staff and visitors by failing to: 1. Ensure that the facility's roof was free from cracks, holes and other damage that allowed water from rain to penetrate through and drip into the space between the roof and ceiling. 2. Ensure that the ceiling structure inside the building did not become damaged from rainwater leaking in through holes, cracks, and other damage to the roof. 3. Maintain the ceiling structure free from moisture, water damage, active leaking, and degradation due to rainwater penetrating through cracks, holes, or other damaged areas of the roof. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide call lights to call for assistance from 2/6/2024 to 2/9/2024 for five (Resident 15, 39, 68, 69, and 78) out of six residents who experienced a temporary room change due to ceiling leaks, in accordance with their care plans. This failure had the potential to prevent Resident 15, 39, 68, 69, and 78 from asking assistance especially during emergency situations, and not receiving necessary care and services, which could negatively affect the residents ' physical comfort and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain comfortable and safe room temperature levels between 71 to 81-degree Fahrenheit (° F, unit of measurement) in the resident's rooms as required by the Federal regulation for five out of 17 residents (Resident 40, 49, 12, 47, and 30). This deficient practice resulted in the resident's increased level of discomfort and the potential to result in loss of body heat that could negatively impact the resident's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report allegations of abuse (intentional causing of harm or injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental suffering; includes verbal, sexual, physical, and mental abuse) to the facility ' s abuse coordinator between two residents (Resident 43 and Resident 51) out of a census of 81 residents on 2/8/2024 in accordance with the facility ' s policy on Abuse Allegation Reporting. This failure had the potential to under report alleged cases of abuse, which could lead to a failure to investigate alleged abuse in a timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess range of motion [ROM, full movement potential of a joint (where two bones meet)] for two of six sampled residents (Resident 4 and 24) with limited ROM. 1. For Resident 24, the facility failed to include any assessment of Resident 24 ' s actual ROM in both arms and both legs for a quarterly Joint Mobility Screen (brief assessment of a resident's range of motion in both arms and both legs), dated 2/6/2024, which included a conclusion statement that indicated Resident 24 did not have any decline in ROM. This failure resulted in the inaccurate assessment and transmission of Resident 24 ' s Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool) assessment, dated 1/25/2024, for ROM limitations. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain range of motion [ROM, full movement potential of a joint (where two bones meet)] and mobility for three (Resident 15, Resident 62, and Resident 24) of six sampled residents with positioning and mobility (ability to move) concerns. 1. For Resident 15 and 62, the facility failed to use a front-wheeled walker (FWW, an assistive device with two front wheels used for stability when walking) in accordance with the Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) recommendations and physician orders. The facility also failed to specify the distance for Resident 15 and 62 to walk to maintain their mobility after discharge from PT services. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply bed brakes and repair wheelchair brakes for one (Resident 15) of six sampled residents with positioning and mobility (ability to move) concerns. This failure had the potential to cause Resident 15, who was assessed as a high risk for fall, to fall from both the bed and the wheelchair, placing Resident 15 at increased risk for physical injury.

Inspectors wroteBased on interview and record review, the facility failed to monitor adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) and target behaviors (behaviors related to a diagnoses of mental illness) of restlessness and aggression related to the use of lorazepam (a medication used to treat mental illness) between 2/6/24 and 2/8/24 in one of five sampled residents (Resident 62.) This deficient practice of failing to monitor for adverse effects and target behaviors increased the risk Resident 62 could have experienced adverse effects related to her psychotropic medication (medications that affect brain activities associated with mental processes and behavior) therapy possibly leading to impairment or decline in her mental or physical condition or functional or psychosocial status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medication error rate was less than five percent (%). Three medication errors out of 29 total opportunities contributed to an overall medication error rate of 10.34 % affecting two of nine residents observed for medication administration (Residents 11 and 483). The medication errors noted were as follows: Omitted or late administration of vitamin C (a vitamin supplement) 500 milligrams (mg - a unit of measure for mass) for Resident 11. Omitted or late administration of zinc sulfate (a vitamin supplement) 220 mg for Resident 11. Attempted administration of one dose of expired insulin aspart (a medication used to treat high blood sugar) prior to surveyor intervention for Resident 483. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance. Pureed sausage was served with sweet syrup, puree waffle was drenched with syrup and oatmeal had lumps. This deficient practice placed 6 of 92 facility residents at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide lunch at the facility ' s established mealtime on 2/6/2024 and served lunch to residents in the facility ' s East Wing at least 30 minutes late. This deficient practice caused three of 10 sampled residents (Resident 12, 62 and 68) for dining observation to feel hungry and agitated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately reflect the amount of time the facility provided Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) services on 2/7/2024 to three of six sampled residents (Resident 62, 15, and 26) with positioning and mobility (ability to move) concerns. This failure resulted in the inaccurate records for the provision of RNA services to Residents 62, 15, and 26.

Inspectors wroteBased on interview, and record review the facility failed to ensure three of three sampled residents (Residents 24, 49, 68) were competent in understanding the terms of the facility ' s binding arbitration agreement (an agreement that allows parties to resolve disputes and lawsuits privately rather than going to the court). This failure had the potential for Resident 24, 49, 68 to not understand their rights for a binding arbitration agreement.

Inspectors wroteBased on interview and record review, the facility failed to implement, monitor, and evaluate identified Quality Assurance and Performance Improvement Program (QAPI, a program that is focused on action plan to correct identified quality deficiencies (a deviation in performance resulting in an actual or potential undesirable outcome, or an opportunity for improvement) relating to building maintenance and safety. The facility failed to: 1. Documented evidence the QAPI program implemented a plan to maintain the kitchen in good working condition and ensure the safe renovation of the kitchen, including a plan for providing meals to residents while the kitchen is closed. 2. Document evidence that the QAPI program implemented a plan to ensure the maintenance of the buildings roofing were maintained to prevent leaks and protect residents from a hazardous situation. [...]

Inspectors wroteBased on observation and interview, the facility failed to disinfect shared equipments for four sampled residents (Resident 52, 57, 15, and 26) out of of 15 residents observed for medication administration and position and mobility (ability to move) concerns. 1. Two (Residents 52 and 57) of nine residents observed for medication administration, the facility failed to disinfect the blood pressure cuff (material placed around a person ' s arm and then inflated to measure blood pressure) before and after use. 2. Two of six residents (Resident 15 and 26) observed for positioning and mobility concerns, the facility failed to disinfect a vinyl (type of nonporous material) gait belt (assistive device placed around a person ' s waist to assist with safe transferring between surfaces or while walking) before and after resident use. [...]

Inspectors wroteBased on interview and record review, the facility failed to assist one of two sampled resident ' s representative (Resident 49) in formulating an Advance Directives (AD-a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor). This deficient practice had the potential to cause conflict with Resident 49's wishes regarding health care treatment especially in an event of emergency.

Inspectors wroteBased on interview and record review, the facility failed to: Create a comprehensive care plan for the use of lorazepam (a medication used to treat mental illness) to treat behaviors of restlessness and aggression in one of five sampled residents (Resident 62). Create a comprehensive care plan for the use of lorazepam to treat behaviors of increased agitation, yelling, and screaming toward other and staff in accordance with the facility policy for one of five sampled residents (Resident 70). This deficient practice of failing to create comprehensive, resident-specific care plans related to the use of psychotropic medications (medications that affect brain activities associated with mental processes and behavior) increased the risk that Resident 62 and 70 ' s use of psychotropic medications would not be periodically reevaluated as intended. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise care plans for one of 35 sampled residents (Resident 51). This failure had the potential to affect Resident 51 ' s provision of care and services while residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have more than one staff to provide Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) services out of 12 residents who were supposed to receive RNA services on 2/7/2024. RNA 1 was unable to provide RNA services to three (Resident 6, 24, and 61) of 12 residents on 2/7/2024, because RNA 1 was assigned to supervise multiple residents out in the facility ' s patio on 2/7/2024. On 2/8/2024, RNA 1 was assigned as a Certified Nurse Assistant assigned to perform resident care and was not able to provide RNA services to the 12 residents requiring RNA. On 2/9/2024, the facility failed to provide RNA services to the 12 residents requiring RNA because RNA 1 did not report to work. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure the physician responded to a recommendation from November 2023 to justify prolonged use of pantoprazole (a medication used to reduce stomach acid) in one of five sampled residents (Resident 62). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 70) was free of unnecessary medications. Resident 70 was ordered for psychotropic medications (medications that affect the mind and behavior) with an inadequate indication of use for Seroquel (a medication used to treat mental illness) to treat psychosis (a mental disorder characterized by a disconnection from reality) without adequate indication for use and the resident's manifestations of behavior of constant worrying was not monitored. This deficient practice had the potential to place Resident 70 at risk for unrecognized adverse reactions associated with the use of psychotropic drug.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors by attempting to administer one dose of expired insulin (a medication used to treat high blood sugar) prior to surveyor intervention for one of nine residents observed for medication administration (Resident 483.) This deficient practice of failing to administer medications in accordance with professional standards of practice increased the risk that Resident 483 may have experienced medical complications from ineffective insulin possibly resulting in hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to: Ensure unopened insulin (a medication used to control high blood sugar) was stored in the refrigerator per the manufacturer ' s requirements affecting Resident 483 in one out of two medication carts (East Wing Medication Cart). Remove expired insulin (a medication used to treat high blood sugar) from the medication cart affecting Resident 483 in one out of two inspected medication carts (East Wing Medication Cart). These deficient practices of failing to store medications per the manufacturers ' requirements and remove expired medications from the medication carts increased the risk that Resident 483 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one seated leg bicycles in the Rehabilitation Room was functioning properly, including during use for one of 13 residents (Resident 43) receiving Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 40 resident rooms (Rooms 6, 15. and 26) did not accommodate more than four residents per room. This deficient practice had the potential to affect the health and safety of the residents in the room due to inadequate space for resident care, mobility, and privacy of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident bedrooms measure at least 100 square feet (sq. ft) per resident in a single resident room for four of 12 single rooms (Rooms 4, 5, 16 and 17). This deficient practice had the potential to affect the health and safety of the residents in the room due to inadequate space for resident care, mobility, and privacy of the resident.

Inspectors wroteBased on observation. interview, and record review the facility failed to ensure four of 40 resident's bedrooms (Rooms 4, 5, 16, and 17) were accessible from the corridor without passing through another resident's bedroom. This deficient practice had the potential to affect the health and safety of the residents in the room due lack of direct access to an exit during an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) in accordance the facility's policy and procedure titled Procedure for Prevention of Resident abuse and mistreatment by failing to ensure: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess and provide the necessary behavioral health care and services for one of three sampled residents (Resident 2) with diagnosis of schizoaffective disorder (a chronic and severe mental disorder that affects how a person thinks, feels, behaves and experience psychosis [behavioral symptoms that affect the mind, and loss of contact with reality]) manifested by history of increase agitation, aggressive behavior toward staff, and paranoid delusion (profound fear and loss of the ability to tell what's real and what's not real) believing other people are against him causing outburst of anger as indicated in the facility's policy and procedure by failing to: 1. The Licensed Vocational Nurse (LVN) did not appropriately assess and monitor Resident 2's aggressive behaviors. 2. [...]