Santa Clara Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff for the food and nutrition services department competently carried out kitchen duties in a safe, and sanitary manner when a staff member was unable to verbalize and demonstrate correct techniques related to testing the sanitizer buckets. This practice had the potential for 172 residents who received food from the kitchen to be exposed to food borne illness due to lack of staff training and monitoring of their duties.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice when:1. A licensed nurse failed to administer one medication to one of 10 residents observed during medication administration;2. The facility failed to ensure four of 45 residents (Residents 14, 32, 45, and 174) had physician's orders for bed rails. The facility also failed to ensure Resident 32 had a care plan to address the use of bed rails;3. Licensed nurses failed to accurately complete multiple Daily Documentation forms for one of 35 sampled residents (Resident 76); and 4. Licensed nurses failed to document multiple administrations of treatments on the treatment administration record (TAR) for three of 35 sampled residents (Residents 76, 95, and 129). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications were taken out of the medication rooms and carts when expired medications were observed in two of four medication rooms and one of eight medication carts. This failure had the potential for residents being administered ineffective medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection prevention and control practices were followed when:1. The door of a Covid-19 (a respiratory illness caused by SARS-CoV-2 virus) isolation room for two residents (Residents 79 and 124) was left open after Certified Nursing Assistant (CNA) K entered and exited the room;2. A CNA was observed improperly handling dirty linen;3. There was no enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes) signage posted at the entrance to Resident 202's room; and4. The indwelling catheter (a flexible tube inserted through the urethra (a tube like structure that connects to the bladder] and into the bladder [urine sac] to drain urine) urine drainage bags for Residents 2 and 140 were on the floor. [...]

Inspectors wroteBased on observation, interview and record review, the interdisciplinary team (IDT, group of healthcare members that meet to discuss and plan residents' care) failed to identify and determine if one of 35 sampled residents (Resident 116) could safely self-administer and store medications that were kept at bedside. This failure placed Resident 116 at risk for unsafe medication self-administration, and had the potential to result in medications being accessed by unauthorized individuals such as other residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light button (button used to activate a visible and audible alarm when a resident needs assistance) was within reach for four of 178 residents (Residents 74, 129, 140, and 182). This deficient practice had the potential to result in a delay in meeting the residents' needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five residents (Resident 53) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) when:1a. Resident 53 had an as-needed (PRN) order for lorazepam (medication used to treat anxiety [excessive worry, fear and nervousness]) without a stop date, and there was no side effects monitoring for lorazepam use; and1b. Resident 53 had a PRN order for haloperidol (an antipsychotic medication that helps treat several kinds of mental health conditions) without a stop date. These failures had the potential for increased risks associated with the use of psychotropic medications that could negatively affect the residents' physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) was accurately completed for two of 35 sampled residents (Residents 16 and 46). This failure had the potential to compromise the facility's ability to develop and implement an individualized plan of care for the residents. This failure also had the potential to compromise the accuracy of the facility's quality measures (reports that reflect the facility's performance in certain care areas), which could negatively affect the facility's ability to identify areas for improvement and implement interventions accordingly.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Serious Mental Illness (SMI) Level II Health Evaluation (an assessment that determines if an individual with mental illness requires special services) was completed for one of seven sampled residents (Resident 7). This failure had the potential to result in Resident 7's needs not being met while residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of 11 sampled residents (Residents 6, 88 and 206) received necessary respiratory care and services in accordance with professional standards of practice when:1. Licensed staff failed to ensure oxygen (O2, a colorless, odorless gas) was administered as specified in the physician's order for Resident 6;2. Resident 6's door or entrance did not have a posted Oxygen in use/No smoking sign; 3. Resident 88's door or entrance did not have a posted Oxygen in use/No smoking sign; and4. Resident 206's door or entrance did not have a posted Oxygen in use/No smoking sign. These failures had the potential to compromise the residents' health and safety.

Inspectors wroteBased on interview and record review, the facility failed to complete multiple Facility-Dialysis Unit Communication Report forms for one of seven residents (Resident 76). This failure had the potential to compromise the facility's ability to identify potential complications and implement interventions accordingly.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure bed rails were assessed for the risk of entrapment (person's head, neck or body becoming trapped or entangled in the spaces of a bed's side rails, frame or mattress) for one of 45 residents (Resident 14). Resident 14 was observed to be in bed with two half bed rails elevated at the head of bed. There was no assessment supporting the bed rails were evaluated to be safe from entrapment. This failure created a potential for health and safety risk for the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five residents (Residents 85 and 95) were free from unnecessary medication when.1. Resident 95 had no side effects monitoring for rivaroxaban (an anticoagulant medication used to treat and prevent blood clots); and2. Resident 85 received furosemide (used to treat edema [fluid retention; excess fluid held in body tissues]) without monitoring for edema. These failures resulted in unmonitored side effects of anticoagulant medication and unmonitored medical condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food according to the scheduled menu for three of 172 residents (Residents 84, 89 and 196). The lunch menu for 9/8/25 indicated strawberry poke cake was to be provided and two residents were not served cake. This failure had the potential to cause disappointment for the residents.

Inspectors wroteBased on interview and record review, the facility failed to implement their antibiotic stewardship program (program intended to prevent overuse of antibiotics) for one of five residents (Resident 168) on antibiotics (medications used to treat bacterial infections) when the McGeer Criteria (a tool used to track infection) and/or Loeb's Criteria (a tool used to determine when to initiate antibiotic treatment for suspected infections) were not done. This failure had the potential to increase the prevalence of multi-drug-resistant organisms in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a medication was administered as prescribed by the physician for one of three sampled residents (Resident 1) when Resident 1 received 12 doses of Tacrolimus (a medication used to suppress [preventing something] the immune system) 5 milligrams (mg, unit of measurement), which was 10 times the ordered dose of 0.5 mg. This failure had the potential to result in Tacrolimus toxicity (the quality of being poisonous or harmful) for Resident 1 and could potentially contribute to Resident 1's hospitalization on 4/19/25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow guidelines for masking during respiratory illness season when four staff members were observed not wearing face mask. This failure had the potential to spread infection throughout the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure appropriate treatment and services were provided to one of two residents (Resident 1) when the restorative nursing assistant (RNA, program that helps residents to gain and improve quality of life by increasing their level of strength and mobility) services were not implemented per the physician's order. The deficient practice had the potential to result in residents' decline in range of motion.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, staff performed their job functions competently according to standards of practice when one cook did not properly verbalize the cool down process for cooking any hot foods such as meat dishes. This failure had the potential to expose 175 residents to food borne illnesses.

Inspectors wrote2. Review of Resident 55's medical record indicated Resident 55 was admitted on [DATE] and had diagnoses including diabetes (a disease that impairs the body's ability to control blood sugar) and depression (a mood disorder that causes persistent feelings of sadness and loss of interest). Review of Resident 55's Order Summary Report indicated Resident 55 had the following physician's orders, dated 1/24/24, for diabetes: 1. Insulin aspart (medication used to lower blood sugar) 100 units per milliliter (unit/ml, dose measurement) inject 14 units subcutaneously (SQ, under all layers of the skin) before meals; and 2. Insulin NPH (medication used to lower blood sugar) 100 unit/ml inject 7 units SQ two times a day. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure significant weight loss was monitored and assessed for one of five sampled residents (Resident 165) when staff did not address significant weight losses, did not initiate weekly weights, and did not convene an interdisciplinary team (IDT, team members from different departments involved in a resident's care) meeting regarding Resident 165's significant weight losses. These failures had the potential to result in Resident 165's further unplanned weight loss.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for two of 39 sampled residents (Residents 68 and 50). Failure to accurately assess had the potential to compromise the facility's ability to develop care plans and provide interventions to meet the residents' needs.

Inspectors wroteBased on observation, interview and record reviews, the facility failed to ensure, a complete monitoring and documentation of the change of condition for one out of six residents investigated, (Resident 179), when nurses did not have complete documentation and monitoring for Resident 179's change of condition. These failures had the potential to affect the resident's care and could compromise the resident's health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper care was provided to one of two sampled residents receiving oxygen (Resident 48) when Resident 48 did not have a physician order for her oxygen use. This failure had the potential to compromise Resident 48's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate accountability of controlled medications (those with high potential for abuse and addiction) when random controlled medication use audit for three of eight residents (Residents 64, 173, and 183) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate they were administered to the residents. The failure resulted in inaccurate accountability and had the potential for misuse or diversion of controlled medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow a menu, approved by the facility's registered dietitian (RD) according to the facility's policy, for three out of three sampled residents, when a fruit cup was served instead of a snickerdoodle cookie for the consistent carbohydrate (CCD, eating the same amount of carbohydrates everyday, a nutritionally balanced diet to meet specific nutrition needs) renal diet and renal diet (diet that is low in sodium, phosphorous and protein). This failure had the potential to cause decreased food intake and compromise the resident's nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hospice services were provided in accordance with professional standards of practice for one of three sampled residents (Resident 68) when Hospice Aide G (HA G) transferred Resident 68 with a Hoyer lift (mechanical lift, machine used to transfer immobile residents with a sling) without assistance from another person. This failure had the potential to compromise Resident 68's safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection prevention and control practices for five out of 39 sampled Residents (Residents 5, 82, 37, 47, and 166, ) when: 1. Residents 5 and 82 were fed at the same time by two Certified Nurse Aides without performing hand hygiene; and 2. For Residents 37, 47, and 166, their urine drainage bags (a bag that collect urine) were on the floor; These deficient practices had the potential to result in transmission and spread of infection to the residents and staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from physical abuse for one out of two residents (Resident 1) when Resident 2 hit Resident 1 in the face, causing injury to Resident 1's above the eyebrow area and first aid being administered. Resident 2's act of hitting Resident 1 in the face was a deliberate act to inflict harm or injury, not accidental; therefore, his action was deemed a willful act and considered abuse. This failure had the potential to cause both physical and emotional harm to all residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and sanitary environment for residents when four of seven shower stalls were found to have molds. This failure had the potential to compromise residents' safety, health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure proper technique was used when transferring one of three sampled residents (Resident 1) with a Hoyer lift (machine used to transfer immobile residents with a sling). This failure resulted in Resident 1's assisted fall and had the potential to result in injury.

Inspectors wroteBased on interview and record review the facility failed to ensure staff followed their fall policy for two of three sampled residents who fell and sustained injuries (Residents 1 and 2). Resident 1 fell eleven times and there were missing interdisciplinary team (IDT, members of the health care team who meet to discuss and plan residents' care) meetings to indicate comprehensive post fall assessments were conducted and post fall care plans were not consistently updated with preventative measures. For Resident 2, there was a lack of post fall monitoring of the resident's status. These failures placed residents at risk for further falls, pain and suffering and resulted in a delay in treatment for Resident 2's hip fracture.

Inspectors wroteBased on interview and record review, the facility failed to ensure a care conference (a meeting with the resident or representative to discuss and plan care) was conducted for one of three sampled residents (Resident 1). The facility also failed to provide Resident 1 with a written summary of her baseline care plans (care plan developed within the first 48 hours that includes the minimum information necessary to properly care for the resident upon admission). These failures had the potential to compromise the resident's right to participate in developing and implementing her plan of care.

Inspectors wroteBased on interview and record review, the facility failed to provide care and service in accordance with professional standards of practice for one of three sampled residents (Resident 1) when: 1. There were multiple days for which there was no documentation that wound treatment was provided as ordered; 2. Nurses did not administer Juven (supplement given to support wound healing) as ordered by the physician; and 3. Nurses inaccurately assessed the resident on multiple days. These failures had the potential to compromise Resident 1's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for four of six sampled residents (Residents 1, 2, 3, and 6) when: 1) Licensed nurses did not follow a physician's order for the administration of oxygen (O2 , a colorless, odorless reactive gas) for Resident 1; 2) Social services (SS) did not conduct an initial assessment and an admission care conference for Resident 1; 3) Registered dietitian's recommendation for Resident 1 was not followed; 4) Licensed nurses did not follow a physician order for Resident 1's follow up appointment with neurologist, cardiologist, orthopedic and spine center; and 5) There were no No Smoking; Oxygen in Use sign posted at the entrance of Resident 2, 3, and 6's bedroom. [...]

Inspectors wroteBased an interview and record review the facility failed to provide required assistance while eating for one out of four sampled residents (Resident 1). Resident 1's minimum data assessment (MDS: Clinical and functional assessment tool) dated 3/8/2023 indicated, Resident 1 required extensive assist (extensive assistance: resident involved in part of the activity and staff provided full assistance with no participation by resident three or more times over the 7 days period) with 1 staff physical assist with his eating. This failure resulted in Resident 1 to aspirate (happens when food, liquid, or other material enters a person's airway and eventually the lungs by accident) the food, became unresponsive, with no blood pressure, no pulse, stopped breathing, and physician pronounced Resident 1's death in the facility.

Inspectors wroteBased on interview and record review the facility failed to provide a thorough five-day investigation addressing an allegation of financial abuse to the California Department of Public Health (CDPH) in a timely manner for one of three sampled incidents of alleged resident abuse (Incident 1). This failure had the potential to delay corrective actions had the allegation had been proven true.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for one of three residents investigated, (Resident 1), when the facility failed to ensure, for Resident 1: 1. a care plan specific to Resident 1's altercation with other residents and hitting them with his cane, was developed and 2. his care plan, related to episodes of wanting to have a cane or walker, indicating that it was unsafe for Resident 1 to use a cane or walker, was followed. These failures had the potential to result in the resident, not receiving the interventions and care, necessary to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan intervention for one of five sampled residents (Resident 1), when staff failed to ensure Resident 1's bed alarm (device that alerts staff if resident gets out of bed) was in place while Resident 1 was in bed. This failure had the potential for Resident 1 to sustain a fall injury.

Inspectors wroteBased on interview and record review the facility failed to implement written facility abuse policy and procedures to prevent abuse for three of three sampled residents (Resident 32, Resident 100, and Resident 119) when the facility failed to: 1. Report Resident 32's and Resident 100's allegation of abuse regarding humiliation. The facility failed to suspend the accused admissions coordinator (AC) when the facility became aware of the allegation of abuse, did not investigate the allegation of abuse and complete a written report of the investigation's findings within five working days of the occurrence, or complete a background check on the AC prior to employment with the facility; 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: a. A refrigerated injectable antibiotic (to treat various infections) was stored at the appropriate refrigerated temperature to prevent freezing; b. An eye drop bottle and an inhaler were labeled properly with a pharmacy label to ensure it was used for the right residents; c. Eleven opened biologicals, multi-dose eye medications, inhalers, and insulin (medication to lower blood sugar level) vials were dated with an open and discard date, to make sure they were not used beyond the discard date; d. Twenty-two expired medications were not available for resident use; and e. One medication had the expiration date on the pharmacy label The deficient practices had a potential for residents to receive vaccine and medications with unsafe and reduced potency from being used past their discard date.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 12 of 27 residents (9, 24, 148, 59, 499, 28, 399, 46, 95, 110, 124, and 151) received necessary and proper care and services when: 1. Certified nursing assistant Y (CNA Y) and certified nursing assistant Z (CNA Z) delivered Resident 24's lunch tray to Resident 9 and delivered Resident 101's lunch tray to Resident 24; 2. Resident 148 did not have heel protectors on as ordered; 3. Assessment for pain was not done prior to dressing change for Resident 499; 4. Dressing orders were not followed for Resident 499; 5. For two days, urinary catheter was not secured or anchored to thigh with device for Resident 499; 6. Toenail trimming was not completed for two residents (Resident 59, Resident 499) resulting in long unkempt nails; 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when: 1. Random controlled medication use audits for four of four residents (Residents 53, 75, 128, and 399) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR, a medical record documenting administered doses of medication) to indicate they were given to the residents. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to act upon the Consultant Pharmacist's (CP) recommendations in a timely manner for two of 27 sampled residents (Residents 95 and 100). The failure resulted in medication-related problems, errors, or irregularities identified and reported by the CP not acted upon and resolved, and the potential for unnecessary medications (such as prolonged use, excessive dose, unmonitored use, duplication, etc.) for the residents.

Inspectors wroteBased on observation, interview and, record review, the facility failed to ensure six out of 27 sampled residents (Residents 19, 38, 64, 95, 100, and 104) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when: 1. Resident 19 received Seroquel (an anti-psychotic medication) for schizophrenia (a chronic, severe mental disorder that affects how a person thinks, acts, expresses emotions, perceives reality, and relates to others) without evidence of behaviors or symptoms of schizophrenia. Also, there was no documented evidence the facility implemented non-pharmacological (non-drug) interventions before starting the Seroquel; 2. Resident 95 received olanzapine (an antipsychotic medication) without documented clinical indication of hallucinations. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a 20.58% error rate when seven medication errors out of 34 opportunities were observed during a medication pass for 5 of 8 Residents (Residents 15, 62, 72, 96, and 249). These failures resulted in medications not given in accordance with the prescriber's orders and/or manufacturer's specifications, which resulted in residents not receiving the full therapeutic effect of the medications and may cause preventable side effects for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 27 sampled residents (Resident 15) was free of a significant medication error when he received insulin lispro (brand name: Humalo) a rapid-acting insulin, medication to lower blood sugar level) twenty-six (26) times (doses) past the discard (expiration) date. This deficient practice had the potential for ineffective use of the insulin, resulting in uncontrolled high blood sugar for the resident.

Inspectors wroteBased on observation, interview and facility document review, the facility failed to provide and served food that was palatable and at an appropriate temperature. These failures placed the 135 residents eating at the facility at risk of poor food intake further compromising their nutritional status.

Inspectors wroteBased on observation, interview and facility document review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety when: 1. The walk-in freezer had ice buildup. 2. The staff did not practice proper hygiene during meal distribution. 3. Food containers were stacked wet. These failures had the potential to cause the growth of microorganisms which could cause foodborne illness or cross contaminate food (cross contamination occurs when unclean surfaces or utensils spread germs to food and can potentially cause foodborne illness) for the residents eating at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control practices when: 1. Certified nurse assistant F (CNA F) did not perform hand hygiene before and after assisting Resident 21 and Resident 145 with lunch; 2. Licensed nurses did not properly store Resident 36's nasal cannula (a tubing used to deliver oxygen (a colorless and a life supporting component of the air) from the machine through the nostrils) when not in use; 3. A licensed staff failed to wipe down the vial stopper of an insulin (a medication for high blood sugar) vial before drawing up the medication; and 4. Two nursing staff used the incorrect disinfectant wipe to clean/disinfect the glucometer (a medical device used to measure blood sugar levels) after resident use. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to treat two of four residents (Residents 21 and 36) with respect and dignity when: 1. Certified nurse assistant F (CNA F) was standing while feeding Resident 21; 2. Licensed vocational nurse C (LVN C) was standing while feeding Resident 36. These failures had the potential to negatively affect residents' emotional and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 12 residents (108 and 127) had informed consents (written permission before implementing a healthcare intervention) prior to initiating psychotropic medication (medication capable of affecting the mind, emotions, and behavior). This failure resulted in the residents receiving psychotropic medications without being informed about their risks and side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents (148) received services and treatment to prevent further decrease in range of motion (ROM, refers to how far a person can move or stretch a part of the body, such as a joint or a muscle) when a hand roll was not applied to Resident 148's contractured left hand as ordered. This failure had the potential to result in declining of the ROM for Resident 148's left hand.

Inspectors wroteBased on interview and record review, the facility failed to consistently complete the dialysis (the clinical purification of blood as a substitute for the normal function of the kidney) post assessment for four of four residents (Residents 2, 46, 111 and 137) who received dialysis services. Failure to assess had the potential to compromise the facility's ability to identify and address potential complications after dialysis.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure residents' food was stored in a safe and sanitary manner, when one of three refrigerators designated for residents had perishable food (likely to spoil, decay or become unsafe to consume) that were not dated and discarded, and staff food or drinks were stored inside the same refrigerator. This failure had the potential for the contamination of residents' food.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure to ensure all staff were fully vaccinated for COVID-19 (a new infectious viral disease that can cause respiratory illness) when there was no evidence proof of vaccination were obtained for two certified nursing assistants (CNA T and CNA U). This had the potential to spread COVID-19 infection to staff, residents, and visitors. During interview and concurrent record review with the Infection Preventionist (IP), on 4/25/2022 at 2:02 p.m., the IP stated that two certified nursing assistants are booster eligible for the COVID-19 vaccine and had not provided proof of vaccine. The IP stated neither CNA provided a declination from either their clergy or a health care provider to the facility. [...]

Inspectors wroteBased on observation interview, and record review, the facility failed to provide a safe and comfortable environment for seven of seven residents and any visitors when the janitor closet door on the memory care unit was open to the hall with cleaning chemicals inside. This had the potential to adversely affect the health and safety of those seven residents and any visitors.