Hilltop Village Nursing and Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication irregularities reported from the pharmacist were reported to the attending physician and the facility's medical director and director of nursing, and these reports were acted upon for 1 of 4 residents (Resident #4) reviewed for medications. The facility failed to ensure an order discrepancy for Resident #4's medication Pramipexole (a medication for a progressive neurological disorder known as Parkinson's Disease) identified by a report from the pharmacist to the facility on 6/23/2025 was resolved causing Resident #4 to receive dosing of the medication greater than intended for June, July, and August of 2025. This failure could lead to toxic ingestion or unintended side effects of residents' medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents are free from unnecessary drugs for 1 of 4 (Resident #4) residents reviewed for unnecessary medications. The facility failed to ensure Resident #4 received the correct dosage of Pramipexole (a medication used to treat the neurological degenerative disorder known as Parkinson's Disease) in June, July, and August of 2025. This failure could result in accidental overdose or unintended effects of a resident's medication.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. The facility failed to ensure 08/27/25 fruit and tossed salad had a temperature of less than 41 degrees prior to service. 2. The facility failed to ensure [NAME] G put parsley on 08/27/25 lunch with food tongs instead of using unsanitary gloves. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 8 residents (Resident #61) observed for resident rights. The facility failed to ensure Resident #61 was allowed to eat her dinner meal on her food tray when she requested because she wanted to reduce mess in her area on the dining table. These failures could place residents at risk of not being treated with dignity and respect.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure residents had the right to be informed of, and participate in, their treatments, for 1 of 8 residents (Resident #107) reviewed for antipsychotic medication administration. Resident #107 was prescribed and received the antipsychotic medication Perphenazine for schizophrenia without evidence in her medical record of the state consent form 3713. The medication dose and frequency were not included in the consent form. The deficient practices could place residents at risk for side effects for which they did not consent.

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to ensure the resident environment was free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (#51) whose care was reviewed for smoking. The facility failed to provide effective monitoring and interventions to prevent Resident #51's unsupervised smoking. This deficient practice could affect resident's safety by smoking unsupervised and residents storing their smoking materials in their rooms and on their person instead of a central lock box which could lead to an unsafe smoking environment.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 8 residents (Resident #88) reviewed for pharmacy services. Nurse A failed to administer Resident #88's medications in a timely manner from 08/22/25 to 08/24/25 (medications to include Duloxetine HCl capsule delayed release particles 30 MG, dexamethasone Oral Tablet 4 MG, Methadone HCl Oral Tablet 10 MG, Lorazepam Oral tablet 0.5 MG, PHENobarbital Oral Tablet 15 MG). This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, interviews, and record review, the facility failed to follow menus for 2 of 3 resident (Residents #24 and #76) meals reviewed for menus in that: The facility failed to follow the menu for Residents #24 and #76 for 08/25/25 lunch meal service. This failure could place residents who consume food prepared by the facility kitchen at risk of not having their nutritional needs met and/or weight loss.

Inspectors wroteBased on observations, record reviews and interviews the facility failed to follow their own established smoking policy for 1 of 8 residents (Resident #51) reviewed for smoking in that:Resident #51 was observed smoking unsupervised in the smoking area and stating he keeps the smoking paraphernalia on his person. This deficient practice could place smoking residents at risk for injury while smoking unsupervised.

Inspectors wroteBased on interview and record review the facility failed to have bedrooms that measured 80 square feet per resident in multiple bedrooms for 15 of 99 rooms (Rooms #1-5, 7-9, 12-14, 21, 27, 28, and 46) resident rooms reviewed for square footage. Based on List of measured rooms, Rooms #1-5, 7-9, 12-14, 21, 27-28 and 46 were between 72.4 and 76.4 square feet per resident per bedroom. This failure could negatively affect the quality of life for the residents living in these rooms by restricting the amount of resident care equipment and resident's personal effects that could be accommodated in these resident rooms, limiting the resident's ability to move about the room, and decreasing resident's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of quality of life, recognizing each resident's individuality for 1 (Resident #1) of 7 reviewed for dignity. The facility failed to ensure CNA A treated Resident #1' room, supplies and personal space with respect. This failure could place the residents at risk of feeling uncomfortable, disrespected and could decrease residents' self-esteem and/or diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to report all allegations of abuse, neglect exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but not later than 2 hours after the allegation is made to the administrator of the facility and to other officials in accordance with State law through established procedures for 1 (Resident #7) of 7 residents reviewed for reporting requirements. The DON failed to report to the Administrator and the state survey agency when Resident #7's family reported rough care and treatment. This failure could put the residents at risk of abuse and harm.

Inspectors wroteBased on interviews, and record reviews the facility failed to have evidence all allegations of abuse, neglect or mistreatment were thoroughly investigated and documented for 1 of 9 residents (Resident #7) reviewed for abuse. The facility failed to ensure an allegation of rough care and treatment was investigated and the DON's notes/documentation were retained regarding Resident #7 family complaints of rough care and treatment. These failures could place residents as risk for abuse and neglect by not investigating allegations of abuse, neglect, exploitation, or mistreatment.

Inspectors wroteBased on interview and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 resident (Resident # 7) reviewed for activities of daily living. The facility failed to ensure CNA B utilized a gait belt to transfer Resident #7 while toileting. This failure could place residents at risk for falls, injury and a diminished quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents' right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriate for 4 of 4 residents (Residents #2-5) reviewed for medication self-administration. 1. The facility failed to assess Residents #2-5 for medication self-administration and ensure the medications were being administered per the physician's order. 2. The facility failed to implement care planning for Residents #2-5 for medication self-administration. These failures put residents at risk for incorrect medication administration, which could lead to unintended medication side effects, ineffective therapeutic effects of medications, or illness. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store all drugs in locked compartments for 4 of 4 residents (Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for self-administration of medications. The facility failed to ensure that residents (Residents #2-5) with physician orders to self-administer medications had methods of securing medications that prevented other residents from having access. This failure could lead to unintended access and ingestion of medication causing illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents were free from abuse for 1 (Resident #1) of 7 residents reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #1 was free from abuse of unwanted sexual exposure from Resident #6 when he masturbated in front of her. This failure puts residents at risk for abuse and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse are reported not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law established procedures for 1 (Resident #1) of 7 residents reviewed for abuse, neglect, and exploitation. The facility failed to report unwanted sexual exposure/sexual abuse to the Administrator and SSA from a resident to Resident #1. This failure puts residents at risk for abuse and diminished quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 of 3 residents (Resident #2) reviewed for quality of care. The facility to provide supervision of Resident #2 while he was showering causing the resident to exit the bathroom independently. These failures could lead to injury or decreased quality of life.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice and the comprehensive care plan for 1 of 3 residents (Resident #2) reviewed for quality of care. The facility failed to ensure Resident #2 had signed physician's orders and care planning for nightly use of continuous positive airway pressure (CPAP) therapy. This failure could place residents at risk for inadequate oxygenation and respiratory complications.

Inspectors wroteBased on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 25 residents (Residents #94) reviewed for resident's rights, in that: On 07/09/24, Resident #94 was not served her lunch meal while other residents at her table had received their lunch meals and were eating. These deficient practices could affect residents' self-esteem and feelings of dignity.

Inspectors wroteBased on interview and record review the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 5 of 32 residents (Residents #9, #36, #19, #13, and #44) whose records were reviewed for hygiene, in that. Nursing staff failed to ensure Residents #9, #36, #19, #13, and #44 received a shower on Monday 07/08/24. This deficient practice could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for problems, and/or a diminished quality of life.

Inspectors wroteBased on observation, interview and record review revealed the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 5 Residents (Resident #17) whose environment was observed for call light placement. Nursing staff failed to ensure Resident #17's call light was within reach for personal use during a lunch meal. This deficient practice could affect any resident and could result in residents' not getting their needs met.

Inspectors wroteBased on observation, interview and record review revealed the facility failed to provide a clean and homelike environment for 1 of 5 Residents (Resident #17) whose environment was observed for cleanliness. Staff failed to clean Resident #17's wall which was stained with food residue after eating her meals. 2. The facility failed to ensure a homelike environment on 1 hallway (D-wing Hallway) when a large industrial barrel was put into place, on an unknown date, to contain a ceiling water leak. This deficient practice could affect any resident and could result in residents' dissatisfaction.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 21 residents (Residents #7 and #51) whose assessments were reviewed, in that: 1. Resident #7's quarterly MDS, dated [DATE], incorrectly documented the resident as receiving an anticoagulant medication. 2. Resident #51's quarterly MDS, dated [DATE],, reflected he did not have upper or lower range of motion limitations which was inaccurate related to the fact he had contractures on both upper and lower extremities. This failure could place residents at-risk for inadequate care and services due to an inaccurate assessments.

Inspectors wroteBased on interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program under Medicaid to the maximum extent practicable to avoid duplicative and effort which includes referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon significant change in status assessment for 2 of 5 residents (Resident #29 and #13) reviewed for PASRR. 1. The facility failed to ensure Resident #29 had an accurate PASRR Level 1 Screening which indicated a diagnosis of developmental disability related to Multiple sclerosis on 01/29/2022. 2. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure food prepared in a form designed to meet individual needs for 1 of 25 (#13) residents, in that: The facility failed to ensure Resident #13 was served a mechanical soft diet for 07/09/24 lunch, instead of a regular diet. The facility failed to ensure Resident #13 was not served gravy, as was voiced and preferred by resident. The date this was voiced was unknown. This could affect all residents with diet orders that were prescribed by a physician and could result in residents not served the correct diet texture, which could leave residents at risk for poor intake, weight loss and diminished quality of life.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure a therapeutic diet was prescribed by the attending physician for 1 of 25 residents (Resident #13) reviewed for food and nutrition services, in that. The facility failed to ensure Resident #13 received her prescribed regular diet for 07/09/24 lunch. The resident was prescribed a regular diet and was provided a mechanical soft diet. This deficient practice could place residents who were provided a modified texture diet at risk for poor intake, weight loss, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review revealed the facility did not provide special eating equipment and utensils for residents who need them for 2 of 7 Residents (Resident #21 and Resident #95) who were observed during meal service. Staff failed to ensure: 1. Resident #21 had a plate guard on her plate during a lunch meal to ensure she did not spill the food all over her clothes; 2. Resident #63 had a divided plate during a lunch meal so she could scoop up her food while eating the food on her plate. These deficient practices could affect residents who depended on assistive devices and infringe on the residents dignity and feeding independence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 of 8 residents (Residents #18, #50 and, #80) reviewed for infection control, in that: 1. Medication Aide B did not sanitize the blood pressure cuff between Residents #50 and #80. 2. While providing incontinent care for Resident #18, CNA C did not change her gloves or wash her hands after touching the bed remote and between touching soiled and clean incontinent pads These deficient practices could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on interview and record review the facility failed to have bedrooms that measured 80 square feet per resident in multiple bedrooms for 15 of 99 rooms (Rooms #1-5, 7-9, 12-14, 21, 27, 28, and 46) resident rooms reviewed for square footage. Based on measured rooms on 07/20/24, Rooms #1-9, 12-14, 21, 27-28 and 46 were between 72.4 and 76.4 square feet per resident per bedroom. This failure could negatively affect the quality of life for the residents living in these rooms by restricting the amount of resident care equipment and resident's personal effects that could be accommodated in these resident rooms, limiting the resident's ability to move about the room, and decreasing resident's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be free from verbal abuse for 3 of 7 residents (Residents #1, #2, and #3) reviewed for abuse. 1. The facility failed to prevent RN A from verbally abusing Resident #1 and Resident #2 when RN A yelled at both residents. 2. The facility failed to protect Resident #3 when OT called resident a liar and yelled at her. These failures could place residents at risk of verbal abuse from facility staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident was free of any significant medication errors for 1 of 7 residents (Resident #4) reviewed for medications. -The facility failed to provide Resident #4 with Doxycycline (an anti-infective). This deficient practice could result in a risk to the residents' health and complications which can lead to infection.

Inspectors wroteBased on observation, interview and record review the facility failed to follow physician orders and the resident's advance directives for 1 of 24 Residents (Resident #76) whose records were reviewed for DNR code status. The facility failed to ensure nursing staff followed emergency protocol and failed to ensure staff did not provide Resident #76, who had a DNR in place, CPR, after the resident choked and became unresponsive, according to professional standards of practice. An Immediate Jeopardy (IJ) situation was identified on 05/26/2023. While the IJ was removed on 05/27/2023, the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated. These deficient practices could contribute to a resident's decline in emotional, physical and psychological health and result in serious injury and or death. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen for review: 1. DA L had facial hair and was not wearing a facial hair restraint while engaged in food preparation. 2. There were frozen omelets, pizza crusts, pie crusts and garlic bread that were improperly stored in the reach-in freezers. 3. There was an opened carton of thickened orange juice and an opened carton of thickened sweet tea without labels indicating the dates they were opened. 4. There was a case of frozen fish fillets and a case of frozen carrots that were improperly stored in the walk-in freezer. 5. CNA S touched Resident #36's sandwiches with her bare hands while cutting them on his plate. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents had the right to be free of discrimination from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights for 1 of 7 residents (Resident #69) reviewed for resident rights, in that: Facility staff did not ensure Resident #69 had equal rights to smoking privileges as other residents. This failure could place residents at risk of feelings of poor self-esteem and loss of dignity.

Inspectors wroteBased on observation, interview and record review the facility failed to consider the views of a resident group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility for 1 of 1 resident council group whose minutes were reviewed. The facility failed to address the groups grievances presented since February 2023. This deficient practice could affect residents in attendance and result in feelings of worthlessness.

Inspectors wroteBased on interview and record review the facility failed to ensure the right to refuse and/or discontinue treatment and to formulate an advance directive for 4 of 24 Residents (Resident #28, #53, #69 and #324) whose records were reviewed for DNR status. 1. The facility failed to ensure Resident #28's DNR include his date of birth making it an invalid document. 2. The facility failed to ensure Resident #53's DNR contained two witness signatures twice on the document. 3. The facility failed to ensure Resident #69's OOH-DNR was valid. 4. The facility failed to ensure Resident #324's DNR had a licensed physician signature. The DNR was signed by a nurse practitioner. These failures could place residents at-risk for having their end of life wishes dishonored.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete an accurate assessment of each resident's functional capacity for 4 of 16 residents (Residents #1, #18 and #116) whose assessments were reviewed. 1. The facility failed to accurately assess Resident #1's diagnosis of UTI after returning from the hospital. 2. The facility failed to accurately assess Resident 18's fall history on her quarterly assessment. 3. The facility failed to accurately assess Resident #116's cognition status on his admission assessment. These failures could lead to the residents' not receiving the care and services they needed based on their assessment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for 1 of 1 facility and that each resident received adequate supervision to prevent accidents for 2 of 24 residents (Residents #41 and #103) reviewed for accidents/supervision, in that: 1. Resident #41 had a lighter and package of cigarettes on her bed. 2. Resident #103 was smoking unsupervised prior to assigned smoking times. 3. The metal receptacle in the smoking area for ashes, marked no trash, contained a can and cigarette package. These failures could place residents at risk for smoking-related injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 4 of 16 residents (Residents #24, #37, #55 and #274) reviewed for respiratory care, in that: 1. Resident #24's nebulizer mask was unbagged and resting on top of the resident's bedside table. 2. The water reservoir attached to Resident #37's oxygen concentrator was empty and was not replaced in accordance with the facility's changing schedule. 3. Resident #55's nebulizer mask was unbagged and resting on top of the cabinet behind the resident's bed. 4. Resident #274's CPAP mask was unbagged and resting on top of the cabinet behind the resident's bed. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide or obtain laboratory services to meet the needs of its residents. The facility failed to ensure its own its own laboratory services met the applicable requirements for laboratories in that: The facility did not have a current CLIA certificate of waiver. This deficient practice placed residents' laboratory tests at risk of not meeting certain quality standards due to lack of oversight from CMS. The finding was: Record review of the binder provided by the facility that contained its contracts revealed there was no CLIA certificate waiver present. Interview on [DATE] at 7:30 p.m. with the Administrator revealed that she had taken over the position of Administrator in [DATE] and discovered that the facility's CLIA waiver had expired [DATE] while reviewing documents left by the previous administrator. [...]

Inspectors wroteBased on record review and interview the facility with more than 120 beds, failed to employ a qualified social worker on a full-time basis, for 1 of 1 social services staff reviewed, in that: The facility, licensed for 150 beds, did not employ a full-time social worker. This failure could place residents at risk of social service and psychosocial needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 2 of 5 staff (LVN O and CAN P) reviewed for infection control, in that: 1. LVN O did not sanitize her hands prior to setting up wound care supplies for Resident #43. LVN O did not sanitizer the scissors prior to cutting gauze while setting up wound care supplies for Resident #43. 2. CNA P did not sanitize her hands in between glove changes while providing catheter care for Resident #1. These deficient practices could place residents who receive wound care or catheter care at-risk for infections.

Inspectors wroteBased on interview and record review the facility failed to provide notice to residents of the change as soon as was reasonably possible. where changes in coverage were made to items and services covered by Medicare for 2 of 3 Residents (Resident #87 and Resident #277) whose records were reviewed for Medicare eligibility. 1. The facility failed to provide Resident #87 with a beneficiary protection notification before skilled services were terminated. 2. The facility failed to provide Resident # 277 with a beneficiary protection notification before skilled services were terminated. These deficient practices could affect residents whose covered status changed and could result in residents not having sufficient time to consider their options.

Inspectors wroteBased on interview and record review the facility failed to have physician orders for the resident's immediate care at the time the resident was admitted for 1 of 8 (Resident #274) residents whose records was reviewed for physician orders in that; The facility failed to obtain a physician order for Resident #274's CPAP machine. This failure could place residents at-risk of inadequate monitoring of medical conditions and not receiving the correct amount of oxygen while sleeping.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 8 residents (Resident #274) reviewed for baseline care plan, in that: The facility failed to ensure Resident #274's baseline care plan included information related to resident's use of a CPAP. This failure could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met.

Inspectors wroteBased on interview and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's mental, nursing, and psychosocial needs that were identified in the comprehensive assessment, for 1 of 8 Residents (Resident #116) reviewed for care plans.: The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #116 to address the resident's communication problem. This failure could place residents at risk for not getting their medical, physical, and psychosocial needs met and not being provided with the necessary care or services and having personalized plans developed to address their specific needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 of 16 residents (Residents #1 & #24) for care plan revisions, in that: 1. The facility failed to ensure Resident #1's Care Plan was revised to include his most recent hospitalization, diagnoses while in the hospital and referral for skilled services. 2. The facility failed to ensure Resident #24's care plan was revised to include oxygen therapy and nebulizer treatments. These failures could place residents at risk for not receiving care according to their needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received and the facility provided food that accommodated resident preferences for 1 of 6 Residents (Resident #77) whose records were reviewed for food preferences. Facility staff failed to ensure Resident #77 received substitutes for foods he did not like. This deficient practice could result in residents not being satisfied with meal service when served foods they disliked.

Inspectors wroteBased on interview and record review the facility failed to have bedrooms that measured 80 square feet per resident in multiple bedrooms for 16 of 99 rooms (Rooms #1-9, 12-14, 21, 27-28, and 46) resident rooms reviewed for square footage. Based on measured rooms, Rooms #1-9, 12-14, 21, 27-28 and 46 were between 72.2 and 77.25 per resident. This failure could negatively affect the quality of life for the residents living in these rooms by restricting the amount of resident care equipment and resident's personal effects that could be accommodated in these resident rooms, limiting the resident's ability to move about the room, and decreasing resident's quality of life.