Tulare Healthcare & Wellness Center, LP

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) when one of three sampled resident's (Resident 1) Release for responsibility for leave of absence (RFRFLOA) form was incomplete. This failure had the potential for Resident 1 to be at risk for injury or harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Ensure four of 45 sampled residents (Resident 38, Resident 86, Resident 76, and Resident 29) were provided palatable (pleasant to taste) meals at a safe temperature. This failure had the potential for to cause foodborne illness (illness caused by the ingestion of contaminated food or beverages) and unintended weight loss.2. Ensure 45 of 45 sampled residents were served foods prepared in a method which maintained nutritive value of food, when vegetables were not prepared as close as possible to serving time. This failure had the potential to decrease the nutritional value of the food, cause nutritional decline, and negatively affect the resident's health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 45 of 45 sampled residents were served food prepared according to professional standards for food service safety and sanitary kitchen conditions when: 1. Dry food item was not stored in an airtight sealed container. 2. Three boxes of produce were not labeled with received dates. 3. Clean cooking utensils were not covered to prevent contamination. 4. Temperature of vegetable was not taken before serving to resident plate. 5. Dirty food serving pan was not sanitized before re-use. These failures had the potential to cause foodborne illnesses (illness caused by the ingestion of contaminated food or beverages) for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 45 sampled residents (Resident 38, Resident 86, and Resident 53) were provided a homelike environment that ensured comfortable sound levels and reduced chronic noise. This failure had the potential to cause stress, decreased rest, and other health concerns. for Resident 38, Resident 86, and Resident 53.

Inspectors wroteBased on observations, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Person-Centered Care Planning, for three of 24 residents (Resident 64, Resident 5 and Resident 10). This failure had the potential to result in Resident 64, Resident 5 and Resident 10's care needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 98) physician order for oxygen therapy was followed. This failure had the potential to result in oxygen toxicity (a condition where breathing too much oxygen starts to harm the body's cells instead of helping them) for Resident 98.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an environment free of accident hazards for 45 of 45 sampled residents when a pack of cigarettes and a lighter were found unsupervised on a table, outside, near the 300 hallway exit door. This failure had the potential to result in the burn injuries, fire or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three sampled Licensed Vocational Nurses (LVN 2, LVN 1, and LVN 3) completed a wound vacuum (a device that removes fluid, reduces swelling and increases blood flow to wound and stimulates tissue growth) care and dressing change competency. This failure had the potential to result in severe complications including infection, bleeding, skin damage, pain, and tissue damage to the wound.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 8) had an informed consent for psychotropic (medication to treat mental disorders) medication prior to administration. This failure resulted in Resident 8 receiving psychotropic medication without his consent and without knowing the risks and benefits of the medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure a discharge notice was sent to Ombudsman (an advocate for residents of nursing homes, board and care centers and assisted living facilities) for one of two sampled residents (Resident 85). This failure had the potential to result in Resident 85 not having an advocate who could inform them of their admission, transfer, and discharge rights.

Inspectors wroteBased on interview and records review, the facility failed to ensure one of five sampled staff (Certified Nursing Assistant [CNA] 2) had a completed initial competency evaluation completed upon hire. This failure had the potential to result in CNA 2 providing care that did not meet the resident's needs.

Inspectors wroteBased on interview and records review, the facility failed to ensure one of five staff (Certified Nursing Assistant [CNA] 1) completed an annual performance review. This failure had the potential to result in CNA 1 providing care that did not meet the residents' needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Monthly Medication Regimen Review (MRR evaluation of medications by a pharmacist to identify, prevent or resolve medication related problems) recommendations was acted upon for one of five sample residents (Resident 85). This failure had the potential to result in adverse health outcomes for Resident 85.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure medications were properly labeled in two of four sampled medication carts (Med Cart 1 and Med Cart 2). This failure had the potential to result in residents receiving the wrong medication, the wrong dose, or another resident's medication. 2. Ensure medications were stored in a safe and secure manner when;a. One of four sampled medication carts (Med cart 2) was left unlocked;b. One of 24 sampled residents (Resident 44) medications were left unattended on Resident 44's bedside table. These failures had the potential to result in accidental ingestion by residents, drug diversion/theft, medication being misplaced and/or tampered with, and data breech of resident health information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention practices when:1. One of two clean laundry bins had dirt-like debris at the bottom.2. One of one unmarked laundry bin containing clean pillows was stored in the dirty laundry area.3. Two of five sampled staff members (Medical Doctor [MD] 1, Nurse Practitioner [NP] 1) did not apply appropriate Personal Protective equipment (PPE, gowns, gloves, face masks, face shields or other equipment designed to protect the wearer from injury or the spread of infection or illness) prior to providing care to a resident on enhanced barrier precautions (EBP, an infection control practice that utilizes the use of gown and gloves during high contact care activities to stop the spread of multi-drug resistant organisms [MDRO]). 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident's (Resident 9) feeding pump (used to deliver feeding and nutrition through a gastrostomy tube [G-tube inserted through the abdominal wall into the stomach) was secured to a pole to prevent pump from falling. This failure had the potential to cause injury to Residents, staff, and visitors and cause injury to Resident 9's G-tube if feeding pump falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, functional, sanitary, and comfortable environment when:1. Two of two laundry dryer filters were not free of thick lint buildup. This failure had the potential to increase the risk of a fire affecting residents' safety. 2. One of one shower room ceiling had cracked ceiling plaster. This failure had the potential to increase the risk mold and contaminants which can contribute to respiratory illness in residents.3. One of two housekeeping carts containing chemicals was missing the locking top. This failure had the potential to result in an increased risk of residents' exposure to accidental ingestion, poisoning, skin and or eye irritation, and burns from housekeeping chemicals. 4. Two of two resident restrooms had cracked flooring. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it's policy and procedure (P&P) was followed when apple crisp was substituted with apple cake and the Registered Dietician (RD) was not notified. This failure had the potential for the residents to be at risk of inadequate nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide accommodation of needs for one of five sampled resident (Resident 1), when Resident 1 was left lying in bed while side rails (prevent falls and assist getting in and out of bed) were placed to Resident 1's bed using a drill (power tool). This failure resulted in Resident 1's bed shaking, causing severe pain to Resident 1's fractured (broken) left leg.

Inspectors wroteBased on interview and record review, the facility failed to ensure transportation was provided for one of five sampled residents (Resident 1). This failure resulted in Resident 1 missing scheduled follow up appointment with orthopedic doctor (treats injuries and disease affecting bones, muscle, and etc.) and potential for increased risk of complications, prolonged recovery, and worsening pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the care plan for one of three sampled resident's (Resident 1) when Resident 1's abrasion to the left shin treatment order ended and it was not re-evaluated. This resulted in Resident 1 not receiving treatment or monitoring of the abrasion and had the potential for the abrasion to worsen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care plan intervention for one of three sampled residents (Resident 1) with a known history of elopement (the act of leaving facility unsupervised and without prior authorization) attempts. This failure resulted in Resident 1 leaving the facility unsupervised and without a wander guard (wearable bracelet that detects resident with cognitive impairments approaches or attempts to exit), putting Resident 1 at risk for serious injury.

Inspectors wroteBased on interview and record review, the facility failed to follow its own policy and procedure when an allegation of abuse was not reported to the proper authorities for one of three sampled residents (Resident 1). This failure resulted in violation of Resident 1's rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a working generator for 13 of 13 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, and Resident 13) requiring an oxygen concentrator (a device that provides oxygen) during a power outage. This failure resulted in the facility having no power for approximately 15 minutes and potential for Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, and Resident 13 without oxygen and potential for respiratory distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when: 1. The facility policy and procedure (P&P) titled Laundry Services was not followed for one of one laundry room not clean and sanitary. 2. The facility P&P titled Housekeeping-General was not followed when a used toilet brush was left on top of the clean area of one of two housekeeping carts. 3. The facility P&P titled Personal Protective Equipment was not followed when two of 19 nursing staff (Licensed Vocational Nurse [LVN] 9 and Certified Nursing Assistant [CNA] 4) did not remove the N95 mask (respiratory protective device) before leaving an transmission based precaution (measures used to protect staff, patient and visitors from infection) room. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to arrange regularly scheduled resident council meetings for three out of three sampled residents (Resident 53, Resident 51 and Resident 29). This failure resulted in the denial of Residents to meet regularly to discuss care and quality of life issues, and for the facility to be unaware of and unable to address residents' concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1. Follow physician orders (PO) to wrap one of one sampled resident's (Resident 287) left leg daily. This failure resulted in Resident 287's leg to become red and swollen. 2. Complete weekly nursing assessments for two of three sampled residents (Resident 77 and Resident 36). This failure had the potential for residents' physical and emotional care needs to go unmet. 3. Follow its policy and procedure (P&P) titled, Medication-Self Administration, for three of 22 sampled residents (Resident 1, Resident 24, and Resident 43) when the facility did not complete the Assessment for Self Administration of Medications ([NAME]). This failure had the potential for medication to be inaccurately administered by the resident.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled Activity Program when: 1. Activity assessments were not completed for five of five sampled residents (Resident 337, Resident 46, Resident 438, Resident 42, and Resident 41). 2. Activity care plan was not completed for one of five sampled residents (Resident 438). These failures had the potential for the facility to not be aware of Resident 337, Resident 46, Resident 438, Resident 42, and Resident 41 activity preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete Social Service Assessments (SSA) within seven days of admissin for three of seven sampled residents (Resident 388, Resident 438, and Resident 337). This failure had the potential for not meeting residents' psychosocial needs.

Inspectors wroteBased on observation and interview, the facility failed to ensure meals were served at a safe and palatable (appetizing) temperature for two of three sampled residents (Resident 41 and Resident 42). This failure had the potential for residents not meeting their nutritional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Dietary Department-Infection Control when one of one Dietary Aide (DA) 1 did not wash his contaminated hands before returning to food service. This failure had the potential to contaminate food and cause food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of 41 sampled resident's (Resident 337, Resident 70, Resident 10, and Resident 41) call lights were within reach. This failure had the potential for residents to be unable to call for assistance and had the potential for delayed care provision.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Advance Directive [legal document indicating resident's decision for end-of-life treatment and care] when one of two sampled residents' (Resident 41) request for more information on advanced directives was not provided.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled Disclosure of PHI [protected health information] for one of one sampled residents (Resident 61) when one of Resident 61's medical diagnoses was disclosed to Resident 61's roommate. This failure resulted in the Former Director of Nursing (FDON) revealing Resident 61's PHI to another resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policies and procedure titled Pressure Injury Prevention for one of seven sampled residents (Resident 75) did not receive preventative interventions for a pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). This failure resulted in Wound Care Provider (WCP) performing a surgical excisional procedure to remove non-living tissue in Resident 75's pressure wound and had the potential for Resident 75 to continue to develop further skin breakdown and the Stage 3 pressure injury to worsen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policies and procedures (P&P) titled, Gait Belt dated 9/16 and Ambulation when Physical Therapy Assistant (PTA) ambulated one of three sampled residents (Resident 438) without a facility provided gait belt, and supported Resident 438 by holding onto her pants waistband. This failure had the potential for Resident 438 to fall and sustain injuries.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders (PO) for pain management for one of one sampled residents (Resident 75) when: 1. Physician ordered pain medications were not given as ordered for one of one sampled residents (Resident 75). 2. Physician ordered non-pharmacological (not using non-medication) interventions were not implemented for one of one sampled residents (Resident 75). These failures resulted in Resident 75 refusing to eat, pain not being managed and had the potential for more pain medication to be used.

Inspectors wroteBased on observation, interview, and record review, the facility failed to reorder medication timely for one of 13 sampled residents (Resident 28) This failure resulted Resident 28 not receiving his physician ordered medication and had the potential for Resident 28's glaucoma to worsen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its: 1. Policy and procedure (P&P) titled, Medication Storage in the Facility for three of 22 sampled residents (Resident 1, Resident 24, and Resident 43) when medications were found at residents' bedside. This failure had the potential for medication to be accessed by unauthorized staff and residents. 2. P&P titled Medication Storage in the Facility and the Manufacturer's Instructions for use (IFU) for one of one medication. This failure had the potential to result in a loss of medication potency (strength), inaccurate test results and adversely affect the residents' health. 3. P&P titled Medication Storage in the Facility was not followed when two of two medication carts stored topical medications (eye drops, injectable medications, creams, ointments, lotions and patches) with oral medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 27) had a follow-up dental appointment. This failure had the potential to result in decreased appetite and weight loss due to difficulty eating.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meal preferences were honored for two of 41 sampled residents (Resident 55 and Resident 1). This failure had the potential for Resident 55 and Resident 1's nutritional needs to not be met and the potential for unintended weight loss due to the food not meeting their nutritional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed obtain a therapeutic diet order for one of three sampled residents (Resident 388). This failure had the potential for Resident 388 to not obtain sufficient calories and nutrients.

Inspectors wroteBased on interview and record review, the facility failed to follow the facility's policy and procedure (P&P) titled, Completion & Correction when two of 4 sampled residents' (Resident 27 and Resident 36) medical record were not accurate. This failure had the potential to negatively impact the interventions and treatments for Resident 27 and the continuity of care for Resident 36

Inspectors wroteBased on interview and record review, the facility failed to ensure previous employment and personal reference checks were completed for two of two sampled employees (Registered Nurse [RN] 1 and RN 2) prior to being hired. This failure had the potential to put residents at risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was monitored every 30 minutes after eloping from the facility. This failure had the potential for Resident 1 to be at risk for further elopement and at risk for harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe discharge was provided for one of two sampled resident (Resident 1) when Resident 1 was discharged home with Resident 2's prescribed medications. This had the potential for Resident 1 to take the wrong medication and potential for adverse effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with respect. This failure resulted in Resident 1's rights being violated.

Inspectors wroteBased on interview and record review, the facility failed to notify one of three sampled residents (Resident 1) Physician when Resident 1 had a significant change in condition requiring hospitalization. This failure resulted in a delay of care.

Inspectors wroteBased on interview and record review, the facility failed to assess one of three sampled residents (Resident 1) when Resident 1 had a significant change in condition. This failure has the potential for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure wound care was provided for one of three sampled residents (Resident 1) according to physician's order. This failure has the potential to result in worsening of Resident 1's wounds.

Inspectors wroteBased on interview and record review, the facility failed to notify one of two sampled residents (Resident 1) Responsible Party (RP) after a fall resulting with a black left eye and a cut to left lower lip. This failure resulted Resident 1's RP not being notified of the fall incident.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician ' s orders were followed for one of three sampled residents (Resident 1). This failure resulted in Resident 1 not receiving an antibiotic as ordered for an infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement infection control and prevention practices according to facility ' s policy and procedure for 18 of 18 residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 16, Resident 17, Resident 18) during an outbreak of Covid (a highly contagious easily spread viral infection) infection in the facility. This failure had the potential to result in spread of Covid infection and other infectious diseases to residents, staff, and visitors. During an observation on 11/8/23 at 11:14 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility: 1. Failed to implement plan of care for one of four sampled residents (Resident 2). 2. Failed to develop a plan of care for one of four sampled residents (Resident 1). These failures had the potential for Resident 1 and Resident 2 to have further falls.

Inspectors wroteBased on interview and record review the facility failed to implement their policy titled Transfer and Discharge for one of three sampled residents (Resident 1). This failure resulted in a delay in return to facility from an acute hospital and had the potential for an adverse outcome due to an unsafe discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure a criminal background check was completed prior to hire for one Licensed Vocational Nurse (LVN) 1. This failure had the potential for residents to be at risk for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Maintain food storage and food handling practices in a safe and sanitary manner. 2. Keep the ice machine in the kitchen clean and sanitary. 3. Dispose food beyond used-by-date. These failures had the potential for transmission of food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control practices when: 1. Hand-held nebulizer (a device that turns liquid medications into a fine mist, allowing for easy absorption into the lungs) mouthpiece and facemask connected to a continuous positive airway pressure (CPAP machine- used in the treatment of sleep apnea) were left exposed and unlabeled on the shelf located on the wall behind Resident 37's bed. 2. Oxygen tubing/connector was on the floor. 3. Certified Nursing Assistant (CNA) 1 did not properly dispose of her gown and gloves when exiting Resident 36's room, which was on transmission-based precaution (used to help stop the spread of germs from one person to another), and touched the doorknob with used and contaminated gloves to open the door. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents or residents' representatives participated in the care planning conferences for four of five sampled residents (Resident 4, Resident 29, Resident 34, and Resident 176). This failure had the potential for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Re-evaluate and document current condition for Level 1 Preadmission Screening and Resident Review (PASARR-a federal requirement to ensure residents with mental disorder or intellectual disabilities are not inappropriately placed in a nursing home) for one of four sampled residents (Resident 29). 2. Refer and coordinate with the appropriate State-designated authority for three of four sampled residents (Resident 4, Resident 18, and Resident 36) with positive Level 1 PASARR for Level ll PASARR (filled out if Level I is positive) determination. These failures had the potential for Resident 4, Resident 18, Resident 29, and Resident 36 to not receive the appropriate services related to their mental disorder, intellectual disabilities, or other related cognitive impairment.

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan (initial plan of care for newly admitted residents completed within 48 hours of admission) was completed for four of eight sampled residents (Resident 237, Resident 240, Resident 235, Resident 241) within 48 hours of admission. This failure had the potential to result in unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' Informed Consents (process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) for psychoactive medications (drugs that cause changes in mood, thoughts, feelings, or behavior) were signed appropriately for two of three sampled residents (Resident 4 and Resident 36). This failure had the potential for Resident 4 and Resident 36 to not fully understand the treatment/intervention and consequences of the decisions regarding the use of psychoactive or psychotropic medications (drugs/medications use to manage symptoms of anxiety, depression, psychological distress, and/or insomnia [difficulty sleeping]).

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents (Resident 36 and Resident 37) had physician's orders and were determined to self-administer medications safely. This failure had the potential for adverse consequences.

Inspectors wroteBased on interview and record review, the facility failed to ensure personal property for one of one sampled resident (Resident 176) was secured and free from theft or loss. This failure resulted in Resident 176's feeling deeply upset from the loss of her personal cell phone.

Inspectors wroteBased on interview and record review, the facility failed to conduct further investigation of an alleged theft by facility staff for one of one sampled resident (Resident 176)'s personal cell phone. This failure had the potential for more incidents of theft and loss in the facility when further investigations are not completed.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive care plans for two of eight sampled residents (Resident 235 and Resident 241). This failure had the potential to result in unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to evaluate the effectiveness of the fall care plan and update the care plan with physician participation for the care of one of one sampled resident (Resident 29) who had fallen seven times during the course of her stay at the facility. This failure resulted in Resident 29's reoccurrence of multiple falls with the same plan of care.

Inspectors wroteBased on interview and record review, the facility failed to provide an ongoing activity program to meet the needs and interests for one of eight sampled residents (Resident 241. This failure resulted in Resident 241 feeling socially isolated and depressed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain skin integrity related to wound healing in accordance with the comprehensive assessment and plan of care for one of one sampled resident (Resident 237). This failure resulted in increased swelling and pain for Resident 237.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 241) received services to meet the resident's behavioral health care needs. This failure resulted in Resident 241's increase episodes of sadness and feelings of depression causing decreased appetite.

Inspectors wroteBased on interview and record review, the facility failed to make a dental referral for two of two sampled residents (Resident 18 and Resident 49 ) with cracked, broken, and missing teeth. This failure had the potential to result in unplanned weight loss due to poor dentition affecting residents' ability to eat.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were accurate for one of one sampled resident (Resident 34). This failure had the potential to affect resident's care when information, progress, and condition of the resident were not properly documented in accordance with Resident 34's health condition.