Highland Park Skilled Nursing and Wellness Center

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to prevent resident to resident physical altercation for two of sampled residents (Resident 1 and Resident 2). This physical altercation led to Resident 1 sustaining mild injuries to his face. This deficient practice not only resulted in Resident 1 sustained mild injuries to his face but also potentially leads to emotion, psychosocial, physical distress, create negative impact to Resident 1's well-being and quality of life. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) physician was informed when Resident 1 had a change of condition (COC - a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains) of upper extremities skin discoloration and swelling on 6/18/2026. This deficient practice has the potential to result in a delay in the necessary care and services for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices for one (1) of two (2) sampled residents (Resident 1) by failing to accurately document the resident's skin check form dated 6/18/2026 and 6/19/2026. This deficient practice had the potential to negatively impact on the delivery of services.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, administering of drugs and biologicals to meet the needs for two (2) of four (4) sampled residents (Resident 4 and 8) reviewed and observed for medication administration, in accordance with the facility's policy and procedure (P&P) by failing to ensure:Resident 4's Amiodarone Hydrocholoride (HCL) (used to treat and prevent serious, life-threatening heart rhythm problems) was administered and failing to follow gastrostomy tube (g-tube, surgical procedure wherein a tube is inserted through the abdomen wall and into the stomach used for nutrition and medication administration) flush as indicated on the physician's orderResident 8's Percocet (used to treat moderate to severe pain) was given as indicated on the physician's order. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure its medication error rate was less than five (5) percent (%). Three medication errors (the observed or identified preparation or administration of medication or biologicals which is not in accordance with the prescriber's order/manufacturer's specifications/accepted professional standards and principles) out of 25 opportunities (observed administered medications) for error which yielded a facility medication error rate of 50% for two (2) of four (4) sampled residents (Residents 4 and 8) observed for medication administration (med pass). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food storage handling practices and infection prevention in accordance with its policy and procedure (P&P) by failing to ensure:1. Dietary Aide 1 (DA 1) was wearing a hair cover (hair net- a protective, typically disposable, mesh or non-woven covering worn over the hair by food service workers to prevent contamination from loose hair and dandruff) while in the kitchen. 2. Two (2) dry food items (a bag of pasta and a bag of sugar) were sealed tightly after being opened.3. One (1) expired dry food items (a bag of grits) were discarded.4. Pots and pans were stored away from the trash can, in a clean and sanitary manner. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all the food items brought into the facility by visitors for residents were labeled and dated with the resident's name as indicated in the facility's policy titled Food Brought in by Visitors,. This failure had potential for residents to receive and consume the food of another resident and/or not receive their food brought into the facility.

Inspectors wroteBased on interview and record review, the facility failed to obtain an informed consent (is the act of agreeing to allow something to happen, or to do something, with a full understanding of all the relevant facts, including risks, and available alternatives) ) prior to administering psychotropic medications (substance that affects the brain and alters mood, perception, behavior, or consciousness) for two (2) of five (5) sampled residents (Resident 1 and 28) reviewed for unnecessary medications in accordance with the facility policy when:Resident 1 did not have an informed consent prior to the use of antidepressant (prescription drugs designed to alleviate the symptoms of depression and other mental health conditions). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a comfortable, safe and homelike environment for one (1) of 20 sampled residents (Resident 28) by failing to ensure resident's room did not have crack and peeled off paints on the walls. This deficient practice had the potential for Resident 28 to have increased level of discomfort which can impact the resident's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) behaviors for one (1) of 20 sampled residents (Resident 9), was monitored and documented as ordered while the resident is receiving Remeron (a medication used to treat depression). This failure had the potential for Resident 9 to receive an unnecessary psychotropic medication (the use of drugs that alter brain chemistry to treat mental health conditions by managing mood, thoughts, and behavior, that are inappropriate for a patient's condition, taken in excessive doses, or used to manage behaviors for staff convenience rather than treating a specific, documented diagnosis).

Inspectors wroteBased on interview and record review, the facility failed to complete the Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Level 1 Screening accurately for one of one sampled residents (Resident 2) reviewed for PASARR. This resulted in an inaccurate evaluation that Resident 2 did not require a Level 2 PASARR, with the potential for Resident 2 not to receive the appropriate level of care

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) for two (2) of 20 sampled residents (Residents 21 and 46) by failing to:Include resident centered interventions to address Resident 21's risk for fall. This deficient practice has the potential to increase Resident 21's risk for falls resulting in incidents of fall and injury. Reflect Resident 46's fluid restriction as indicated on the physician's order. This deficient practice has the potential for Resident 46's fluid restriction not to be followed, which could result in respiratory complications, cardiovascular strain and fluid overload.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 5) reviewed for hearing received proper treatment to improve hearing abilities by failing to follow up with Resident 55's authorization for audiogram (measures hearing sensitivity across different pitches and volume to detect hearing loss) and tympanogram (assess middle ear function [eardrum movement, fluid, pressures]) (non-invasive diagnostic tests used to evaluate ear health) after the resident's Ears, Nose and Throat (ENT) appointment on 1/21/2026. This deficient practice had the potential for Resident 55 to have increased hearing loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide supervision for one (1) of 1 sampled resident (Resident 29) reviewed for smoking when Resident 29 was observed smoking by himself outside in the patio. This deficient practice has the potential for safety concerns and accidents for Resident 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the fluid restriction (a dietary change that limits the amount of liquid a person can consume in a day) as indicated on the physician order for one (1) of two (2) sampled residents (Resident 13), who were receiving dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney/s have failed) treatment. This deficient practice has the potential to cause fluid overload (a condition where there is too much fluid in the body which could result in swelling, particularly in the ankles and legs, shortness of breath and health complications) to Resident 13.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (1) of four (4) sampled residents (Resident 4) reviewed and observed for medication administration was free from significant medication error (the identified preparation or administration of medication was not in accordance with the physician's order, which may have cause the resident discomfort or jeopardize health and safety) by failing to administer Resident 4's Amiodarone Hydrocholoride (HCL) (used to treat and prevent serious, life-threatening heart rhythm problems) as indicated on the physician order. This deficient practice placed Resident 4 at risk of not getting the full effect of the medication which can result in blood pressure and heart rhythm problems.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe provision of pharmaceutical services as indicated in the facility policy by failing to refrigerate two unopened latanoprost eye drops (medication used to lower high pressure in the eye) in accordance with the facility policy. This deficient practice increases the risk of the residents receiving a medication that had become ineffective or toxic due to improper storage, possibly leading to health complications resulting in damage to the optic nerve (a bundle of over one million nerve fibers that transmits visual information from the retina to the brain, acting as the sole communication path for sight) and potential vision loss or blindness.

Inspectors wroteBased on observation and interview, the facility failed to ensure one (1) of twenty (20) sampled residents (Resident 37) breathing treatment mask and tubing (deliver aerosolized medication directly to the lungs. It includes vinyl mask, medication cup and plastic tube), and respiratory set up bag was changed every seven days per facility's policy and procedure. This failure had the potential to cause respiratory tract (airways including lungs) infection which can lead to Resident 37's hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 12 of 22 resident's rooms (Rooms 3, 4, 5, 6, 7, 8, 11, 14, 15, 16, 17 and 18) met the requirements of 80 square feet (sq. ft) for each resident in multiple resident bedrooms. This deficient practice had the potential to affect the residents' personal space, decrease freedom of mobility and could compromise the provision of care.

Inspectors wroteBased on interview and record review, the facility failed to supervise, monitor and provide safety measures, leading to oversight of one (1) of two (2) sampled residents (Resident 1) who attempted to elope (leave the facility without the staff's knowledge and/or supervision) multiple times prior to eloping from the facility on 1/4/2026 in accordance with the facility's policy and procedure (P&P). This failure resulted in Resident 1 eloped from the facility on 1/4/2026 around 1:20 PM which placed the resident at risk for exposure to injury, serious harm, medical complications and/or death.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) were free from unnecessary psychotropic drugs (any medication capable of affecting the mind, emotions, and behavior) as indicated in the facility's policy and procedure and care plan by failing to ensure Resident 1:1. Had a specific indication for the use of Ativan (a medication that treats anxiety { fear characterized by behavioral disturbances}).2. Was monitored for specific manifested behavior and side effects for the use of Ativan. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled Resident (Resident 1) received treatment and care in accordance with facility's policies and procedures by failing to: 1. Call alternate transportation to ensure Resident 1 receive hemodialysis (HD-a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment as ordered and as scheduled on 2/12/2025. 2. Transcribe the order for Resident 1 to be monitored for fluid overload (too much fluid in the body which can raise the blood pressure [BP-the pressure of blood on the walls of the arteries as the heart pumps blood around the body] and force the heart to work harder and can also make it hard to breathe) after missing the HD treatment on 2/12/2025. 3. Administer BP medications on 2/12/2025 as ordered by the physician. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an environment free of accident hazards for one of one sampled resident (Resident 1) by failing to ensure Licensed Vocational Nurse (LVN) 2 did not leave medications at the bedside table. This deficient practice had the potential to result in accidental ingestion of the medications by other residents and cause complications from taking medications not prescribed for the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Daily Posted Nurse Staffing (Nurse Staffing Information- refers to the actual hours of work performed per patient day by a direct caregiver) for 2/14/2025 to 2/25/2025 were posted in accordance with the facility's policy titled Nursing Department - Staffing, Scheduling & Postings. This deficient practice had the potential for residents and visitors not to be accurately informed of the census and staffing for the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat two of two sampled residents (Resident 35 and 43) with respect and dignity in accordance with the facility policy by failing to ensure: 1. Certified Nursing Assistant 2 (CNA 2) sat and be at eye level while assisting Resident 35 during feeding. 2. Resident 43's urinary collection bag was covered with a privacy bag (specially designed fabric pouch that conceals and protects urinary drainage bags). This failure had the potential to negatively affect Resident 35 and 43's self-esteem which could result in problems with emotional, psychosocial, and mental well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate assessment of the Minimum Data Set (MDS -resident assessment tool) for two (2) of two sampled residents (Residents 42 and 49) by failing to reflect the following on the MDS: 1. Resident 42's diagnosis of anxiety (mental disorder that involves persistent and excessive worry that can interfere with daily activities). 2. Resident 49's diagnoses of anxiety and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory services for three (3) of 3 sampled residents (Residents 49 and 54) as indicated on the facility policy by failing to: 1. Administer two (2) liters (metric unit of capacity) per minute (LPM) of continuous (without interruption) oxygen therapy (administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of low oxygen) to Resident 49 as indicated in the physician's order. The facility also failed to label and date Resident 49's plastic respiratory equipment bag (a plastic bag that holds and transports respiratory equipment), which contained a nasal cannula (NC- a tube that provides oxygen through the nose) tubing. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food storage handling practices in accordance with its policy and procedure (P&P) by failing to ensure: 1. Food was labeled and stored in refrigerators, freezers and dry storage. 2. Proper sanitization of dishes by ensuring all dishes in the dishwasher were washed with a temperature of at least 120 degrees Fahrenheit (F) during use. These deficient practices have the potential to result in food borne illness (any sickness that is caused by the consumption of foods or beverages that are contaminated with certain infectious or noninfectious agents) in a population of 50 residents consuming food by mouth.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of three garbage container (dumpster) lids remained closed and were not overflowing with trash as indicated on the facility policy. This failure had the potential to result in the attraction and spread of vermin (animals that are believed to be harmful, or that carry diseases, e.g., rodent's parasitic worms or insects) that could potentially enter the facility and spread diseases to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update and revise the care plan for two (2) of 21 sampled residents (Resident 42 and Resident 33) as indicated on the facility policy when: 1. Resident 42's fall care plan was not updated and revised after Resident 42 had a fall with injury on 1/3/2025. 2. Resident 33's care plan was not revised to reflect the updated fluid restriction in accordance with the physician's order on 1/15/2025. This failure had the potential to negatively affect the provisions of care and services for Residents 33 and 42 and had the potential to place Resident 42 at risk for further falls.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality in accordance with the facility's policy for one of 21 sampled residents (Resident 42) by: a. Failing to ensure an Interdisciplinary Team (IDT, group of healthcare professionals from diverse fields who work in a coordinated manner toward a common goal for the resident) meeting was conducted after Resident 42 had a fall with an injury. b. Failing to ensure a Post Fall Evaluation was done after Resident 42 had a fall with an injury. c. Failing to ensure neurological exam (neuro check, an assessment of the brain, spine or nerves done to evaluate the nervous system function for potential brain injury) was done after Resident 42 had a fall with an injury to the eyebrow. These deficient practices had the potential to result in further falls for Resident 42.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 43) who had an indwelling urinary catheter (Foley Catheter, tube inserted into the bladder to drain urine into a drainage bag) received appropriate care and services as indicated in the physician's orders, by failing to appropriately assess and document signs and symptoms of urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, bladder [organ that stores urine] or urethra [the tube through which urine leave the body]). This deficient practice resulted in delayed UTI identification and had the potential to lead to worsening infection and delayed treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately monitor the fluid intake for one of one sampled resident (Resident 33) with fluid restrictions and on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment in accordance with the facility's policy and procedure. This deficient practice had the potential to cause fluid overload (too much fluid in the body) or increase risk for dehydration (harmful reduction in the amount of water in the body).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services by not supervising medication administration when eight (8) medications were given and left on the nightstand for one (1) of 21 sampled residents (Resident 39). This deficient practice had the potential to result in medication errors and had the potential to harm Resident 39. This also had the potential for other residents to access the medications and in the event that the medications were ingested, could cause harm to the other residents.

Inspectors wroteBased on interview and record review, the facility failed to act upon the facility's Pharmacy Consultant's recommendations during the Medication Regimen Review (MRR, a monthly thorough evaluation by the consulting pharmacist of a resident's medication regimen, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) to address the recommendation/ irregularities for the month of December 2024's MRR for one of five sampled residents (Resident 41) as indicated on the facility's MRR policy. This deficient practice had the potential to result in adverse medication outcome for potential unnecessary medications to Resident 41.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the temperatures of the facility's one of one Activity Room Refrigerator, which contained resident food brought by family/visitor, was checked daily per facility policy. This deficient practice had the potential for Resident 40 to experience food borne illness (any sickness that is caused by the consumption of foods or beverages that are contaminated with certain infectious or noninfectious agents).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 12 out of 22 resident rooms (Rooms 3, 4, 5, 6, 7, 8, 11, 14, 15,16, 17, and 18) met the requirements of 80 square feet (sq. ft.) for each resident in multiple resident bedrooms. This deficient practice had the potential to affect the residents' personal space, decrease freedom of mobility and could compromise the provision of care.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident ' s physician/medical doctor when the resident was refusing more than 50% of his meal 3 consecutive times for one of two sampled residents (Resident 1) on 10/4/2024 to 10/5/2024. This deficient practice had the potential to delay in the necessary care and services for Resident 1 and lead to severe malnutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity and respect for two of three sampled residents (Resident 16 and 11) for the dignity care area by: 1. Ensuring Resident 16's urinary catheter bag (tube that drains urine from the bladder into a drainage bag) was covered with a dignity bag (a bag used to cover and hold the catheter drainage/collection bag, so it is not visible). 2. Failing to ensure facility staff did not stand above Resident 11's eye level while assisting the resident to eat. These deficient practices have the potential to affect Resident 16 and 11's self-esteem and self-worth and violates Resident 16 and 11's right to be treated with dignity.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services to ensure the resident's abilities in activities of daily living (ADLs) for two of two sampled residents (Resident 15 and 29) of advance daily living (ADLs) care area. 1. Facility failed to ensure Resident 15 was provided communication device with the resident's primary language and failed to ensure Resident 15 with limited range of motion (ROM - movement of the joints) receive appropriate positioning in bed. 2. Facility failed to ensure Resident 29 was provided a communication device (a visual aid with symbols, pictures, or words that users can point to or select to express their thoughts and needs) with the language that the resident was able to understand. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 16 and 36) were provided with a safe environment to prevent avoidable accidents and hazards for accidents care area. This deficient practice had the potential to place the residents at risk for falls, injuries, and delayed care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the storage, preparation and distribution of food was done under sanitary conditions for fifty-two (52) residents of the facility by: 1. Facility failed to ensure that conventional oven temperature knob indicates the temperature setting. 2. Facility failed to ensure that food items inside kitchen produce refrigerator and dry storage were labeled with a received date and/ or expiration date, and expired food items were discarded and not mixed with other non-expired foods. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to implement its protocol for Antibiotic Stewardship to reduce inappropriate antibiotic (medication used to kill bacteria and to treat infections) use by not administering antibiotic drug if the McGeers (named Infection Screening Evaluation in facility's medical record, surveillance definitions of infections in Long-Term Care Facilities) criteria were not met for two (2) of three (3) sampled residents (Residents 16 and 35) for antibiotic care area. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide education, offer, and/or document the updated Covid-19 (Coronavirus Disease 19, a respiratory viral infection that affects primarily the lungs and result in cough and difficulty breathing) for the year 2023-2024 vaccinations for 96 of 105 employees. This deficient practice placed the residents and staff at risk for possible Covid-19 infection due to missed vaccination dosage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light (a device used by patients to call for assistance from hospital staff) was within reach (an arm's length) of three of 13 sampled residents (Resident 5, Resident 27, and Resident 15). This deficient practice had the potential to result in delayed provision of services, delay in care and Residents 5, 27, and 15 not receiving assistance with activities of daily living (ADLs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS- an assessment and care screening tool) related to eating was accurately documented to reflect the resident's ability to eat for one of one sampled resident (Resident 6) for the resident assessment care area. This deficient practice had the potential to negatively affect Resident 6's plan of care and delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the preadmission screening assessment (PASRR - Preadmission Screening and Resident Review - a federal requirement to ensure that every person entering a Medicaid Certified Nursing Facility [NF] receive a Level I screening and if necessary a Level II evaluation to ensure that their NF residence is appropriate and to identity what specialized services they may need) form was accurately completed for a resident who had a mental illness for one of three sampled residents (Resident 24) for PASRR care area. This deficient practice led to the resident not receiving the necessary and appropriate psychiatric level of treatment and evaluation in the facility.

Inspectors wroteBased on interview and record review the facility failed to review and revise the care plan for one of 13 sampled residents (Resident 11) who has a history of seizures (epilepsy- abnormal electrical activity in the brain that happens quickly). This deficient practice had the potential to negatively affect the provision of care and services for Resident 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for one (1) of 1 sampled resident (Resident 16) for respiratory care area by failing to: 1. Ensure Resident 16's nasal cannula (NC, device used to deliver supplemental oxygen placed directly on a resident's nostril) tubing was changed per facility's policy. This deficient practice had the potential for Resident 16 to develop a respiratory infection. 2. Place visible oxygen signage by Resident 16's door/wall prior to entering the room. This deficient practice had the potential for harm to Resident 16 and other residents, in an event of a fire.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of six (6) sampled residents (Resident 40) receive all medications in accordance with the physician's order and facility's policy and procedure (P&P) when Resident 40 was observed in possession of three (3) clear red capsules on 3/28/2024. This deficient practice had the potential for Resident 40 to have an overdose of the medication, which could result in harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a shower chair used by residents was in good condition and free from stains. This deficient practice had the potential for the resident to feel uncomfortable during showers and affect the resident's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy to post the nurse staffing information hours at the start of each shift. On 3/26/2024, the facility did not post the nurse staffing information for the current date and did not indicate the total number of projected hours and the actual hours of licensed and unlicensed nursing staff directly responsible for resident care per shift. This deficient practice had the potential to inaccurately reflect the actual nurses providing direct care to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 12 out of 22 resident rooms (Rooms 3, 4, 5, 6, 7, 8, 11, 14, 15, 16, 17, and 18) met the requirements of 80 square feet (sq. ft.) for each resident in multiple resident bedrooms. This deficient practice had the potential to affect the residents' personal space, decrease freedom of mobility and could compromise the provision of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the care plan for one (1) of three (3) sampled residents (Resident 1) to include bowel and bladder retraining assessment as indicated on the bowel and bladder screener (assessment of how the resident's bladder and bowel are working). This deficient practice had the potential for Resident 1 not to receive specific interventions to maximize control of the bowel and bladder function.

Inspectors wroteBased on interview and record review, the facility failed to ensure a bowel and bladder retraining program (use of a timed schedule for voiding/bowel movement based on the resident's identified need and routine to maximize control of their bowel and bladder function as much as possible) and scheduled toileting program (use of a timed schedule for voiding/bowel movement to match the Resident's voiding/bowel habits. Appropriate Residents for this program are caregiver dependent, cognitively impaired and cannot gain control of their bowel and bladder function) were implemented for one of three sampled residents (Resident 1) as indicated on the facility policy. [...]