Vineyards at Fowler

Inspectors wroteBased on interviews and record review, the facility failed to ensure all alleged violations involving abuse or neglect were reported immediately (but not later than 2 hours if serious bodily injury is involved, or within 24 hours if no serious bodily injury) to the local ombudsman (neutral, independent public official or office tasked with defending the public's interests and investigating complaints), state survey agency (SA- a state-level government department that inspects health care facilities) and local law enforcement for one of four sampled residents (Resident 1) when Resident 1 reported to Licensed Vocational Nurse (LVN) and Infection Preventionist (IP- professionals who make sure healthcare workers and patients are doing all the things they should to prevent infections) that Certified Nurse Assistant (CNA) 1 showed her a nude video of CNA 2, and the facility did not report the [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Dietary Manager was qualified to perform the duties of a dietary supervisor when the facility was unable to provide documentation the Dietary Supervisor (DS) completed a state-approved program in dietetic service supervision. Regulatory requires individuals in this role to meet one of seven recognized qualification pathways. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the food preparation sink was equipped with a required air gap to prevent contamination, when the food preparation sink was observed without an air gap, creating the potential for backflow and contamination of food and food-contact surfaces. This failure had the potential to affect 40 of 41 residents who received meals prepared in the facility. During an observation on 9/30/25 at 8:16a.m. in the kitchen, the one-compartment sink located next to Fridge 2 was observed with beans soaking. During an interview on 1/6/26 at 12:51p.m. with Kitchen Staff (KS) 1, KS 1 stated the small, one-compartment sink was used as the food preparation sink. KS 1 indicated the two-compartment sink was used only as a backup if the dishwasher was not functioning. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure garbage was stored and disposed of in a manner that prevented unsanitary conditions when 3 of 3 outdoor dumpsters were observed with lids open and one dumpster was overflowing. This failure had the potential to attract pests, create offensive odors and negatively impact food safety and the overall sanitary environment of the facility. During an observation on 1/6/26 at 12:44 p.m. the facility's dumpsters located behind the building were observed with all three lids in the open position. One dumpster contained overflowing boxes, which prevented the lid from closing securely. During an interview on 1/6/26 at 12:51 p.m. with Kitchen Staff (KS) 1, KS1 stated the lids of the dumpsters were required to remain closed at all times to prevent pests. During an interview on 1/7/26 at 3:08p.m. [...]

Inspectors wroteNumber of residents sampled: 4Number of residents cited: 1Based on observation, interview and record review, the facility failed to ensure professional standards of practice and the facility's policies and procedures were followed for one of four sampled residents (Resident 46) when Resident 46's psychotropic medication (psychoactive drugs that alter brain chemistry to treat mental illness) brexpiprazole (used to treat Alzheimer's disease- disease characterized by a progressive decline in mental abilities) ordered on 12/7/25, was not available for administration and was documented in the Electronic Medication Administration Record (EMAR- a digital system that replaces paper charts to streamline and secure the process of giving medications to patients) as administered on 12/10/25, 12/18/25, 12/19/25, 1/5/26 and 1/6/26. [...]

Inspectors wroteNumber of residents sampled: 6Number of residents cited: 2Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent when the facility's medication error rate was 9.68 percent. There were 31 opportunities for errors and three medication errors occurred for three of six sampled residents (Resident 5 and Resident 46) when:1. Licensed Vocational Nurse (LVN)1 did not follow Resident 46's physician's order of multivitamins when she administered multivitamin with minerals to Resident 46 on 1/7/26. This failure had the potential for Resident 46 to develop adverse reaction to medication that was not prescribed to her which could result in serious health condition.2. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview and record review, the facility failed to ensure proper storage and disposal of medications and biologicals in accordance with facility policy and procedures when:1. Two expired medications were found in one of one medication rooms. This failure had the potential for residents to receive medication that no longer had the desired efficacy with the potential to slow healing, and or relieve pain and discomfort.2. [...]

Inspectors wroteNumber of residents sampled: 4Number of residents cited: 1Based on interview and record review, the facility failed to ensure Minimum Data Set Assessment (MDS-assessment of physical and psychological function needs) accurately reflected resident's health and function for one of four sampled residents (Resident 21) when Resident 21's use of lorazepam (medication uses for anxiety) was inaccurately coded in the MDS assessment dated [DATE]. This failure had the potential to result in Resident 21's care needs not being met and the potential risk for adverse medication reactions not be monitored. [...]

Inspectors wroteNumber of residents sampled: 4Number of residents cited: 2Based on interview and record review, the facility failed to ensure a level 1 Preadmission Screening and Resident Review (PASARR-a federal requirement to ensure residents with mental disorder or intellectual disorder or intellectual disabilities are not appropriately placed in a nursing home) were completed and the state mental health authority or stated intellectual disability authority was notified promptly after a significant change of condition for two of four sampled residents (Resident 21 and Resident 46). This failure had a potential risk for Resident 21 and Resident 46 not to have received the appropriate services related to their mental health needs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a nurse staffing data was posted in a visible location for residents, families, and visitors. This failure did not allow the residents and their families to access important information about the facility staffing levels, which could affect their ability to make informed decisions about safety and quality of care provided. During a concurrent observation and record review on 1-8-26 at 12:30 p.m., with the facility's administrator (ADM), outside of the business office, the nurse staffing data was not displayed. The ADM stated that the nurse staffing data belongs in the empty clear folder that is taped to the outside of the window. [...]

Inspectors wroteNumber of residents sampled: 6Number of residents cited: 2 Based on observation, interview and record review, the facility failed to provide pharmaceutical services which ensured appropriate administration of medications to meet residents needs for two of six sampled residents (Resident 46 and Resident 5) when Resident 46's psychotropic (medications that alter brain chemistry to affect mood, thoughts, and behavior) medication brexpiprazole (used to treat Alzheimer's Disease-a disease characterized by a progressive decline in mental abilities) and Resident 5's inhaler (a small, handheld medical device that delivers medicine as a mist or spray directly to the lungs for treating respiratory conditions like asthma) medication fluticasone propionate/salmeterol (used for treatment of breathing problems in patients with asthma) were not available to administer on 1/7/25. [...]

Inspectors wroteNumber of residents sampled: 4Number of residents cited: 1Based on observation, interview, and record review, the facility failed to ensure food preferences were accommodated for one of four sampled residents (Resident 16) when Resident 16's standing physician order for strawberry shake was not served to Resident 16 during lunch on 9/30/25. This failure had the potential risk to result in Resident 16 not meeting nutritional needs, which could lead to unplanned weight loss. During a concurrent interview and record review on 9/30/25 at 12:20 p.m. in the dining room, Resident 16 was sitting in her wheelchair with her lunch tray positioned in front of her. Resident 16's lunch tray did not include a strawberry health shake. Certified Nursing Assistant (CNA) 1, was observed seated next to Resident 16 and assisting with lunch. [...]

Inspectors wroteNumber of residents sampled: 4Number of residents cited: 2Based on observation, interview, and record review, the facility failed to ensure adaptive equipment was provided for two of four sampled residents (Resident 14 and Resident 16) when:1. During a meal observation in the dining room on 9/30/25, Rehabilitative Nursing Assistant (RNA) used plastic straws instead of spoon for Resident 14's liquids. This failure had the potential for Resident 14 to aspirate while drinking fluids.2. Resident 16 was not provided sippy cup on her meal tray during lunch on 9/30/25. This failure had the potential to limit Resident 16's ability to drink independently and safely. 1. During a concurrent observation and interview on 9/30/25 at 12:12 p.m. [...]

Inspectors wroteBased on observation and interview during the survey period from 9/30/25 through 1/9/26, the facility failed to ensure each bedroom accommodated no more than four residents (rooms [ROOM NUMBERS]). This failure had the potential to adversely affect care provided to residents in room [ROOM NUMBER] and 14. During an observation on 9/30/25 through 1/9/26, in room [ROOM NUMBER] and 14, the two resident bedrooms had more than four residents. Each room met the required needs of the residents, as well as the square footage. Closet and storage space were adequate. Bedside stands were available. There were sufficient room for nursing care to be provided to the residents. Wheelchair and toilet facilities were accessible. The health and safety of residents would not be adversely affected by the continuance of this waiver. [...]

Inspectors wroteBased on observation, interview and record review during the survey period of 9/30/25 to 1/9/2026, the facility failed to provide the minimum of at least 80 square feet per resident in multiple rooms (Rooms 1, 6, 8, 10, 11 and 16). This failure had the potential for residents not to have reasonable accommodations for privacy or adequate space for care to be rendered. During a concurrent observation and interview on 1/9/25, at 12:47 P.m., with the Maintenance Supervisor (MS), an environmental tour was conducted. The MS measured six rooms and stated the rooms did not meet the minimum square footage of 80 square feet per resident. These rooms were as follows: Room Number: Square Feet: [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents were treated with dignity and respect for one of seven residents (Resident 1) when two Certified Nurse Assistants (CNA 2, CNA 3) spoke loudly and disrespectfully to Resident 1 and accused her of taking her roommate's remote control and adjusting the television to face Resident 1. This failure placed Resident 1 at potential risk for emotional distress, depression, mental instability, and decline in overall health. During an interview on 11/25/25 at 9:38 a.m., Resident 1 reported two CNAs (CNA 2, CNA 3) accused her of turning her roommate's TV and taking the remote control. Resident 1 stated the CNAs spoke loudly and angrily, calling her a liar, which she found unprofessional and hurtful. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to protect residents' rights and ensure they were free from misappropriation of property, medications were administered as prescribed, and controlled drugs were properly accounted for and discarded according to facility's policy and procedure for two of three sampled residents (Resident 5 and Resident 6) when License Vocational Nurse (LVN) 5 diverted controlled medications (drugs regulated by law for potential abuse, addiction, or dependence) prescribed for Resident 5 and Resident 6 for personal use and failed to properly document, discard discontinued medications according to facility's policies and procedures. These failures resulted in Resident 5 and Resident 6 not receiving their prescribed medications as ordered which placed them at risk for inadequate pain management and anxiety. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain accurate controlled substance records, documentation and reconciliation in accordance with facility's policies and procedures for two of three sampled residents (Resident 5, 6) when the license nurses (LNs) failed to accurately document and account Resident 5 and Resident 6 controlled substance on the Controlled Drug Records and Medication Administration Record to accurately reflect the controlled substance disposition or resident administration. These failures resulted in the facility's delayed detection of controlled substances diversion for Residents 5 and 6, and placed residents at potential risk for medication errors, untreated pain, and overdose, compromising residents' safety and quality of care. During an interview on 11/25/25 at 12:09 p.m. [...]

Inspectors wroteBased on interviews, and record reviews the facility failed to ensure residents were free from unnecessary medications administration for three of three sampled residents (Resident 1, 5, and 6) when license nurses (LN) assessed Resident 1, Resident 5, and Resident 6's pain levels as mild to moderate and administered pain medications prescribed for severe pain, not in accordance with the physician's order. These failures had the potential to place Resident 1, Resident 5, and Resident 6 at risk for over-medication, respiratory distress, impaired cognition, falls, and inadequate pain control. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the residents responsible party (RP- an individual who has the authority to act on behalf of the patient)/family/emergency contact of a change in condition for two of three sampled residents (Resident 1, 6) when Resident 1 experienced seizures (abnormal electrical activity in the brain) and Resident 6 reported chest pain and were transferred to acute care hospital. This failure had the potential to result in Resident 1 and Resident 6's RP/family/emergency contact being unaware of the acute health conditions, hospital transfers, and treatment decisions, which could negatively impact continuity of care and right to have their representatives involved in care decisions. During a concurrent interview and record review on 8/22/25 at 1:41 p.m. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents received adequate supervision to prevent elopement for one of six sampled residents (Resident 1) when Resident 1 left the faciity on 2/17/25 without facility staff's knowledge and did not return. This failure resulted for Resident 1 at a higher risk of harm such as dangerous weather exposure, getting hit by a car or being assaulted.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Licensed Nurses have the competencies necessary to meet the needs and safety of the residents for one of six sampled residents (Resident 1) when Licensed Vocational Nurses (LVN) 3 and LVN 4 failed to notify the facility Administrator (ADM), Director of Nursing (DON) and the authorities when Resident 1 left the facility and did not return. This failure resulted in delayed in emergency response and placed Resident 1 at increased risk for harm such as dangerous weather exposure, getting hit by a car or being assaulted.

Inspectors wroteBased on interview, facility document review, and facility policy review, the facility failed to ensure the facility-wide assessment was updated and reviewed annually. This deficient practice had the potential to affect all residents who resided in the facility.

Inspectors wroteBased on interview and facility policy review, the facility failed to maintain an effective infection control program. Specifically, the facility failed to establish and implement a surveillance plan to identify, track, and monitor infections. This had the potential to affect all residents who resided in the facility.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to support a resident's choice to be out of bed by not providing the necessary specialized wheelchair needed for the resident to be out of bed for 1 (Resident #26) of 16 sampled residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure activities of daily living (ADLs) were provided for 1 (Resident #4) of 16 sampled residents. Specifically, Resident #4's fingernails were not properly trimmed.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to have a physician's order for the use of supplemental oxygen for 1 (Resident #98) of 1 sampled resident reviewed for respiratory care.

Inspectors wroteBased on interview, facility document review, and facility policy review, the facility failed to ensure a registered nurse (RN) was on duty daily for eight consecutive hours. This deficient practice had the potential to affect all residents who resided in the facility.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a PRN (pro re nata, as-needed) psychotropic medication had a 14-day stop date for 1 (Resident #12) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to accurately transcribe hospital discharge medication orders for 1 (Resident #12) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, facility document review, and facility policy review, the facility failed to ensure 2 (room [ROOM NUMBER] and room [ROOM NUMBER]) of 16 residents' rooms accommodated no more than four residents per room.

Inspectors wroteBased on observation, interview, facility document review, and facility policy review, the facility failed to provide the required 80 square (sq) feet (ft) of living space per resident in 6 (Rooms 1, 6, 8, 10, 11, and 16) of 16 multiple occupancy resident rooms. This failure had the potential for residents to not have reasonable accommodations for privacy or adequate space for care to be rendered.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two residents (Resident 1) had a correctly completed Minimum Data Set Assessment (MDS, a comprehensive, standardized assessment tool) when a review indicated six (6) incorrect entries. These six (6) errors indicated a pattern of incorrect assessment results, resulting in Resident 1's MDS that was not reflective of her status at the time of the assessment, and had the potential for Resident 1 to have unmet care needs that did not address her status, needs, strengths, and areas of decline.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of three sampled residents (Resident 1) when Resident 1 had a new onset of confusion, hallucinations (seeing and/or hearing things that are not real) and was yelling. This failure resulted for Resident 1's new onset of altered level of consciousness needs such as monitoring and safety to go unmet.

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards of quality for one of three sampled residents (Resident 1) when Resident 1 was assessed with a new onset of confusion and hallucination (seeing and/or hearing things that are not real) and a physician's order for urine culture and sensitivity test (lab test to check for bacteria and germs in the urine) was not done to determine if an infection was present and the cause of the confusion. This failure resulted for Resident 1's urinary tract infection (UTI-a condition in which bacteria invades and grow in the urinary tract) to go untreated which led to Resident 1's new onset of confusion and hallucination.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had a history of psychological problems and previous attempts to leave the facility on 4/11/24, received the necessary supervision from staff during another attempt to leave the facility on 5/12/24. This failure resulted in Resident 1 being unattended while in the parking area of the facility, who then quickly left the facility without supervision and was found 20 minutes later wandering on a nearby street. This failure had the potential for injury to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 48 sampled residents (Resident 1) received Trauma Informed Care Evaluation (a process that acknowledge the need to understand patients ' life experiences to deliver effective care and treatment) performed when the Social Services Director (SSD) did not complete a Trauma Informed Care Evaluation for Resident 1. This failure had the potential for the facility ' s inability to identify triggers which could result in Resident 1 ' s re-traumatization (the reactivation of trauma symptoms by way of thoughts, memories, or feelings related to past experienced).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 48 sampled residents (Resident 1) had a Social Services Evaluation completed. This failure had the potential for unmet care needs for Resident 1, who was recently admitted to the facility, including care for mood and behaviors, adjustment to the new environment, mental health history, support systems, and behavioral interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure seven of 13 sampled residents (Residents 10, 11, 13, 25, 32, 33, and 36) received diabetic (disease in which the body's ability to produce or respond to the hormone insulin is impaired) management care in accordance with professional standards of practice when: 1. Resident 10 did not have a baseline (starting point) hemoglobin A1C (HBA1c- test tells you your average level of blood sugar over the past two to three months; the target A1c level for people with diabetes is usually less than 7% [percent]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to make information available for three of seven sampled residents (Residents 23, 25 and 29) when residents were unaware of how to file a grievance or complaint. This failure had the potential to result in Resident 23, 25 and 29 to have their concerns or grievances unaddressed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS-a resident assessment tool used to identify resident care needs) assessment accurately reflected the resident's current status for three of three sampled residents (Residents 5, 13, and 39) when: 1. Resident 5's MDS assessment of hearing and cognition were not coded accurately; 2. Resident 13's dialysis (use of machine to remove wastes from the body and keep body in balance) status was not coded (a system of signals used to represent letters or numbers in transmitting messages) accurately in Section O (Special Treatments, Procedures, and Programs) of the MDS assessment; and 3. Resident 39's MDS assessment for identification information was not coded accurately to indicate the accurate discharge status. [...]

Inspectors wroteDuring an observation, interview, and record review the facility failed to provide an ongoing activities program for three of seven sampled residents (Residents 1, 11, and 23) when the facility did not support residents in their choice of activities. This failure had the potential to result in Resident 1, 11, and 23 being bored and verbalizing the facility did not have activities to do daily.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food served met the daily nutritional needs for 21 of 37 residents (Residents 1, 3, 7, 10, 12, 13, 15, 16, 19, 20, 21, 22, 23, 28, 29, 31, 33, 34, 187, 189 and 190) when residents on regular and large portion diets were served more than the required portion size of the main dish [meatballs]. This failure had the potential to result in Resident 1, 3, 7, 10, 12, 13, 15, 16, 19, 20, 21, 22, 23, 28, 29, 31, 33, 34, 187, 189 and 190 to receive more than the recommended daily calorie intake based on residents nutritional dietary needs.

Inspectors wroteBased on interview, and record review the facility failed to provide suitable, nourishing snacks for four of seven sampled residents (Residents 1, 11, 23, and 29) when facility staff did not provide a variety of snacks for residents in the facility. This failure resulted in Resident 1, 11, 23, and 29 verbalizing and requesting different types of snacks from staff and staff did not notify the Dietary Service Manager (DSM).

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve food in accordance with professional standards for food safety when the Dietary [NAME] (DC) did not document the temperatures of the food served on 5/10/21 and 5/11/21. This failure had the potential to cause foodborne illness (caused by consuming contaminated foods or beverages) in 37 of 39 residents who consumed food prepared the kitchen.

Inspectors wroteBased on observation, interview and record review the facility failed provide a safe, clean, and homelike environment when: 1. One of one bathroom (Bathroom [ROOM NUMBER]) had baseboards there were peeled, the walls had even paint, and tiles were missing and broken near the shower tub; 2. One of one bathroom (Bathroom [ROOM NUMBER]) had a soap dispenser that was not functional; and 3. One of 35 Residents (Resident 34) had a gap between the window and the window seal. These failures created an environment that was not homelike and had the potential to result in a decreased quality of life for residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline (starting point) care plan for one of six sampled residents (Resident 188), when Resident 188 did not have a care plan for hospice (care focuses on terminally ill patient's pain and symptoms and emotional and spiritual needs at the end of life) care within 48 hours of admission. This failure had the potential to result in Resident 188's hospice needs to go unmet.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan for one of three sampled residents (Resident 187), when Resident 187's did not have a care plan to address his hard of hearing and Resident 187's care plan for activities of daily living (ADL- routine activities people do every day without assistance. There are six basic ADLs: eating, bathing, getting dressed, toileting, mobility, and continence) was incomplete. This failure had the potential to result in Resident 187's hard of hearing and ADL care needs to go unmet.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure professional standards of practice were implemented for two of two sampled residents (Resident 7 and Resident 20) when: 1. Resident 7 was provided a house supplement (beverage containing protein and other performance substances as ingredients mixed with milk or water for the purposes of improved nutrition) for weight loss and did not have a physician's order for a house supplement; and 2. Resident 20 suffered a fall on 2/12/21 and the licensed nurse on duty did not complete an assessment of Resident 20. Resident 20 had an x-ray (type of radiation called electromagnetic waves, creates pictures of the inside of your body, the images show the parts of the body in different shades of black and white to checking for broken bones) completed on 2/17/21 which indicated a fracture of the long middle finger. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary care and services to ensure a resident's abilities of daily living did not diminish for two of twelve sampled residents (Resident 5 and Resident 29) when: 1. Resident 5 requested a grooming services for a haircut from staff and there was not staff available to provide him with a haircut; and 2. Resident 29's Restorative Nurse Assistant (RNA-helps residents gain/improve strength and mobility) exercises and ambulation were not provided per the physician's order. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain a safe environment with an effective infection prevention and control program for the prevention of Corona Virus (COVID-19- a contagious serious respiratory infection transmitted from person to person) transmission when one of one sampled Licensed Vocational Nurses (LVN 4) did not follow the use of a fit tested (a fit test determines if a tight-fitting respirator can be worn without having any leaks) N95 respirator (protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) when caring residents identified as PUI (person under investigation- someone on observation for symptoms of COVID-19 [a serious respiratory illness caused by a virus which is the cause of a current worldwide pandemic [prevalent over a whole country or the world]) [...]

Inspectors wroteBased on observation and interview during the survey period from 5/10/21 through 5/19/21, the facility failed to ensure each bedroom accommodated no more than four residents (rooms [ROOM NUMBERS]). This failure had the potential to adversely effect care provided to residents in room [ROOM NUMBER] and 14.

Inspectors wroteBased on observation, interview and record review during the survey period of 5/10/2021 to 5/19/2021, the facility failed to provide the minimum of at least 80 square feet per resident in multiple rooms (Rooms 1, 2, 6, 8, 10, 11 and 16). This failure had the potential for residents to not have reasonable accommodations for privacy or adequate space for care to be rendered.