Every finding on record at Garfield Neurobehavioral Center

Based on observation, interview, and record review, the facility failed to protect one of four sampled residents (Resident 1) from physical abuse when Resident 1 was hit on the head and arms by Resident 2 during an altercation on 8/16/25. This failure resulted in Resident 1 suffering facial pain and a headache.During a review of Resident 1's facility document admission Record (AD), printed on 7/2/26, the AD indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (a general term for a group of conditions that affect the brain. It causes problems with memory, thinking, and decision-making that are severe enough to interfere with a person's daily life), antisocial personality disorder, impulsive disorder (a condition where a person has a very hard time resisting sudden urges to do something, even when they know it may be harmful or not appropriate), and intellectual disabilities (a condition that affects the way a person learns, thinks and handles everyday life).During a review of Resident 2's admission Record (AD), printed on 7/2/26, the AD indicated Resident 2 was admitted to the facility on [DATE] and discharged on 9/24/25 with diagnoses including dementia, schizoaffective disorder (a mental illness that affects how a person thinks, feels, and understands reality).During an interview on 7/2/26 at 10:00 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 reported observing Resident 1 being struck on the head and arms by Resident 2 in the facility's common area near the small patio in August 2025.During a review of the facility's document Post Event Assessment (PEA), dated 8/19/26, the PEA indicated that on 8/16/25, Resident 1 was hit by Resident 2 and Resident 1 complained of mild pain on the right side of the face. The PEA also indicated Resident 1 was sent to the hospital on 8/16/25 for evaluation due to a headache. Resident 1 returned to the facility on the same day.During an interview on 7/2/26 at 12:40 p.m. with the Administrator (ADM), the ADM stated the facility is responsible for safeguarding residents from all forms of abuse. The ADM further reported that the incident occurred rapidly and confirmed there had been no prior incidents between the two residents.During a review of the facility's Policy and Procedure (P&P) titled Abuse Prevention and Reporting, undated, the P&P indicated the facility is committed to protecting the physical and emotional well-being and personal possessions of every resident.

Based on observation, interview, and record review, the facility failed to keep one resident, Resident 47, free from sexual abuse when Certified Nursing Assistant (CNA) 1 witnessed Resident 47 being sexually abused by Resident 2 and then closed the door without intervening, leaving Resident 47 at risk for further abuse by Resident 2.This failure resulted in Resident 47 being sexually abused and had the potential for psychosocial harm. Furthermore, this failure had the potential to result in further sexual abuse towards Resident 47 and/or other vulnerable residents in the facility.An Immediate Jeopardy situation (IJ, a situation in which a facility's actions places one or more residents in jeopardy of being significantly harmed up to the point of possible death if not immediately corrected) was identified and called due to the failure of the facility to protect Resident 47 and all other vulnerable residents from sexual abuse. The Administrator (ADM) and Director of Nursing (DON) were verbally notified of the IJ situation on 7/30/25 at 8:21 p.m. During a visit to the facility on 8/1/25, the facility provided an acceptable plan of action and the IJ was removed at 3:57 p.m. During a review of Resident 47's admission Record dated 7/29/25, the admission Record showed Resident 47 was admitted to the facility in December 2018.During a review of Resident 47's Quarterly Minimum Data Set (MDS - an assessment tool used to guide care), dated 6/5/25, MDS showed Resident 47 had multiple diagnoses that included Huntington's Disease (brain disorder that causes involuntary movements cognitive decline, and behavioral changes), non-Alzheimer's dementia (a condition that causes decline in cognitive abilities such as thinking), and depression.During a review of Resident 47's Care Plan dated 12/14/18, the Care Plan indicated, Resident 47 had a diagnosis of Huntington's Disease and required dependent assist with two or more staff due to choreic (involuntary, jerking) movements. The Care Plan also indicated, Resident 47 was at risk for victimization (any unwanted or forced sexual activity, ranging from unwanted physical contact to rape) and one of Resident 47's goals was to maintain dignity and self-esteem. Resident 47's Care Plan did not show an active intervention that addressed risk for victimizationDuring a review of Resident 47's Post Event Assessment Form, dated 7/26/25, under B. Situation 1. Description of the event/Why the doctor is being called indicated, CNA 1 reported that he saw [Resident 47's] room door shut. He checked and saw Resident 2 with his pants down and had Resident 47's private area in his [Resident 2's] mouth.During a review of Resident 47's Nursing Progress Notes, dated 7/26/25, the Nursing Progress Notes indicated .staff reported that he saw [Resident 47's] room door shut. He checked and saw Resident 2 with his pants down and had Resident 47's private area in his [Resident 2's] mouth.During a review of Resident 2's admission Record, dated 7/29/25, the admission Record indicated Resident 2 was originally admitted to the facility in December 2020 and was readmitted in August 2022. During a review of Resident 2's Annual MDS, dated [DATE], the MDS showed Resident 2 had multiple diagnoses that included impaired cognitive functions and awareness.During a review of Resident 2's Care Plan dated 8/9/22, the Care Plan indicated Resident 2 was at risk for physical altercations, property destruction and inappropriate sexual behavior. The Care Plan also indicated, Resident 2 made comments of a sexual nature and masturbated in front of staff.During a review of Resident 2's Post Event Assessment Form, dated 7/26/25, under B. Situation 1. Description of the event/Why the doctor is being called indicated, Staff reported that he saw peer [Resident 47] room door shut. He checked and saw Resident 2 with his pants down and had peer's [Resident 47's] private area in his mouth.During a review of Resident 2's Nursing Progress Notes, dated 7/26/25, the Nursing Progress Notes indicated .Staff reported that he saw peer [Resident 47's] room door shut. He checked and saw Resident 2 with his pants down and had peer's [Resident 47] private area in his mouth.During an interview on 7/29/25 at 1:15 p.m. with CNA1, CNA 1 stated, when he opened the door to Resident 47's room, he saw Resident 2 with his pants pulled down to his legs. CNA 1 stated, Resident 2 had his head on Resident 47's private part. CNA 1 also stated, he left Resident 47's room to get help.During a concurrent observation and follow-up interview on 7/29/25 at 1:35 p.m. in Resident 47's room with CNA 1, CNA 1 demonstrated the incident. CNA 1 opened the door to Resident 47's room. CNA1 stated he saw Resident 2 with his pants pulled down to his legs. CNA 1 then walked towards Resident 47's bedside and stated he saw Resident 2 with his head over Resident 47's private area. CNA 1 added, he saw Resident 47's penis showing. CNA 1 further stated, he left Resident 2 in Resident 47's room because he was scared. During a concurrent observation and interview on 7/29/25 at 1:50 p.m., with Clinical Director (CD), in the security room, the video footage from 7/26/25 was reviewed. The video footage showed the following:14:24:42 Resident 2 appeared at the bottom of the screen walking in the hallway.14:24:48 Resident 2 looked towards Resident 47's room.14:24:50 Resident 2 entered Resident 47's room.14:24:56 Resident 47's door closed. 14:25:19 CNA 1 appeared on (bottom) screen and looked towards Resident 47's closed door.14:25:47 CNA 1 opened Resident 47's door, partially stepped in. CNA 1 then stepped outside Resident 47's room. 14:25:57 CNA 1 closed Resident 47's door, walked towards Nursing station 3, then disappeared from the screen.CD confirmed CNA 1 closed the door and left Resident 2 inside Resident 47's room. CD stated, CNA 1 was afraid.14:26:12 Resident 2 exited Resident 47's room. 14:30:16 Registered Nurse (RN) 1 looked into Resident 47's room from the hallway.14:30:23 RN 4 looked into Resident 47's room from the hallway.14:36:40 CNA 1, CNA 2, CNA 3, CNA 4 followed by RN 4, Licensed Vocational Nurse (LVN) 2, RN 1 all entered Resident 47's room.During a follow-up interview on 7/29/25 at 3:14 p.m. with CNA 1, CNA 1 stated, he closed the [Resident 47's] door because he was very scared of Resident 2 following him after he had witnessed Resident 2 sexually abusing Resident 47. During a telephone interview on 7/29/25 at 3:47 p.m. with RN 4, RN 4 stated, RN 1 reported to her that Resident 2 had his mouth in Resident 47's private area. RN 4 stated, she walked by Resident 47's room but did not go inside to assess Resident 47.During a concurrent interview and record review interview on 7/30/25 at 2:38 p.m., with CD, the SOC 341 form (form used in California to report suspected abuse of a dependent adult or elder person) completed by CNA1 and dated 7/26/25 was reviewed. CD confirmed CNA 1's statement under C. REPORTERS'S OBSERVATIONS, BELIEFS, AND STATEMENTS. indicated, I put a resident in the shower and saw Resident 47's door shut. I opened the door and stepped in and saw Resident 2 with his pants down and had Resident 47's private area in his mouth.During a telephone interview on 7/31/25 at 10:11 a.m., with Resident 47's Conservator (CSV), CSV stated, the facility notified her that another resident was giving Resident 47 oral sex. CSV added, she was afraid for the safety and well-being of Resident 47 because this was not the first time Resident 47 was sexually abused in the facility. CSV further added, the facility was not doing enough to keep Resident 47 safe otherwise the abuse would not have happened again. CSV also stated, Resident 47 was vulnerable and was not able to scream or ask for help due to his condition.During a concurrent interview and record review on 7/31/25 at 4:09 p.m. with DON, DON stated Resident 47 was a high risk for victimization due to past incident of being abused by a former staff member at the facility. DON stated, there was no care plan to address risk of victimization, therefore no proper intervention was put in place to ensure Resident 47's safety and well-being. DON also stated, CNA 1 was not supposed to leave Resident 47 when he witnessed abuse happening. DON added, CNA 1 was expected to stay with Resident 47 and initiate a code green to alert other staff of the incident.During a telephone interview on 7/31/25 at 4:40 p.m., with CNA 2, CNA 2 stated on 7/26/25 at around 2:25 p.m., CNA 1 approached her in the hallway near nursing station 1. CNA 2 stated, she followed CNA 1 inside room [ROOM NUMBER] where she was told by CNA 1 he saw Resident 2 with his pants down, bent over sucking Resident 47's penis. CNA 2 added, she and CNA 1 did not immediately check on Resident 47's well-being. CNA 2 stated the expectation was to not leave Resident 47 alone, especially when CNA 1 saw Resident 47 being abused. CNA 2 added, we were supposed to stay with Resident 47 and call code green to alert other staff of the situation. During an interview on 8/1/25 at 9:18 a.m., with RN 1, RN 1 stated, CNA 1 should not have left Resident 47's room when abuse was happening because this placed the resident [Resident 47] at risk for further abuse. RN 1 further added, she did not check on Resident 47 right away after learning Resident 47 was sexually abused. During a review of facility's policy and procedure (P&P) titled, Abuse Prevention and Reporting, undated, revealed under definitions: .3. Sexual abuse - means non-consensual contact of any type with a resident. Sexual abuse includes, but is not limited to: *Unwanted intimate touching of any kind especially of breast or perineal area. *All types of sexual assault or battery, such as rape, sodomy, and coerced nudity. *Sexual contact is nonconsensual if the resident either: .lacks the cognitive ability to consent;.6. Resident to Resident Abuse - Aggressive or inappropriate behavior by one resident towards another comprises resident-to-resident abuse.C. Sexual aggression -examples of sexually aggressive behavior include, but not limited to, saying sexual things, inappropriate touching/grabbing. The P&P also indicated under prevention: .F. Staff is required to intervene, identify, and correct the situations where any type of abuse or suspected crimes may occur .

Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were implemented when the following was observed:Registered nurse (RN) 1 did not sanitize (disinfect; removal of bacteria, etc.) a blood pressure cuff between use for Resident 27 and Resident 37. RN 1 did not sanitize a medication tray between uses during morning medication pass between each Residents observed (Resident 36, Resident 27, Resident 37, Resident 44, Resident 30, and Resident 5).This failure placed facility residents at risk for contracting community infections. During an observation on 07/29/2025 at 08:31 AM RN1 did not sanitize a blood pressure cuff or medication tray after use for Resident 27 and before use for Resident 37.During an observation on 07/29/2025 at 08:43 AM, RN 1 used a blood pressure cuff and medication tray for Resident 37 without sanitizing first after use by Resident 27. During an interview on 07/29/2025 at 09:52 AM with RN 1, RN 1 stated shared equipment such as a vital sign machine, blood pressure cuff and medication tray should be sanitized between each resident. RN 1 stated the facility's policy stated shared equipment should be wiped down with a germicidal wipe and allowed to air dry for three minutes. RN 1 stated it is important to sanitize shared equipment in between each resident use for infection control and prevention. During record review of facility's undated policy and procedure (P&P) titled, Cleaning and Non-Critical, Reusable Equipment Used by Persons Served (SNF), the P&P indicated, .Reusable equipment and medical devices are devices that health care providers can reprocess and reuse on multiple individuals served. These devices are designed for multiple uses and are reprocessed through cleaning followed by disinfection between individuals served .

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions when:a. A mounted can opener was dirtyb. A toaster oven was dirtyc. A knife rack was dirtyd. Multiple food items were stored beyond the use by date. e. Food items stored in the freezer were unlabeled There failures placed the facility's 56 residents, who received food from the kitchen, at risk for foodborne illnesses. During the initial kitchen observation on 7/28/25 at 9:30 a.m. with Food Service Manager (FSM), the following was observed: (a) mounted can opener was dirty with yellow/orange and black residue build up and the blade coating was peeling off(b) countertop toaster oven was dirty with white/brown/black debris inside the compartment and the conveyor. (c) stainless steel wall mounted knife rack was dirty with sticky white residue on the surface where clean knives were stored(d) One opened 1-Quart sized container of Half and half received 7/7/25, had no open or use by date, an opened 1-Gallon (G, unit of measurement) container of milk had no open or use by date, an opened container of tofu had a prepared date of 7/22/25 and use by date of 7/25/25, an opened 1/2 gallon carton of half and half creamer had no open or use by date, an 18-ounce (oz -unit of measurement) container of ground white pepper had a use by date of 6/6/25, a 16-oz container of cumin seed had use by date of 2/13/25, a 16-oz container of ground turmeric had a use by date of 6/13/25, an opened bag of waffle fries did not have open and /or use by date , an opened bag of French toast did not have open and /or use by date and an egg frittata did not have open and /or use by date.During an interview on 7/28/25 at 9:36 a.m., with the FSM, FSM stated the mounted can opener needed to be replaced because rust on the blade can get residents sick. FSM also stated, the toaster has not been cleaned, and debris can contaminate the food that resident consume. FSM further stated, the dirty mounted knife rack can contaminate the clean knives used for food preparation. During an interview on 7/28/25 at 9:59 a.m., with FSM, FSM stated, food items that are labeled with beyond use by should not be stored as there was potential to use them in cooking food being served to residents. FSM added, all food items should be labeled so that staff know when it should be discarded.During a review of the facility's policy and procedure (P&P) titled, SANITATION AND INFECTION CONTROL, dated 2018, indicated under subject: CLEANING SMALL APPLIANCES/EQUIPMENT showed, Equipment will be cleaned and sanitized to prevent food borne illness. Under procedures: .2. Can Openers will be cleaned after each use and sanitized daily.4. Toaster will be cleaned after each use. 5. Knives will be cleaned and sanitized after each use.During a review of the facility's (P&P) titled, SANITATION AND INFECTION CONTROL, dated 2018, indicated under subject: FREEZER STORAGE, showed, .6. Frozen food should be labeled with the date it was placed in the freezer. During a review of the facility's CANNED AND DRY GOODS STORAGE Guidelines, dated 2018, indicated, the recommended maximum storage period if unopen for seasonings/spices was 6-12 months.

Based on observation, interview and record review, the facility failed to ensure adequate storage and labeling of medications when the following occurred:Medication refrigerator in Station 3 medication room did not have a working thermometer to allow for accurate temperature monitoring.Mutli-use over the counter (OTC) Artificial Tears (Lubricating Eye Drops; for relief of dry eyes) was opened and unlabeled without Resident identifier, and undated with first use/open date in Station 2 medication cart. Two expired Antipsychotic medication bubble packaging cards found were in Station 2 medication cart. An Apple Juice box was found in Station 3 medication freezer where other medications were stored. Mutli-use, over the counter (OTC) Bisacodyl Suppositories (medication to treat constipation) was opened, unlabeled without Resident identifier, and undated with first use/open date in Station 3 medication refrigerator. This failure had the potential to result in a medication error, negative Resident side effects related to expired medication, and inadequate stored refrigeration temperature.During an observation and interview on 07/30/2025 at12:45 PM an unlabeled, opened, Artificial Tears (Lubricating Eye Drops) were located in top drawer of Station 2 medication cart. Licensed Vocational Nurse (LVN 1) stated she opened eye drops today and it is important to label medications to prevent medication errors.During an observation and interview on 07/30/2025 at 12:52 PM two expired Antipsychotic medication bubble packaging cards (simplifies the process of organizing medications by neatly arranging each dose in individual compartments, often sealed with protective bubbles), dated 02/25/25, of Quetiapine 50mg (medication used to treat bipolar disorder (depressive and manic episodes) and schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) were located in the second drawer of Station 2 medication cart. LVN 1 stated second drawer is for extra medications, not active medications. LVN 1 stated it is all of the nurses job to go through medication carts and double check expiration dates before administration. LVN 1 stated the risk of storing expired medication is medication errors and potential side effects.During an observation and interview on 07/30/2025 at 01:08 PM the thermometer in Station 3 Medication refrigerator appeared broken and unable to read. Registered Nurse (RN) 5 stated thermometer is working, use the silver thermometer holder to read thermometer, which was placed over the 40 degrees Fahrenheit (F), or 0 degrees Celsius (C) mark at that time. RN 5 stated the Station 3 medication refrigerator temperature was 40 degrees F at that time. During an observation and interview on 07/30/2025 at 01:11 PM a boxed apple juice was found in Station 3 medication refrigerator in the freezer compartment in upper right corner. RN 5 stated that apple juice had been there for years and staff have been unable to remove from freezer compartment.During an observation and interview on 7/30/2025 at 1:44 PM Station 3 medication refrigerator thermometer appeared broken. Facility Manager (FM) stated the thermometer in Station 3 medication refrigerator was broken. RN 5 stated it is important to have a working thermometer in medication refrigerator to make sure all medications are controlled at the right temperature. During record review of facility's policy and procedure (P&P) titled, Medication Storage, dated 1/2023, the P&P indicated, .Medications requiring 'refrigeration' or 'temperatures between 2 degrees C (36 degrees F) and 8 degrees C (46 F) are kept in the refrigerator with a thermometer to allow temperature monitoring .During record review of facility's P&P titled, Medication Storage, dated 1/2023, the P&P indicated, .Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock.During record review of facility's P&P titled, Medication Storage, dated 1/2023, the P&P indicated, .Refrigerated medications should be kept in closed and labeled containers, with internal medications separated from external medications and all medications segregated from fruit juices, applesauce, and other foods used in administering medications .During record review of facility's P&P titled, Medication Administration, dated 1/2023, the P&P indicated, .The nurse shall place a 'date opened' sticker on medication if one is not provided by the dispensing pharmacy and enter the date opened .

Based on observation, interview and record review, the facility failed to maintain a medication error rate of 5% (%: percent, a unit of measure) or less when two medication errors were observed out of 36 opportunities: Resident 44 did not receive two drops of Systane Eye Solution in each eye, per physicians order.Resident 30 did not receive Vitamin B12 Oral Tablet Extended Release 1000mcg (Cyanocobalamin), per physicians order. This failure resulted in a medication error rate of 5.56% and placed Resident 44 and Resident 30 at risk for receiving a subtherapeutic dose and compromised effects of the medications.1.A record review of Resident 44's physician orders dated 12/17/2024, indicated to instill 2 drops of Systane Ophthalmic (Eye) Solution 0.4-0.3 % (PolyethyleneGlycol-Propylene Glycol) in both eyes two times a day for chronic dry eyes (when tears are unable to lubricate eyes).During and observation on 07/29/2025 at 09:07 AM Registered Nurse (RN) 1 donned gloves and placed one drop of Systane Eye Solution in Resident 5's right eye, held right inner canthus, changed gloves, placed one drop in Resident 5's left eye, held left inner canthus, removed gloves and performed hand hygiene. During an interview on 07/29/2025 at 09:52 AM with RN 1 confirmed Resident 5's physician order for Systane Ophthalmic (Eye) Solution 0.4-0.3 % (PolyethyleneGlycol-Propylene Glycol; eye drop protectant against further irritation or to relieve dryness of the eye) in both eyes. RN 1 stated, I thought I gave two. RN stated it is important to give medications per physician orders for patient safety. 2. A record review of Resident 30's physician orders dated 03/01/2024, indicated Vitamin B12 Oral Tablet Extended Release 1000 mcg (Cyanocobalamin/B12; is a nutrient that helps keep your body's blood and nerve cells healthy) give 1 tablet by mouth one time a day for as supplement. During an observation on 07/29/2025 at 09:18 AM RN 1 gave Vitamin B12 Oral Tablet Extended Release 500 mcg. During an interview and record review on 07/29/2025 at 09:52 AM with RN 1 she stated she was supposed to give Resident 30 two tabs of Vitamin B12 compared to the one tablet that was given. RN 1 stated she was not confused on physician order but assumed the Vitamin B12 tablets were 1000mcg each, versus the 500mcg that was available in the bottle. RN 1 stated she should have given two tablets of Vitamin B12 to administer 1000mcg ordered dose. During a record review of facility's Policy and Procedure (P&P), dated 01/23, titled 'Medication Administration' the P&P indicated read the medication label three (3) times before preparing/pouring medication; when pulling the medication, when dose is prepared and before dose is administered.

Based on observation, interview and record review, the facility failed to implement its abuse Policy and Procedure (P&P) when the facility did not report an incident of sexual abuse to law enforcement for two of two Residents (Residents 47 and 2) within two hours of the incident occurring. This failure had the potential to put other residents at risk of further abuse.During a review of Resident 47's admission Record dated 7/29/25, the admission record showed Resident 47 was admitted to the facility on [DATE].During a review of Resident 47's Quarterly Minimum Data Set (MDS - an assessment tool used to guide care), dated 6/5/25, MDS showed resident 47 had multiple diagnoses that included Huntington's Disease (brain disorder that causes involuntary movements cognitive decline, and behavioral changes), non-Alzheimer's dementia (a condition that causes decline in cognitive abilities such as thinking), and depression.During a review of Resident 47's nursing progress notes, dated 7/26/25, indicated staff reported that he saw (Resident 47's) room door shut. He checked and saw Resident 2 with his pants down and had Resident 47's private area in Resident 2's mouth.During a review of Resident 2's admission Record, dated 7/29/25, the admission Record showed Resident 2 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. During a review of Resident 2's Annual MDS, dated [DATE], the MDS showed Resident 2 had multiple diagnoses that included unspecified symptoms and signs with cognitive functions and awareness.During a review of Resident 2's nursing progress notes, dated 7/26/25, indicated Staff reported that he saw peer room door shut. He checked and saw Resident 2 with his pants down and had peer's private area in his mouth. During an interview on 7/29/25 at 1:35 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated, he saw Resident 2 with his pants pulled down to his legs. CNA 1 added, Resident 2 had his head on Resident 47's private part. CNA 1 further added, he left Resident 47's room and reported right away.During an interview on 7/29/25 at 2:38 p.m. with Clinical Director (CD), CD stated, as far as I know, there's a three hour time frame for reporting any abuse allegation. CD added, that she initiated the investigation for the sexual abuse but did not notify the law enforcement right away. CD added, the abuse incident occurred on 2:25 p.m. but she did not call law enforcement until 6:25 p.m. When asked why law enforcement was not called immediately, CD stated, .it was a lot going.During a concurrent follow-up interview and record review on 7/30/25 at 3:42 p.m. with CD, the Incident Timeline dated 7/26/25 was reviewed. CD indicated, she called the law enforcement at 6:25 p.m., four hours after the sexual abuse occurred as reported by CNA 1. During an interview on 7/30/25 at 12:33 p.m. with the Director Of Nursing (DON), DON was asked about the facility process of reporting alleged abuse. DON stated, she was aware of the two hour reporting requirement if there was significant injury. DON added, the incident was not reported within two hours because Resident 47 did not have significant injury. During an interview on 8/1/25 at 3:02 p.m. with DON, DON stated, on 7/26/25 at 2:29 p.m. staff called her to report that Resident 2 sexually abused Resident 47. DON added, she contacted CD at 2:51 p.m. to start the investigation and reporting process. DON stated, she instructed CD to call law enforcement after 4:00 p.m.During a review of facility's Communication Result Report, dated 7/26/25, the Communication Result Report indicated the SOC 341 (document used to report suspected abuse), was submitted to the State Agency at 6:19 p.m.During a review of facility's Communication Result Report, dated 7/26/25, the Communication Result Report indicated the SOC 341 was submitted to the Long Term Care Ombudsman at 6:20 p.m. During a review of facility's Communication Result Report, dated 7/26/25, the Communication Result Report indicated the SOC 341 was submitted to the local law enforcement agency at 6:23 p.m. A review of facility's P&P titled, Abuse Prevention and Reporting undated, the P&P indicated under .PROCEDURE: .4. IDENTIFICATION A. Where the incident reasonably appears to be exploitation, physical, mental, sexual, verbal abuse, abandonment, isolation, financial abuse, or neglect, or the employee has been told by a resident that he/she experienced such behavior or there is a reasonable suspicion of a crime against a resident, the employee must comply with the mandated reported requirements.7. REPORTING GUIDELINES AND TIMEFRAMES; Per California Assembly [NAME] 1417, in all situations with one exception, the reported must a) Verbally report to local law enforcement as soon as practically possible and in no event later than 2 hours after observing, obtaining knowledge of, or suspecting abuse or neglect. The P&P also indicated, pursuant to 42 CFR 483.12 (c) 1) All alleged violations of abuse, neglect, exploitation, or mistreatment. The facility was required to, in accordance with the State law, including to the State Agency and the adult protective services where state law provides for jurisdiction in long-term care facilities (e.g., Ombudsman), All alleged violations: Immediately but not later than 2 hours after forming the suspicion with written report. A review of CDPH All Facilities Letter (AFL) 21-26 Mandated Reporting Requirements of Potential Abuse, Neglect, Exploitation, or Mistreatment of Elders or Dependent Adults dated 7/26/21, the AFL indicated, Pursuant to Title 42 CFR section 483.12(c)(1) for incidents that involve abuse or result in serious bodily injury, facilities must: Call local law enforcement immediately, but no later than two hours after the allegation is made. File a written or electronic report to the LTC ombudsman, local law enforcement, and DO within two hours. Pursuant to Title 42 CFR section 483.12(c)(1) for any other reasonable suspicion that does not result in abuse or serious bodily injury, facilities must: Call local law enforcement as soon as possible, but no later than 24 hours after the allegation is made. File a written or electronic report to the LTC ombudsman, local law enforcement and DO (District Office) within 24 hours.

Based on interview and record review, the facility failed to ensure their abuse policy and procedure was implemented for one of one sampled Residents (Resident 47).This failure resulted in Resident 47 being sexually abused and had the potential for other residents to be unprotected against abuse.During a review of Resident 47's admission Record dated 7/29/25, the admission record showed Resident 47 was admitted to the facility on [DATE].During a review of Resident 47's Quarterly Minimum Data Set (MDS - an assessment tool used to guide care), dated 6/5/25, MDS showed resident 47 had multiple diagnoses that included Huntington's Disease (brain disorder that causes involuntary movements cognitive decline, and behavioral changes), non-Alzheimer's dementia (a condition that causes decline in cognitive abilities such as thinking), and depression.During an interview on 7/29/25 at 1:15 p.m. with CNA1, CNA 1 stated, when he opened the door to Resident 47's room, CNA 1 saw Resident 2 with his pants pulled down to his legs. CNA 1 added, Resident 2 had his head on Resident 47's private part. CNA 1 further added, he left Resident 47's room to get help.During a concurrent observation and interview on 7/29/25 at 1:35 p.m. in Resident 47's room with CNA 1, CNA 1 demonstrated the incident. CNA 1 opened the door to Resident 47's room, stated he saw Resident 2 with pants pulled down to his legs. CNA 1 then walked towards Resident 47's bedside and stated he saw Resident 2 with his head over Resident 47's private area. CNA 1 added, he saw Resident 47's penis showing. CNA 1 further stated, he left Resident 2 in Resident 47's room because he was scared. During a concurrent observation and interview on 729/25 at 1:50 p.m., with Clinical Director (CL), in the security room, the video footage showed the following timeline:14:24-42 Resident 2 appeared on bottom screen walking in the hallway.14:24-48 Resident 2 looked towards Resident 47's room.14:24-50 Resident 2 entered Resident 47's room.14:24-56 Resident 47's door closed. 14:25-19 CNA 1 appeared on (bottom) screen looked towards Resident 47's closed door.14:25-47 CNA 1 opened Resident 47's door, partially stepped in. CNA 1 then stepped outside Resident 47's room. 14:25-57 CNA 1 Closed Resident 47's door, walked towards Nursing station 3, then disappeared from the screen.CD confirmed CNA 1 closed the door and left Resident 2 inside Resident 47's room and stated, CNA 1 was afraid.14:26-12 Resident 2 exited Resident 47's room. 14:30-16 Registered Nurse (RN) 1 looked into Resident 47's room from the hallway.14:30-23 RN 4 looked into Resident 47's room from the hallway.14:36:40 CNA 1 , CNA 2, CNA 3, CNA 4 followed by RN 4, Licensed Vocational Nurse (LVN) 2, RN 1 all entered Resident 47's room.During an interview on 7/29/25 at 3:14 p.m. with CNA 1, CNA 1 stated, he closed the door because he was very scared of Resident 2 following him after he had witnessed Resident 47 sexually abusing Resident 47. During a concurrent interview and record review on 7/31/25 at 4:09 p.m. with Director Of Nursing (DON), DON stated, CNA 1 was not supposed to leave Resident 47 when he witnessed an abuse happening. DON added, CNA 1 was expected to stay with Resident 47 and initiate code green to alert other staff of incident.During a review of facility's policy and procedure (P&P) titled, Abuse Prevention and Reporting, undated, revealed under definitions: .3. Sexual abuse - means non-consensual contact of ay type with a resident. Sexual abuse includes, but is not limited to: *Unwanted intimate touching of any kind especially of breast or perineal area. *All types of sexual assault or battery, such as rape, sodomy, and coerced nudity. *Sexual contact is nonconsensual if the resident either: .lacks the cognitive ability to consent;.6. Resident to Resident Abuse - Aggressive or inappropriate behavior by one resident towards another comprises resident-to-resident abuse.C. Sexual aggression -examples of sexually aggressive behavior include, but not limited to, saying sexual things, inappropriate touching/grabbing. The P&P also indicated under prevention: .F. Staff is required to intervene, identify, and correct the situations where any type of abuse or suspected crimes may occur. During a review of facility's P&P titled, Change in Resident Status (SNF) undated, indicated under procedure B. Process: .2. In the event of suspected physical abuse, a licensed nurse will assess involved individuals without delay (Immediately).

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive epistaxis (nosebleed) care plan for Resident 5 to address medical needs. This failure placed Resident 5 at risk for potential harm from bleeding. During record review of admission record, printed on 8/01/25, Resident 5 was admitted on [DATE].During record review of Resident 5's Minimum Data Set (MDS, an assessment used to guide care) dated 7/17/25, indicated Resident 5's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 09 out of 15, indicated Resident was mildly impaired. During record review on 07/29/2025 at 4:30 PM of Resident 5's 'Post Assessment Form Part 1,' dated 4/11/25 at 02:38 AM indicated in the hallway, Resident noted blood dripping on his nose and took 5 mins to stop the bleeding, denies he pick his nose. No change in LOC. Denies pain or discomfort. Resident on Eliquis 2.5mg BID. Informed MD and ordered to hold Eliquis for 3 days. Ordered carried out.During record review of Resident 5's 'Post Assessment Form Part 1,' dated 4/27/25 at 02:11 AM indicated in Station 1, Resident noted blood dripping on his nose and took 15 mins to stop the bleeding, denies he pick his nose. No change in LOC. Denies pain or discomfort. Resident on Eliquis 2.5mg qd. Informed MD and ordered to hold Eliquis for 3 days. Ordered carried out. hold eliquis, apply pressure to stop the bleeding and give ice chips.During record review of Resident 5's 'Post Assessment Form Part 1,' dated 5/01/25 at 15:11 PM indicated in Station 1, Resident came to station and c/o he has nosebleed and noted blood dripping on his nose, denies he pick his nose, able to stop the bleeding. No change in LOC. Denies pain or discomfort. Resident just start Eliquis 2.5mg qd this am. Informed MD and ordered to hold Eliquis for 3 days and ENT consult for frequent nose bleed. Ordered carried out. hold eliquis, apply pressure to stop the bleeding and give ice chips.During record review of Resident 5's 'Post Assessment Form Part 1,' dated 7/20/25 at 07:20 AM indicated in dining room, Resident noted blood dripping on his nose and took 5 mins to stop the bleeding, denies he pick his nose. No change in LOC. Denies pain or discomfort. Resident on Eliquis 5mg BID. Informed MD and ordered to hold Eliquis for 2 days. Ordered carried out. hold eliquis, apply pressure to stop the bleeding and give ice chips.During record review of Resident 5's progress notes dated 6/3/25 indicated, Noted resident was bleeding from the right nostril. Apply pressure, cold compress, nasal spray. it took 30 minutes before the blood stop. MD will be notified.During record review of Resident 5's progress notes dated 7/1/25 indicated Resident 5 had an appointment with Ear Nose and Throat (ENT) with Dr. [NAME] related to a deviated septum (when the cartilage and bone that divides your nose down the middle is not straight). During record review of Resident 5's physicians orders it indicated, Monitor S/S of Bleeding and notify MD if any occur. Bruising, nosebleeds, bleeding gums, prolonged bleeding from wound or IV or surgical sites, blood in urine or feces or vomit, coughing up blood, abrupt onset hypotension or low platelet count. three times a day.During record review of Resident 5's comprehensive care plan there was no active epistaxis/nosebleed care plan initiated. During a record review of Resident 5's ENT After Visit Summary Notes dated 7/1/25 it indicated Resident #5 had chronic nose bleeds over the past year .noted that bleeds seem to come from both sides .Discussed nasal precautions/epistaxis precautions, Vaseline .return at any time if bleeding continues.During record review of Treatment Team Conference Form (IDT meeting; group of people who have a role in Resident's care) dated 7/17/25 at 14:37 PM indicated Resident 5 was recently seen by local ENT outpatient facility related to scab (a hard, dried blood clot that can form over a cut or broken skin) near nasal septum. During an interview on 08/01/2025 at 3:42 PM with Registered Nurse (RN 3) stated Resident 5 is on monitoring for nosebleeds. In the event Resident 5 were to have a nosebleed RN 3 stated his Eliquis 5mg tablet (blood thinner; a medication used to prevent and treat blood clots) should be held for 24 hours and if the Resident does not have a nosebleed within 24 hours, medication can be resumed as ordered. RN 3 stated nosebleed time should be monitored, stop bleeding with a nose clamp, check vital signs, call physician, document event, and endorse to next shift. RN 3 stated Resident 5 does not have a nosebleed care plan at this time in the electronic health record (an electronic version of a patients medical history), but may have a short term care plan with Director of Nursing (DON) or Minimum Data Set (MDS) Coordinator. RN 3 stated a short term care plan is for issues that are short term or the issues have been resolved. RN 3 stated Resident 5 should have a nose bleed care plan initiated because it import to serve as a guide and or plan of Residents' care. RN 3 stated without a care plan Residents may receive disorganized, poor planned care. During an interview and record review on 08/01/2025 at 4:02 PM with the Director of Nursing (DON) and MDS, they stated Resident 5 had a nose bleed care plan initiated on 4/27/25 but it was resolved by MDS on 7/4/25. MDS stated nosebleed care plan was resolved because he checked the progress notes and last nosebleed was 4/12/25. MDS and DON stated Resident 5 does not have an active nose bleed care plan at this time. MDS and DON stated they were not aware Resident 5 had a nose bleed on 7/29/25. DON stated Resident 5 should have an active nosebleed care plan because the issue is ongoing. MDS stated the active potential impairment skin care plan does not specifically identify nosebleed interventions nor goals. DON stated Resident 5 should have a long term care plan related to nosebleeds to identify ongoing issues, interventions and goals. DON and MDS stated unable to give definition for long term and short term care plans, stated use short term care plans for short term issues. MDS stated the important of care planning is to establish Resident centered goals around specific issues. DON stated importance of care planning is collaboration of team as care plan should reflect the totality of resident, identify problem and find solutions to optimize care of the Resident. During record review of facility's undated policy and procedure (P&P) titled, Change in Resident Status indicated, update care plans as indicated.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from abuse when Certified Nursing Assistant 1 (CNA 1) sexually abused Resident 1 twice in one day. This failure resulted in Resident 1 being sexually abused and had the potential for psychosocial harm. Findings: A review of Resident 1's admission record, dated 1/22/25, indicated Resident 1 was admitted to the facility on [DATE] for Huntington's disease (a disease in the brain which results in cognitive and functional decline) and paranoid schizophrenia (psychiatric disease which causes distrust of information and other people). The admission record indicated Resident 1 was conserved (court ordered arrangement which gives a conservator the power to make decisions for a person who is unable to do so for themselves) by family. A record review of Resident 1's minimum data set assessment (MDS, an assessment tool to guide resident care), dated 6/27/24, indicated Resident 1 was non-verbal, cognitively impaired, unable to make safe decisions, non-ambulatory (unable to move from one location to another independently) and was dependent on staff for all aspects of care including hygiene, toileting and feeding. During a record review of the facility map, the map indicated, on 8/18/25, Resident 1's room was located in a hallway two rooms away from the nurse's station. The nurse's station was located in a room at the end of the hallway. A record review of CNA 1's employment record indicated CNA 1 was employed at the facility from 8/8/22 to 10/23/24. During a record review of CNA 1's actual hours worked record titled, [CNA 1] 1/22/2024-1/22/25, the record indicated CNA 1 had worked at the facility on 8/18/24, from 3:15 p.m. to 10:57 p.m During a record review of facility staffing record titled, PM Shift (evening shift), dated 8/18/24, the staffing record indicated on 8/18/24, CNA 1 was assigned to Resident 1. During an interview on 10/30/24, at 10:45 a.m., with the Administrator (Admin) and the Director of Nursing (DON), the Admin stated, on 10/23/24, the facility received information from the police, that they had arrested CNA 1 and during a search of CNA 1's online storage account, found evidence that CNA 1 had sexually abused a resident. The police shared still images from the video which the DON was able to identify Resident 1 as the resident by identification of Resident 1's genitals and by wall postings and toys featured in Resident 1's room. During an interview on 11/1/24, at 10:00 a.m., with Resident 1's conservator, the conservator stated the police informed them of the sexual abuse. The conservator stated Resident 1 was not able to give consent to anything. The conservator stated Resident 1 would have rejected the advance by CNA 1 and would've knocked the guy's block off if he was able. During a record review of the police report of Resident 1's sexual abuse case titled, [City] Police Department Incident Report, dated 10/23/24, the report indicated police had searched CNA 1's online storage account and found on 8/18/24, CNA 1 had taken two videos of an adult patient .both videos began with an adult diaper covering the patients's genitals .[CNA 1] folded the adult diaper down and exposed the patient's flaccid penis. [CNA 1] then manipulated the patient's [genitals] and masturbated the patient's [genitals] .[CNA 1] was wearing clear disposable gloves in the first video and was bare handed in the second video. The report indicated the facility was able to determine Resident 1 was the patient depicted in the videos and confirmed CNA 1's employment with the facility. The report indicated CNA 1 was charged with Lewd Acts on a Dependent Adult by a Caretaker. During a review of facility policy and procedure (P&P) titled Resident's Rights, undated, the P&P indicated resident rights include the resident's right to the following: .be free from abuse.

Based on observation, interview and record review, the facility failed to ensure controlled medications (substances that have an accepted medical use, medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) in emergency kits (e-kit, a box with emergency medications) were stored appropriately when: 1. two e-kits containing controlled substances were found in locked boxes that were not permanently affixed to the refrigerator in Med room [ROOM NUMBER] and Med room [ROOM NUMBER] 2. an e-kit containing controlled substances was found unsecured on a shelf in Med room [ROOM NUMBER] 3. an e-kit containing controlled substances was found unsecured in the refrigerator in Med room [ROOM NUMBER]. These failures had the potential for diversion and unauthorized access of controlled medications. Findings: 1. During a concurrent observation and interview on 3/21/24, at 10:00 a.m., with Licensed Vocational Nurse 1 (LVN 1), a black lock box was found in a refrigerator in Med room [ROOM NUMBER]. LVN 1 removed the black box from the refrigerator, placed the box on a counter and unlocked it. Inside the box was an e-kit containing two vials of lorazepam (a controlled medication to reduce anxiety). LVN 1 stated e-kits containing controlled medications requiring refrigeration were typically stored in the black lock box in the refrigerator. During a concurrent observation and interview on 3/21/24, at 10:20 a.m., with Registered Nurse 1 (RN 1), a black box was found in a refrigerator in Med room [ROOM NUMBER]. RN 1 removed the black box from the refrigerator, placed the box on a counter and unlocked it. Inside the box was an e-kit containing two vials of lorazepam. RN 1 stated e-kits containing controlled medications requiring refrigeration were normally stored in the black lock box and kept in the refrigerator. During an interview on 3/21/24, at 10:31 a.m., with the Director of Nursing (DON), the DON stated e-kits containing controlled medications could be stored in the black boxes in the refrigerators. During a record review of facility policy and procedure (P&P) titled, Controlled Medication Storage, dated 11/2017, the P&P indicated controlled medications requiring refrigeration are stored within a locked, permanently affixed box within the refrigerator. 2. During an observation on 3/20/24, at 11:28 a.m., an e-kit containing controlled medications was found on a shelf in Med room [ROOM NUMBER]. The e-kit was not locked and could be opened after breaking a thin plastic tie. The e-kit had a list of medications contained in the box and indicated the following: a. acetaminophen-codeine (a controlled medication containing opioids for pain relief) 300-30 mg (milligram, unit of measurement), 4 tablets b. clonazepam (a controlled medication to reduce anxiety) 0.5 mg, 8 tablets c. diphenoxylate/atropine (a controlled medication containing opioids to reduce diarrhea) 2.5-0.025mg, 4 tablets d. lorazepam 0.5 mg, 8 tablets e. phenobarbital (a controlled medication for sedation) vial, 2 vials f. temazepam (a controlled medication to difficulty sleeping) 7.5 mg, 8 tablets g. tramadol (an opioid for pain relief) 50 mg, 8 tablets h. zolpidem (a controlled medication to treat difficulty sleeping) 5 mg, 4 tablets. During a concurrent observation and interview on 3/21/24, at 10:19 a.m., with Licensed Vocational Nurse 2 (LVN 2), an e-kit containing controlled medications was found on a shelf in Med room [ROOM NUMBER]. LVN 2 stated the e-kit should not be on the shelf and needed to be in a locked container. LVN 2 stated the e-kit should be kept in a locked drawer in the med cart. LVN 2 attempted to lock the e-kit in a locked drawer but was unable to do so. LVN 2 stated there was not enough room to store the e-kit in the drawer. During an interview on 3/21/24, at 10:31 a.m., with the DON, the DON stated the e-kit containing controlled medications was expected to be locked in the med cart. The DON stated the unsecured e-kit had the potential for drug diversion. During a record review of facility P&P titled, Controlled Medication Storage, dated 11/2017, the P&P indicated medications included in the DEA classification as controlled substances are subject to .storage .in the nursing care center in accordance with federal, state and other applicable laws and regulations. 3. During a concurrent observation and interview on 3/21/24, at 10:00 a.m., with LVN 1, an e-kit containing lorazepam was found on the door of the refrigerator in Med room [ROOM NUMBER]. A black lock box containing another e-kit with controlled medications was in the same refrigerator. LVN 1 stated the e-kit found on the refrigerator door needed to be secured in a locked container. During a record review of facility policy and procedure (P&P) titled, Controlled Medication Storage, dated 11/2017, the P&P indicated controlled medications requiring refrigeration are stored within a locked, permanently affixed box within the refrigerator.

Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared in accordance with professional standards of food and safety when: 1. Freezer and refrigerator: - Inside Freezer 1, a large, half full, opened bag of frozen potato wedges was without a used-by date. - Inside the three-door paneled refrigerator, three cups of individually scooped protein pudding had no label and used-by date. 2. Equipment: - Ice machine scoop holder was unclean. - An unclean bread knife was stored in the knife rack. - Single-door freezer 3 had ice build-up on the top shelf, directly below the freezer fan. - Dietary staff did not sanitize the thermometer in between use. 3. Food Service Worker 1's (FSW 1) hair was not completely secured to the hairnet. 4. Environment: - Kitchen entrance sink had a leaky faucet. - The pantry entrance was dark and had inadequate lighting. - Kitchen work areas had six overhead light fixtures that were not in good working condition. These failures had the potential to result in contamination of food and food borne illness for 60 out of 60 facility resident census who received food from the kitchen. Findings: 1. During a concurrent kitchen observation and interview on 3/18/24, at 9:40 a.m., with Food Services Manager (FSM), the following were found: - Inside the freezer 1 was a large, half bag of frozen potato wedges. The bag had an opened date of 3/12/24 but did not have a used-by date. FSM stated opened bags of food items should be labeled with used-by dates for safe storage. - Inside the three-door paneled refrigerator where three cups of individually scooped protein pudding were stored did not have a label and used-by date. FSM stated the cups should have been labeled with the name of the food item being stored, placed date, and the used-by date. A review of the facility's policy and procedure (P&P) titled, Labeling and Dating for Safe Storage of Food, revised date 3/6/2020, indicated, Participants will learn that labeling and dating are critical in order to promote food safety .Use Use-By dates on all food once opened and stored under refrigeration .When food is taken out of an original container write the name of the food being stored on the container, the placed date, and the Use-by date . 2. During an observation on 3/18/24, at 9:30 a.m., the wall-mounted ice machine scoop holder located outside by the kitchen was found with about a tablespoonful of water with multiple black sediments settled at the bottom of the scoop holder. During a concurrent follow-up observation and interview on 3/19/24, at 10:15 a.m., with FSM, the ice machine scoop holder was checked. FSM stated the scoop holder had black sediments and appeared like there was mold growth at the bottom of the scoop holder. FSM stated it was the responsibility of the dietary staff to ensure the scoop and scoop holder were cleaned and washed daily. During a concurrent kitchen observation and interview on 3/18/24, at 9:50 a.m., with FSM, an unclean bread knife was found stored inside the wall-mounted knife rack. The bread knife had visible and tactile dried matter stuck to the surface of the knife. FSM stated equipment should be washed well, air dried, and stored clean after each use to decrease the risk of bacterial growth and cross-contamination. A review of the facility's P&P titled, Sanitation and Infection Control, subtitled, Cleaning Small Appliances/Equipment, dated 2018, indicated, Equipment will be cleaned and sanitized to prevent food borne illness .Knives will be cleaned and sanitized after each use . During a concurrent kitchen observation and interview on 3/18/24, at 10:00 a.m., with FSM and Registered Dietitian and Nutritionist (RDN), the single-door freezer 3 was checked. FSM confirmed there was ice build-up on the plastic bag of frozen food placed on the top shelf directly below the freezer fan. RDN stated it looked like moisture that leaked from fan perhaps from the constant opening and closing of the freezer door. RDN stated it was not typical and not normal to have an ice build-up inside the freezer below the freezer fan and should be looked upon by Maintenance and/or vendor. During a concurrent observation and interview on 3/19/24, at 11:12 a.m., with FSM and Cook 1, Cook 1 checked the temperature of the cold drinks using the calibrated (the ice-point method done to ensure accurate temperature readings) thermometers. Cook 1 poked the thermometer through the plastic cover of the lemonade juice then pulled the thermometer out and re-inserted the thermometer through the plastic cover of the apple juice. The thermometer was not sanitized after switching from one glass of juice to the next. FSM stated Cook 1 should have sanitized the thermometer in between use. During an interview on 3/20/24, at 11:02 a.m., FSM stated when using the same thermometer on multiple drinks, thermometers should be sanitized in between use to prevent cross- contamination. A review of the facility's P&P titled, Food Thermometer Use and Calibration, undated, indicated, .Cleaning and Sanitizing .Thermometers are cleaned and sanitized after use .Sanitize the thermometer with the food grade sanitizer .When using the same thermometer on multiple different foods during one meal, wipe the thermometer with an alcohol swab, clean cloth, or paper towel between different food items . 3. During a concurrent observation and interview on 3/18/24, at 9:37 a.m., with FSM, FSW 1's hair to the forehead and back of the neck were not completely covered by the hairnet. FSM called the attention of the FSW 1 and gestured to go and fix her hair so that all the hair is fully secured inside the hairnet. FSM stated hairnets prevent staff's hair from getting in contact with the food, drinks, or trays, etc. during meal preparation and service. A review of the facility's P&P titled, Sanitation and Infection Control, subtitled, Personal Hygiene, dated 2018, indicated, .A hair net and/or head covering which completely cover all hair should be worn during meal preparation and service . 4. During a concurrent observation, interview, and record review on 3/18/24, at 9:37 a.m., inside the kitchen, with the Food Services Manager (FSM), entrance sink right faucet handle did not close tightly when turned off. FSM stated food service workers were trained to report kitchen issues to the Environmental Services Director (EVSD) by using the Environmental Maintenance Log Binder located outside by the kitchen next to the Ice Machine. Review of the Environmental Log Binder did not indicate any reported leaky faucet. During a concurrent observation and interview on 3/19/24, at 10:15 a.m., a second observation of the entrance sink continued to reveal a leaking faucet, this time less leaky than the initial observation. FSM stated EVSD was aware and looking for other options to completely fix the leaky faucet. During an interview on 3/21/24, at 10:00 a.m., with the EVSD, EVSD stated food service workers usually gave verbal report instead of using Environmental Maintenance Log Binder located next to the Ice Machine. EVSD stated food service workers informed him about kitchen equipment issues as needed. EVSD stated the entrance sink faucet will be changed to a new fixture to prevent water leak. During a concurrent kitchen pantry observation and interview on 3/18/24, at 9:47 a.m., with FSM, the entrance area to the pantry was dark and had poor lighting. FSM stated it was difficult for the dietary staff to clearly see the food items stored in the shelves due to inadequate lighting and will remind Maintenance to change the ceiling light. During a concurrent kitchen observation and interview on 3/20/24, at 11:02 a.m., with FSM and Cook 1, the kitchen work areas had six overhead light fixtures that were not in good working condition. Cook 1 stated dietary staff workers did not even noticed that some of the light fixtures were not working. Cook 1 stated food service workers report to EVSD verbally when something was needed to be fixed in the kitchen even though they were aware of the EVS Maintenance Log Binder located next to the ice machine outside by the kitchen. During a follow-up interview on 3/21/24, at 10:00 a.m., with the EVSD, EVSD stated the kitchen pantry light will be changed to a brighter bulb and non-working light fixtures throughout the kitchen work area will be fixed to provide adequate lighting in the kitchen.

Based on observation, interview, and record review, the facility failed to ensure that one of two garbage dumpster bins located outside the facility grounds had lids that tightly closed. This failure had the potential to attract pests to the facility and lead to pest-related disease for 60 residents out of a facility census of 60. Findings: During a concurrent observation and interview on 3/19/24, at 10:15 a.m., with the Food Services Manager (FSM), outside the facility parking lot were three large dumpster bins. FSM stated the bin with blue lids was for recycling and the other two bins with black lids were for all the facility trash which included nursing and dietary. One trash bin had a lid that was significantly bent to the back, cracked to the right side, and had a three-inch gap to the front of the two parallel lids that even when the lids were closed revealed multiple gaps between the lids and bin. Flies were observed circling around the area between the dumpster bins and the back door exit. FSM stated this will be reported to the Environmental Services Director (EVSD). During an interview on 3/19/24, at 11:10 a.m., the EVSD stated one of the two trash bins cannot close tightly due to the bent and cracked lids. EVSD stated the lids needed to be changed to get the bins tightly sealed when closed to prevent pest-related issues. According to the 2017 Federal Food Code, receptacles for refuse used with materials that contained food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids or covers.

Based on interview and record review, the facility failed to ensure Minimum Data Set Assessment (MDS a standardized resident assessment tool) was accurate for one of 22 sample residents (Resident 46). For Resident 46, the facility failed to accurately code a fall with major injury (rib fracture) on Resident 46's MDS. Failure to accurately capture fall data may impact care planning and fall interventions for Resident 46. Findings: Review of Resident 46's face sheet, printed on 03/20/2024, indicated he was admitted to the facility on [DATE] with multiple diagnoses including: brain condition causing seizure (seizure= brain disorder that causes changes in behavior, movements, feelings and levels of consciousness), dementia (loss of cognitive function related to thinking, remembering and reasoning), schizophrenia (mental illness manifested by thoughts or experiences that seem out of touch with reality, disorganized speech or behavior, and decreased participation in daily activities). Review of Resident 46's record titled, Post Event Assessment Form, dated 10/09/2023, indicated Resident 46 was .found on the floor on 10/8/23. Alert and verbally responsive.(complained of) left ribs and back pain. Review of Resident 46's record titled, ED to hospital admission (ED= Emergency Department), dated 10/13/2023, indicated Resident 46 .was found down after likely fall. Imaging notable for . rib fractures . Review of Resident 46's MDS, dated [DATE], indicated section J health condition was coded incorrectly. Section J1900, asked for number of falls since admission/entry or reentry or prior assessment. Section J1900 was coded by facility staff as one fall with no injury. During an interview on 03/19/24, at 9:58 AM, the MDS coordinator stated Resident 46's December 2023 MDS fall with no injury data was coded incorrectly; it should have been coded as fall with major injury. Review of the facility's policy titled, Resident Assessment lnstrument (RAI): Minimum Data Set, dated dated [DATE], indicated .Each individual who completes a portion of the assessment will sign and certify the accuracy of that portion of the assessment.

Based on observation, interview, and record review, the facility failed to provide one of four sampled residents (Resident 17), routine housekeeping and maintenance services to maintain a clean, sanitized wheelchair/recliner for resident's daily use. This failure resulted in an undignified and unclean wheelchair for Resident 17's use. Findings: A review of Resident 17's Admission Record, printed 3/20/24, indicated resident was admitted to the facility in 2008 with diagnoses of dementia (memory loss) and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 17's Minimum Data Set (MDS, an assessment tool used to provide nursing care) indicated resident has severely impaired cognition and was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity), with all activities of daily living (ADLs), including chair/bed-to-chair transfer. A review of Resident 17's Care Plan on Risk for Pain and Limitation in Physical Mobility, revised date 9/24/21, indicated resident was non-ambulatory and had limited mobility on lower extremities due to contractures. Care Plan indicated resident was dependent on transfers and demonstrated poor sitting balance and poor sitting posture. Resident used a recliner/wheelchair with thigh belt to facilitate proper sitting position and maintain posture. During a concurrent observation and interview on 3/18/24, at 9:30 a.m., with Certified Nursing Assistant 1 (CNA 1), inside Resident 17's room, Resident 17 was noted seated in a wheelchair with its padded footrest and armrests visibly soiled and stained with dried food and liquid stains in multiple scattered areas. CNA 1 stated resident's wheelchair was unclean and housekeeping should clean the wheelchairs routinely. During an interview on 3/19/24, at 10:34 a.m., with Housekeeping 2 (Hskg 2), Hskg 2 stated she was assigned to Resident 17's room yesterday. Hskg 2 stated resident's wheelchair was supposed to be cleaned and disinfected before each resident use. During an interview on 3/21/24, at 11:00 a.m., with the Director of Nursing (DON), DON stated wheelchairs and all other resident equipment needed to be cleaned and sanitized before and after use to prevent cross-contamination or any other infection-related issues. DON stated cleaning of the wheelchair is a shared responsibility between the nursing and housekeeping departments. A review of the facility's policy and procedure (P&P) titled, Cleaning of Non-Critical, Reusable Equipment Used by Persons Served (Skilled Nursing Facility [SNF]), undated, indicated, It is the policy .to implement and maintain processes to ensure all non-critical, reusable equipment used by residents are routinely cleaned, disinfected, or discarded after use in accordance with existing infection prevention and control policies and procedures .Cleaning is the physical removal of foreign material .Disinfection is the inactivation of disease producing organisms .Cleaning is a shared responsibility between the nursing and housekeeping departments. All reusable equipment are cleaned immediately if visibly soiled .Wheelchairs - between use by each resident and before putting into storage - clean with hospital-approved disinfectant.

Based on observation and interview, the facility failed to provide adequate supervision to prevent a physical altercation for two of two sampled residents (Resident 1 and Resident 2) when assigned staff members did not closely monitor the residents who were dining during dinnertime in the large dining room. This failure resulted in an unwitnessed altercation between Resident 1 and Resident 2 wherein Resident 2 hit Resident 1 with his right-hand ?st. This created a red discoloration underneath Resident 1 ' s left eye and had the potential to cause Resident 1 emotional and/or psychological distress, as well as place all the other residents eating in the large dining room at safety risk. Findings: A review of Resident 1's Admission Record, dated August 16, 2033, indicated Resident 1 was admitted to the facility in January 2022, with diagnoses of vascular dementia (brain damage caused by multiple strokes) and schizophrenia (a disorder that a?ects a person ' s ability to think, feel, and behave clearly). A review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 3/16/23, indicated Resident 1 had a score of 8 on the Brief Interview for Mental Status exam. (BIMS, a scoring system used to determine the resident's cognition status regarding attention, orientation, and ability to register and recall information. The scale is from zero to 15, with a score of eight to 12 an indication of moderate impairment). The MDS indicated Resident 1 was independent and needed supervision (oversight, encouragement, or cueing), with set-up help only during eating, toilet use, and personal hygiene. The MDS indicated Resident 1 used a walker for ambulation. A review of Resident 2's Face Sheet, dated August 16,2023, indicated Resident 2 was admitted to the facility in 2020 with diagnoses of dementia (memory loss) and schizophrenia. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had a BIMS score of 13, an indica??on of intact cognition. The MDS indicated Resident 2 was independent, but required supervision with set-up help only, during eating and personal hygiene. The MDS indicated Resident 2 was ambulatory with no mobility devices needed. During a review of the facility video (without audio) on 8/16/23, at 11:30 a.m., with the Administrator (ADM), video from the big dining room, dated 4/23/23, was reviewed. The video showed both Resident 1 and Resident 2 were eating dinner in the same table while other residents were seated in their assigned tables. No staff members were seen close to the residents. Resident 1 ' s mouth, appeared to be opening and closing, talking while facing Resident 2, then suddenly spat on Resident 2 ' s food plate. Resident 2 got up from his chair and threw a punch twice to Resident 1 ' s face. Resident 1 tried to stand but lost his balance and landed on the floor. Resident 1 attempted to get up and tried to grab Resident 2 ' s chair. Resident 2 grabbed on the same chair when two staff (CNA 1 and CNA 2) came into the picture and appeared to be talking to the two residents. A review of Resident 1's Post Event Assessment Form Part 2 - IDT (Interdisciplinary Team) Notes, dated 5/9/23, indicated Resident 1 had been interviewed by the Behavioral Specialist 1 (BS 1) on 4/25/23, at 10 a.m. The IDT Notes indicated Resident 1 was noted with red discoloration under his left eye and stated Resident 2 had hit him on Sunday, April 23, 2023, in the dining room. Further review of the IDT Notes indicated Resident 2 was also interviewed and stated Resident 1 spat on Resident 2 ' s food and bumped his leg with a chair. Resident 2 stated he hit Resident 1 on his face. The IDT Notes also indicated on Sunday, April 23, staff were assisting the residents with dinner when they heard yelling and observed the two residents pulling on the same chair. Code Green, (facility ' s emergency code for an altercation) was called, and the residents were separated. During a telephone interview on 8/16/23, at 12:20 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 denied seeing or hearing anything unusual between Resident 1 and Resident 2, during dinnertime at the large dining room, on April 23, 202. CNA 1 stated she was busy passing dinner trays to the other residents at that time. During a telephone interview on 8/17/23, at 9:08 a.m., with CNA 2, CNA 2 denied seeing or hearing anything unusual between Resident 1 and Resident 2, during dinnertime at the large dining room, on April 23, 2023. CNA 2 stated she was busy preparing coffee at the back of the food cart. CNA 2 further stated she remembered seeing a chair on the floor and had asked Resident 2 what happened but Resident 2 stated, Nothing. CNA 2 stated she remembered seeing Resident 1 sitting quietly in a chair in front of Resident 1 and Resident 2 ' s shared table. CNA 2 also stated both Resident 1 and Resident 2 showed no signs of injury nor any signs of being upset. During a telephone interview on 8/17/23, at 9:14 a.m., with CNA 3, CNA 3 also denied seeing or hearing anything unusual between Resident 1 and Resident 2, during dinnertime at the large dining room, on April 23, 2023. During an interview on 3/7/24, at 9:59 a.m., with the Director of Nursing (DON), the DON stated the incident between Resident 1 and Resident 2 happened in the large dining room while the staff were getting the dinner trays from the food cart and passing them out to the other residents. The DON stated the food cart usually parked in the middle, next to Resident 1 and Resident 2 ' s dining table, not too far from the dining room entrance, was rectangular in shape, can be opened from two opposite sides, and were tall. The DON stated the food cart door closer to the resident ' s table was kept close to prevent the residents from grabbing trays out of the cart. The DON also stated there were usually two licensed nurses assigned in the large dining room, together with the four CNA ' s who were fluidly in and out of the dining room to assist in passing trays and monitor residents during dining. During an observation and interview on 3/7/24, at 1:20 p.m., inside Resident 2 ' s room, Resident 2 stated Resident 1 was his peer and remained to be his peer up to the time of writing. Resident 2 stated he remembered when Resident 1 spat on his food and so he punched Resident 1 to his face with his right-hand fist. Resident 2 stated he and Resident 1 did not report the incident to anyone until the discoloration to Resident 1 ' s eye appeared a day later. Resident 2 stated he lost his appetite even though he was hungry when Resident 1 spat on his food. During an interview on 3/7/24, at 1:30 p.m., with the ADM, ADM was unable to explain how no staff members assigned in the large dining room, during dinnertime on 4/23/23, were able to witness the incident between Resident 1 and Resident 2. Resident 1 refused to be reinterviewed during the investigation.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received medication according to the physician orders for Quinidine (a medication used to treat fast or irregular heartbeat [arrythmia]). The facility also failed to notify Resident 1 ' s physician of the missed medications in a timely manner. This failure to inform the physician of Resident 1's missed medications prevented the physician from prescribing a change in treatment or monitoring and had contributed to Resident 1 receiving 10 shocks, from the Cardiology Clinic to his defibrillator (a device that provide electric shock to the heart to restore a normal heartbeat) on 5/21/22 and was sent out to acute hospital via 911 for evaluation and further treatment on 5/23/22. Findings: A review of Resident 1's Admission Record, printed on 8/16/23, indicated resident was admitted to the facility in January 1999 with diagnoses of dementia (memory loss), schizophrenia (a chronic brain disorder that affects a person ' s ability to think, feel, and behave), and cardiac arrythmia. A review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide resident care), dated 4/14/22, indicated Resident 1 required supervision with minimal assist on activities of daily living, was rarely/never able to make himself understood, and rarely/never able to understand others. A review of Resident 1 ' s Care Plan titled Potential for Alteration in Cardiac Function related to diagnosis of Ventricular Tachycardia, revised 6/2/22, indicated Resident 1, .had a cardiac defibrillator surgically implanted .He maintains his appointment with cardiologist . The care plan also indicated Resident 1 was connected to a monitoring machine every week for defibrillator check which reading is directly submitted or relayed to his cardiologist. Some of the care plan interventions indicated, .Administer med as ordered. Maintain Cardiology Appointment. Maintain weekly defibrillator check. Monitor for change in heart rhythm and refer accordingly . A review of Resident 1's Order Summary Report, dated 5/23/22, indicated an order with a start date of 1/24/2020, Quinidine Gluconate 324 milligram (mg) tab give 324 mg orally five times a day related to cardiac dysrhythmia (irregular heartbeat). During an interview on 8/16/23, at 12:28 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated he was not able to give Resident 1 his Quinidine once on night shift due to medication unavailability. LVN 1 stated it indicated on the Medication Administration Record (MAR) that the medication had been ordered from the pharmacy on 5/21/22 but had not been received by the facility. LVN 1 stated best practice was to inform the Director of Nursing (DON), Assistant DON, or Administrator (ADM) when facility is unable to receive significant medications ordered and followed up from the pharmacy. LVN 1 also stated he should have informed the physician regarding resident ' s missed doses. During a concurrent interview and record review on 8/16/23, at 1 p.m., with the Director of Nursing (DON), Resident 1 ' s May 2022 Medication Administration Record (MAR) was reviewed. The DON confirmed Resident 1 did not receive Quinidine on the following dates: 5/21/22, at 10 a.m. and 2 p.m., 5/22/22, at 6 a.m., 10 a.m., and 2 p.m., and on 5 /23/22, at 6 a.m. The DON stated the MAR had no checkmarks on the said dates, instead was coded a 9, which meant the medication ran out and was ordered from the pharmacy. The DON stated the risk of Resident 1 not receiving his Quinidine put the resident ' s heart at risk of not functioning properly. The DON further stated licensed nurses are expected to notify the physician anytime medication doses were missed. A review of Resident 1 ' s Progress Notes, printed 8/16/23, dated 5/23/22, at 1 p.m., documentation by Assistant Director of Nursing (ADON) indicated, Resident was noted to have missed several Quinidine doses .MD was notified regarding the missed doses and ordered to give the medication once it arrives. Cardiology clinic was also notified, and Physician Assistant (PA) stated that resident received a total of 10 shocks to his defibrillator since May 21, 2022. The Progress Notes further indicated PA ordered resident sent out to acute hospital via 911 for evaluation and further treatment. During a telephone interview on 3/6/24, at 1:40 p.m., with the Physician, the Physician stated the facility notified him on a Monday, via phone call that Resident 1 had not received the Quinidine over the weekend (including the Monday he was called) and missed a total of six doses. The Physician stated the medication was an antiarrhythmic and if missed longer could result in arrythmia. A review of Resident 1's acute care hospital Discharge Summary, printed on 5/27/22, indicated Resident 1 went to the emergency department on 5/23/22 due to the 10 shocks delivered to resident ' s defibrillator over the weekend and reported missed Quinidine doses and was admitted to the hospital for treatment of resident ' s ventricular fibrillation (a life-threatening heart rhythm that results in a rapid, inadequate heartbeat). The Discharge Summary indicated Resident 1 was discharged from the hospital on 5/27/22 after treatment with ventricular fibrillation and defibrillator battery replacement. A review of the facility's policy and procedure titled, Medication Error and Reporting, undated, indicated, .Medication errors are defined as any failure to give medications as prescribed, or to give any medication without a prescription .When a medication error is discovered: Notify: the Administrator, Director of Nursing or designee, immediately .

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from medication error when Quinidine (a medication used to treat fast or irregular heartbeat [arrythmia]) was not administered as ordered by the physician. This failure contributed to Resident 1 receiving 10 shocks, from the Cardiology Clinic to his defibrillator (a device that provide electric shock to the heart to restore a normal heartbeat) on 5/21/22 and sent out to acute hospital via 911 for evaluation and further treatment on 5/23/22. Findings: A review of Resident 1's Admission Record, printed on 8/16/23, indicated resident was admitted to the facility in January 1999 with diagnoses of dementia (memory loss), schizophrenia (a chronic brain disorder that affects a person ' s ability to think, feel, and behave), and cardiac arrythmia. A review of Resident 1's Order Summary Report, dated 5/23/22, indicated an order with a start date of 1/24/2020, Quinidine Gluconate 324 milligram (mg) tab give 324 mg orally five times a day related to cardiac dysrhythmia (irregular heartbeat). During a concurrent interview and record review on 8/16/23, at 1 p.m., with the Director of Nursing (DON), Resident 1 ' s May 2022 Medication Administration Record (MAR) was reviewed. The DON confirmed Resident 1 did not receive Quinidine on the following dates: 5/21/22, at 10 a.m. and 2 p.m., 5/22/22, at 6 a.m., 10 a.m., and 2 p.m., and on 5 /23/22, at 6 a.m. The DON stated the MAR had no checkmarks on the said dates, instead was coded a 9, which meant the medication ran out and was ordered from the pharmacy. The DON stated the risk of Resident 1 not receiving his Quinidine put the resident ' s heart at risk of not functioning properly. The DON further stated licensed nurses are expected to notify the physician anytime medication doses were missed. A review of Resident 1 ' s Progress Notes, printed 8/16/23, dated 5/23/22, at 1 p.m., documentation by Assistant Director of Nursing (ADON) indicated, Resident was noted to have missed several Quinidine doses .MD was notified regarding the missed doses and ordered to give the medication once it arrives. Cardiology clinic was also notified, and Physician Assistant (PA) stated that resident received a total of 10 shocks to his defibrillator since May 21, 2022. The Progress Notes further indicated PA ordered resident sent out to acute hospital via 911 for evaluation and further treatment. A review of the facility's policy and procedure titled, Medication Error and Reporting, undated, indicated, To establish standards and processes that promote accuracy in the dispensing, administration and monitoring of medications and in the identification and elimination of causes of errors .Medication errors are defined as any failure to give medications as prescribed, or to give any medication without a prescription .When a medication error is discovered: Notify: The Administrator, Director of Nursing or designee, immediately .

Based on observation, interviews, and record review, the facility failed to ensure an environment free of hazards for one of two (Resident 1) sampled residents when spray bottles of cleaning solution on a cleaning cart were not locked in the cart. This failure resulted in Resident 1 orally ingesting the cleaning solution and had the potential to result in chemical burns to Resident 1 ' s mouth, throat, stomach and skin. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted on [DATE] for Huntington ' s Disease (a disease causing progressive loss of motor and cognitive function) and dementia (a disease causing progressive loss of cognitive function). A review of Resident 1 ' s Minimum Data Set (MDS, an assessment tool to guide resident care), dated 8/24/22, indicated Resident 1 was cognitively impaired, was not able to make safe decisions and could not verbally communicate. The MDS indicated Resident 1 was ambulatory and did not have impairments to both upper extremities. During a concurrent interview and video recording review, on 11/29/22, at 10:32 a.m., with the Administrator (ADM) and Director of Nursing (DON), two video recordings, dated 11/28/22, less than one minute in length were reviewed. Both videos showed, at 5:23 a.m., Resident 1, Environmental Service worker (EVS 1) and a cleaning cart were in a facility hallway. Resident 1 and EVS 1 were on opposing sides of the cleaning cart; on Resident 1 ' s side of the cleaning cart two spray bottles of cleaning solution hung off the top of the cart. The video showed EVS 1 faced away from the cleaning cart and Resident 1. Resident 1 faced the cleaning cart and began to unscrew one of the spray bottles. The video showed, at 5:24 a.m., Resident 1 removed the top of the spray bottle, placed the bottle to his mouth and began to tip the bottle up. At this moment, EVS 1 turned around and saw Resident 1 with the bottle to his mouth. EVS 1 quickly took the bottle away from Resident 1 as the bottle was being tipped up. The cleaning solution was observed in the bottle flowing towards Resident 1 ' s mouth, and the bottle was taken away just as the solution appeared to exit the bottle. The video showed cleaning solution splashing out of the bottle and over the face of Resident 1; EVS 1 took possession of both spray bottles and placed them into a compartment in the cleaning cart, while Resident 1 remained standing in the same position. DON stated Resident 1 may have ingested some cleaning solution before EVS 1 could take away the bottle. ADM stated the bottle of cleaning solution Resident 1 picked up was later identified as AF79. A review of Material Safety Data Sheet (MSDS) for AF79, dated 3/26/2004, indicated AF79 can cause burns to mouth, throat and stomach if ingested. The MSDS further indicates skin contact can also cause burns. During a phone interview on 12/2/22, at 10:05 a.m., with EVS 1, EVS 1 stated on 11/28/22, at approximately 5:20 a.m., she performed her normal cleaning routine which included changing the trash bags. EVS 1 stated she observed Resident 1 near her cleaning cart. EVS 1 stated she turned around, away from Resident 1, to change a trash bag in a trash container. She then turned back around and observed Resident 1 trying to drink out of a bottle of cleaning solution left unattended on the cleaning cart. EVS 1 stated the two bottles of cleaning solutions should have been locked away in the cleaning cart when she was changing the trash bag. During an interview on 11/29/22, at 10:55 a.m., with Behavioral Specialist (BS 1), BS 1 stated on 11/28/22, at around 5:25 a.m., EVS 1 informed him that Resident 1 had attempted to drink out of a bottle with cleaning solution. BS 1 stated he observed Resident 1 spit a foamy, white spit on the floor and cough, and he notified Licensed Vocational Nurse (LVN 1). BS 1 stated EVS 1 should have kept the two bottles of cleaning solutions away from Resident 1 by locking it in a compartment in the cleaning cart. During an interview on 11/29/22, at 12:20 p.m., with Facilities Manager (FM), FM stated housekeeping staff were required to keep all cleaning solutions locked in the cart if not in use. FM stated all housekeeping staff should lock away cleaning solutions when not in use to prevent accidents. A review of facility policy and procedure (P&P) titled, Hazardous Materials and Waste Management Plan, undated, indicated, chemicals for general cleaning if not in use, will be locked in housekeeping carts or storage area.

Based on observation, interview, and record review, the facility failed to protect one (Resident 1) of four sampled residents from physical abuse when Certified Nursing Assistant (CNA 1) pushed Resident 1's head upright in a forceful manner while repositioning her head. This failed practice had the potential to make Resident 1 feel unsafe and fearful in a setting which she may consider home. Findings: Review of the medical record showed Resident 1 was admitted to the facility on [DATE]. Continued review of the medical record showed Resident 1 had a [DIAGNOSES REDACTED]. Review of the facility's surveillance video of a rehabilitation group, dated on 1/10/19 at 9:19 a.m., showed Resident 1 in her wheelchair, with her head down and to her left side. The Rehabilitation Aide (RA) and Activity Leader (AL) sat at the same table with Resident 1 during the rehabilitation group. The facility surveillance video then showed CNA 1 going behind Resident 1 and continuously pushing her head up until it was upright. During an observation on 2/7/19 at 12:56 p.m., Resident 1 was in the facility's television room, in her wheelchair, with her neck and head being held in an upright position by a neck wedge pillow for support. During an interview on 2/7/19 at 1:21 p.m., Registered Nurse (RN 1) stated Resident 1 had been assigned to her before. RN 1 stated, We are supposed to gently use our two hands to position Resident 1's head and neck. I always tell her (Resident 1) what I am doing even though she is not alert. During an interview on 2/7/19 at 1:30 p.m., CNA 2 (Resident 1's assigned CNA) stated, I always tell Resident 1 what I am about to do. I use the neck pillow to support her head and neck and I gently prop her head up with my two hands. During an interview on 2/12/19 at 11:46 a.m., CNA 1 stated, I was just tapping Resident 1's head. Her neck was not in the wedge pillow properly. She is overly medicated and that is the way I always do it. That is the only way to make her head stay up. During an interview on 2/12/19 at 12:05 p.m., the RA stated the proper way to position Resident 1's head is to take two hands, place one hand gently on each side of Resident 1's face, then slowly and carefully prop Resident 1's head upright. The RA further stated she did not see CNA 1 reposition Resident 1's head and would have reported it if she saw her use unnecessary force. During an interview on 2/12/19 at 12:13 p.m., the AL stated he was leading the rehabilitation group during the time of the incident. AL further stated, I have seen CNA 1 reposition Resident 1 before. She would use two hands to prop her head up gently. I did not notice CNA 1 use unnecessary force that day. Review of the document Post Event Assessment, dated 1/10/19 showed, While reviewing another incident, it was observed that in an attempt to reposition Resident 1, CNA 1 appears to have used unnecessary force to reposition Resident 1's head. No physical injury observed, range of motion intact, no cues of emotional distress, neuro checks initiated. Review of the facility's policy and procedure titled, Abuse Prevention and Reporting, dated 9/20/98, showed Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, medical director, consultants, contractors, or volunteers, staff of other agencies serving the resident, the family members of legal guardians, friends, or other individuals. The policy further showed The facility has systems, procedures and a program of employee training and supervision in place to foster dignified treatment, respect, and [MEDICATION NAME] for residents. Any form of mistreatment of [REDACTED].

Based on observation, interview and record review, the facility failed to prevent one of three sampled residents from being sexually assaulted by a male peer (Resident 2). This failure resulted in Resident 1 being sexually assaulted twice by Resident 2 and left her at risk for continued assault. An Immediate Jeopardy (IJ) situation was called on 12/11/18 at 4: 27 p.m., with the facility Administrator (Admin 1), Assistant Administrator (Admin 2), and the Director of Nursing present during the notification. The facility had knowledge of the inappropriate sexual behavior of Resident 2 and failed to provide Resident 1 with adequate safety and put in place preventative measures to protect her from being sexually assaulted a second time by Resident 2. The IJ was abated on 12/11/18 at 6:54 p.m. after receiving a plan of correction indicating Resident 2 would be placed on one to one supervision to protect Resident 1 and other females in the facility from Resident 2's sexually assaultive behavior. Findings: Review of the Minimum Data Set (MDS-an assessment tool used to direct health care needs) on 12/11/18 showed Resident 1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident 1 was dependent on staff for all of her daily care needs, was non-verbal, and required one person to assist her with mobility on the unit. Review of the MDS dated [DATE] showed Resident 2 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident 2 was independent with his daily care needs and his ability to move around the unit. Observation of Resident 1's room on 12/11/18 at 2:25 p.m., showed Resident 1's room was not visible from the Nursing Station and was located toward the back of the building. Review of Resident 2's Care Plan revised 11/19/18, showed Resident 2 had displayed sexually aberrant (abnormal) behavior by attempting to grab other residents' and staffs' genitalia. The care plan also showed on 11/18/18, that Resident 2 laid on top of Resident 1 and as a result, Resident 2 would be placed on indefinite close monitoring due to his wandering into other rooms. Review of Resident 1's Care Plan dated 11/18/18 showed Resident 1 was, found with male peer (Resident 2) on top of her with his pants and underwear down; Resident 1's brief was open, but no sexual contact yet, staff separated them right away. This care plan showed that some interventions were to inform the physician and responsible party for unusual changes and monitor Resident 1 for emotional distress and safety every 15 minutes. Review of Resident 1's Care Plan dated 12/8/18 showed, On (MONTH) 8, (YEAR), a male peer (Resident 2) on top of Resident 1 with his pants down and staff (Hskp 1) intervened and stopped male peer (Resident 2) right away. The interventions for the 12/8/18 care plan were to monitor Resident 1 every 15 minutes for safety and a sign was placed on Resident 1's door that read Females Only. The added intervention for the second sexual assault was the sign placed on Resident 1's door. Review of the facility's Every 15 minute-24 hour Precautionary Checklist/Contact Log dated 12/8/18 showed, there was no observations made of Resident 1 on the unit or of her in her room (by staff indication of initials) from 11:15 p.m. to 12:45 a.m. Review of the facility's Every 15 minute - 24 hour Precautionary Checklist/Contact Log dated 12/8/18 showed, there were no observations made of Resident 2 on the unit or of him in his room (by staff indication of initials) 11:15 p.m. to 12:45 a.m During an interview with CNA 1 on 12/21/18 at 2:22 p.m., CNA 1 stated, I was doing the rounds from 12 a.m. to 1 a.m Resident 2 was given a sandwich around 12:45 a.m I went to the Chart Room to fill out the rounds book and about five to ten minutes later I heard the laundry lady calling for help. We went out, the RN 1, myself, and CNA 2; Resident 2 was already off of Resident 1's bed, coming out of the room. Resident 1's gown was up and her brief was off on one side. Resident 1 was awake; she didn't say anything; she didn't respond. We then changed Resident 1's brief and put another gown on her. During an interview on 1/4/19 at 10:33 a.m., Housekeeper (Hskp 1) stated, It was around 12:58 a.m., and I was working the night shift and I was exiting the elevator that is next to Resident 1's room. As I was passing Resident 1's room, I saw Resident 2 on top of her. Resident 1's gown was open, you could see her breasts and stomach, and the brief was unfastened on one side. Resident 2 was on his knees with pants down and he was on top of Resident 1 and he was holding his shirt up; Resident 2 did not have a gown on. I saw his butt and his private and I don't think he had the chance to do much more because the brief was still partially on. I yelled, 'Stop! Get off of her!' There should have been somebody at the desk (Nurse Station 2) at all times, but no one was there. I kept yelling for staff to come and help and no one came. Resident 2 then got off of Resident 1 and came at me. I put my work cart between us; and finally the Charge Nurse (RN 1) came out and Resident 2's attention went towards her. Resident 1 was yelling in her own way. We tried to figure out what her needs were. I don't think she wanted Resident 2 in her room or on top of her. Resident 1 was not capable of communicating and I heard this was not the first time. During an interview with RN 1 on 12/21/18 at 2:45 p.m., Registered Nurse (RN 1) stated, Resident 2 had been bothering staff for a snack. One staff had already given him a snack then I gave him a snack. CNA 2 was making rounds and CNA 2 also gave him a snack. It is 12 a.m. or 1 a.m., this was at night-early morning. I stayed at Station 2 and saw Resident 2 eating there at the station. I went to check on him four to five minutes later and he was gone. Then two or three minutes later I heard staff screaming, 'Hey, hey, hey'. I went to check why the screaming and who was screaming and I saw Resident 2 trying to hit Hskp 1, who was screaming for help. I instructed Resident 2 to stop and go back to his room. RN 1 stated that Hskp 1 told her that she saw Resident 2 with his pants down on top of Resident 1. RN 1 stated, I went to Resident 1 and saw Resident 1's gown and her brief were on the left side; I checked for semen and I didn't see any. I called the DON, Admin 1 and Medical Director. I did not call the police. During an interview on 12/11/18 at 2:40 p.m., Resident 2 stated he knew the black girl in the back; she couldn't talk, he may have been in her room, and if he was on top of her; she liked it. During an interview with the SS 1 on 1/4/19 at 9:08 a.m., the SS 1 stated I spoke to Resident 2 and did not write a note for the 11/18/18 incident. SS 1 further stated Resident 2 showed no insight to his behavior, denied he did it and because of his cognitive impairment and mental health issues, he was at risk for doing it again. Review of the facility's policy and procedure titled, Abuse Prevention and Reporting, revised date of 11/14/17, showed under definitions that sexual abuse was defined as: sexual harassment, sexual coercion, and sexual assault. The same policy continued by indicating that, Staff is required to intervene, identify and correct situations where any type of abuse or suspected crimes may occur, and The administrator/designee will take all measures to protect the resident from further potential abuse.

Based on observation, interview, and record review, the facility failed to provide an environment free of physical abuse for one (Resident 1) of three sampled residents, when Certified Nursing Assistant (CNA 1) pushed, pulled, and yelled at Resident 1 multiple times. This failure resulted in Resident 1 being physically and verbally abused. Findings: Review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS - An assessment tool used to direct resident care) assessment dated [DATE], showed a Brief Interview of Mental Status (BIMS) score of 14 out of 15; which represents an intact cognition (ability to understand and make one's own decisions daily) . During a review of the surveillance video recordings, from cameras 3 and 7, dated 8/13/18 from 12:02 p.m. to 12:04 p.m., showed that three food carts were parked in the middle of the dining room. CNA 1 walked back towards the food cart; Resident 1 was seen approaching the food carts as well. CNA 1 and Resident 1 met in front of food cart 1. As Resident 1 attempted to open the first food cart, CNA 1 pushed the Resident 1's right hand away. As Resident 1 walked behind food cart 1, CNA 1 grabbed Resident 1's right wrist and pushed Resident 1 away from the cart. CNA 1 grabbed Resident 1's right arm again and pushed him, this time to stop Resident 1 from opening the middle cart. CNA 1 was shaking his finger at Resident 1. CNA 1 grabbed Resident 1's right wrist and pushed him while still holding Resident 1's wrist. CNA 1 grabbed both of Resident 1's lower arms. CNA 1 pushed Resident 1 towards the window while still holding Resident 1's right wrist. CNA 1 pulled Resident 1 away, grabbed Resident 1's left hand and then pushed Resident 1 away. CNA 1 then pushed Resident 1 in the back. CNA 1 walked away from Resident 1. When Resident 1 was charging towards CNA 1, CNA 1 tried to push Resident 1 away. CNA 1 then pushed Resident 1's left arm away. Resident 1 lost his balance and another CNA (CNA 5) tried to brace Resident 1's fall to the floor, but was unsuccessful. Resident 1 fell to the floor. During a telephone interview with CNA 1 on 8/30/18 at 10:10 a.m., CNA 1 began by stating that one day in (MONTH) (YEAR), CNA 1 was trying to serve coffee to another resident when Resident 1 walked into the dining room asking for his lunch tray. CNA 1 instructed Resident 1 to sit and CNA 1 would bring Resident 1's tray to his table. When Resident 1 insisted to get his tray, CNA 1 blocked the food cart because he did not want the other trays to get contaminated. When Resident 1 came close to CNA 1, CNA 1 pushed Resident 1. CNA 1 admitted he pushed Resident 1 more than once. During an interview with Resident 1 on 8/29/18, at 12:30 p.m., Resident 1 stated when he asked if he can have his tray served, CNA 1 told him to wait, as CNA 1 was busy serving coffee to the other residents. When Resident 1 told CNA 1 that he could get his tray for himself, CNA 1 hit him to keep him from touching the cart. Resident 1 stated CNA 1 pushed him out of the way and he landed on the floor, on his bottom. Resident 1 continued stating that one of his slippers came off so he tried to pick it up, but when CNA 1 thought he was going to the cart again, CNA 1 pushed him two more times. In an interview on 8/29/18 at 11:59 a.m. with CNA 2 (who was also present in the dining room during the incident) CNA 2 stated when Resident 1 walked to the food cart to look for his tray, CNA 1 followed him and the two went around the food cart. CNA 1 pushed Resident 1 and then Resident 1 fell on the floor. CNA 2 stated she told CNA 1 to stop pushing Resident 1, but CNA 1 would not listen. In an interview on 8/29/18, at 11:35 a.m., CNA 4 stated that when she stopped by the dining room, CNA 4 saw CNA 1 and Resident 1 talking by the food cart. CNA 1 walked away but Resident 1 followed CNA 1 so CNA 1 turned around, came back, and with his two hands, pushed Resident 1 in his chest, making Resident 1 fall to the floor on his bottom. Then CNA 4 stated she heard somebody call, Code Green. According to facility's Policy and Procedure titled, Abuse Reporting, dated 9/20/98 and revised on 4/10/13, showed that, Each resident has the right to be free from abuse .Residents must not be subjected to abuse by anyone, including but not limited to facility staff .Definitions: 1) Physical Abuse - hitting, slapping, pinching, kicking and controlling behavior through corporal punishment, and non-accidental use of physical force that results in bodily injury, pain or impairment (including but not limited to bruising, skin tears or fractures) are physically abusive actions .pushing and shoving are also physically abusive behaviors.

Based on interview and record review the facility failed to keep one of three sampled residents (Resident 1) free from sexual abuse. Resident 1 was identified by the facility as being at risk for sexual victimization due to prior history of sexual abuse, mental illness, post-traumatic stress (a psychological reaction occurring after experiencing a highly stressing event), and dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities. Resident 1 was sexually abused by a facility housekeeper (HK) on 6/3/17 when HK was found in Resident 1's room with his penis in the resident's mouth. This failure resulted in Resident 1 being sexually violated. Findings: According to the undated medical record Resident Information, Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly psychiatry report dated 3/20/17 indicated Resident 1 had a history of [REDACTED]. The psychiatry report further indicated Resident 1's insight and judgement were poor and her memory was grossly impaired. Review of the Minimal Data Set (MDS), (A set of screening, clinical assessment, and functional status tools, providing a comprehensive assessment for residents of long term care facilities), Cognitive Patterns section C, dated 5/25/17, indicated the brief interview of mental status (BIMS) reflected a score of 5 of 15 or severely impaired. Review of Resident 1's care plan for, At risk for altercations with others, initiated 12/19/14 and revised 6/23/16 indicated Resident 1 was at risk of being victimized by others given her history of abuse, mental illness, post-traumatic stress, and dementia. The care plan interventions indicated Resident 1 was to attend activities with increased supervision to decrease the risk of victimization. Review of Resident 1 care plan for, At risk for sexually inappropriate behavior, initiated 12/19/14 and revised 6/23/16 indicated a history of initiating sexual relationships due to poor judgment. The care plan interventions were to redirect resident when she was observed to be sexually provocative or inappropriate with peers; encourage Resident 1 to say No! when receiving unwanted attention from male peers. In an interview with Certified Nursing Aide (CNA) on 6/13/17, at 12 p.m., CNA stated on 6/3/17 at about 1 p.m. she walked into the residents room and saw (HK) with his pants pulled down to his mid thighs and Resident 1 was on her knees facing HK. CNA stated she was shocked and said what are you doing?, HK replied, you didn't see anything and quickly left the room. CNA stated she asked Resident 1 if she was having sex with HK, Resident 1 replied no she was just sucking his d***. During an interview with the Medical Records Technician (MRT) on 6/13/17, at 12:30 p.m., the MRT stated she was assigned manager of the day 6/3/17. CNA came to MRT's office at about 1 p.m. to report the incident she just witnessed between Resident 1 and HK. The MRT stated when she found HK in the break room, the MRT requested his key and escorted him from the building. The MRT stated Resident 1 was then brought to MRT's office and when questioned about what had happened, Resident 1 said she sucked HK's d***. According to the facility's Policy and Procedure on Abuse reporting dated 9/20/98 and revised 4/10/13: Purpose . Residents must not be subjected to abuse by anyone, including but not limited to facility staff .Definition 3) Sexual Abuse - sexual harassment, sexual coercion, and sexual assault are examples .

The facility violated the above regulations by failing to monitor the effectiveness of medications given to Resident 1 to relieve his constipation and by failing to have a pharmacy review Resident 1 ' s medication regime to alert physician and nursing staff of the potential side effects of constipation, who subsequently died from complications of chronic constipation. On [DATE], review of the medical record showed that Resident 1 was admitted to the facility in 1996. His [DIAGNOSES REDACTED]. A review of the facility ' s physician discharge summary, dated [DATE] showed " On the day of his death ([DATE]), (Resident 1) vomited once and then vomited again a huge amount of fluid according to observers, 911 was called, but he collapsed and they were unable to resuscitate him. It is not known what the cause of this acute event was, but it was described to me that the vomitus was fecal in nature. " A review of the coroner ' s report, dated [DATE], showed that Resident 1 ' s causes of death included: a. Complications of bowel obstruction b. Adynamic Ileus (an obstruction due to intestinal muscle paralysis) c. Adverse Drug Reaction-bowel obstruction due to a reaction to Clozaril (clozapine). The autopsy showed " foreign material in bronchi " and possible aspirated material in the tracheobronchial tree. It indicated " The small intestine shows dilated loops of bowel to 3 to 4 centimeters, consistent with ileus (obstruction). There is extensive fecal impaction that dilates the entire colon to about 8 centimeters. Hard, fixed fecal debris is noted within and throughout the colon. " According to <http://www.webmd.com/digestive-disorders/picture-of-the-intestines>, the small intestine is normally about 2.5 centimeters (cm) in diameter; the large intestine is about 3 to 6 cm. The Coroner ' s autopsy report, dated [DATE], referenced an article, " Death from Clozapine-Induced Constipation, " Psychosomatics 43:1 Jan-[DATE], P 71. According to the article, although constipation was a common and usually harmless side effect of treatment with clozapine, the consequences of undertreated or unrecognized severe constipation, that was associated with use of clozapine, had led to fatal bowel obstruction and death. The article referenced 15 cases of serious constipation related to clozapine, two cases involved fatalities secondary to inhalation of feculent vomitus and four cases involved fecal impactions. The referenced article, in reference to patients with mental illness " may have altered sensitivity to pain, and may have difficulty expressing the abdominal pain that they feel. " The article further recommended that clinicians should not trivialize constipation as a minor side effect and should actively inquire about symptoms of constipation. A review of Resident 1 ' s physician's order [REDACTED]. Clozapine, 200 mg (milligrams), twice daily since [DATE] Clozapine 250 mg at night since [DATE] Trilafon 12 mg three times daily since [DATE] Cogentin 1 mg twice daily, since [DATE]. On [DATE], Resident 1 began receiving a new medication, Clonidine, for the treatment of [REDACTED]. According to Lexi-Comp, a nationally recognized drug reference source, all of Resident 1 ' s psychoactive medications could cause constipation. a. Clozapine: ,[DATE]% of patients receiving clozapine develop constipation b. Trilafon: use with caution in patients with decreased gastrointestinal motility, paralytic ileus (intestinal obstruction), constipation, fecal impaction c. Cogentin: can cause constipation and ileus d. Clonidine: can cause constipation (Reference: <http://online.lexi.com/crlsql/servlet/crlonline>) Review of the facility ' s care plan for Resident 1, dated [DATE] and updated on [DATE], showed the facility had identified that Resident 1 was at risk for constipation due to a long standing history of constipation, with the use of multiple psychotropic drugs as a contributing factor. The goal was for Resident 1 to have a bowel movement every three days. Resident 1 ' s physician's order [REDACTED]. Senekot 2 tabs every evening since [DATE]. Milk of Magnesia 30 ml (milliliter/1 tablespoon), every evening since [DATE]. Dulcolax 2 tabs in the morning three times weekly since [DATE]. DSS 250 mg twice daily, since [DATE]. Milk of Magnesia 45 ml every 12 hours as needed for constipation since [DATE]. During interview on [DATE] at 4:15 p.m., the Director of Nurses said that since Resident 1 was independent with bowel movements, it was sometimes impossible to determine whether Resident 1 had a bowel movement every three days. The facility relied on Resident 1 to report whether he had a bowel movement and to report abdominal discomfort or symptoms of discomfort. The Director of Nurses said that Resident 1 was not a reliable source of information because he was cognitively impaired. Review of the Nursing Assistant Daily Flow Sheets from [DATE] through [DATE] showed under " Bowel- Continent- S (small), M (medium) L (large) " : 0 (zero) was written for each and every night shift. PM shifts wrote " C " (continent) or " Y " (yes). The Day shift CNA ' s wrote " C " , " Y " or " 0 " during that time period. For the month of ,[DATE], " 0 ' s " were written for every night shift and " 0 " or " Y " for pm shift. These letters did not follow the key on that part of the form which required assessing the size of stools. On [DATE] at 3:30 p.m., during a telephone interview, CNA 2 said she had been assigned to Resident 1 on the day shift frequently and documented either " Y " or BRP (bathroom privileges) next to Bowels on the ADL form for day shift. CNA 2 stated, " He (Resident 1) had a habit of beating on his stomach so you never knew what it meant in terms of discomfort. He never showed or said anything about abdominal discomfort. Frequently he ' d be on the toilet just sitting there. He rubbed his butt a lot. He was never incontinent. I would see him on the toilet so I would put " Y " on the BM part of the ADL sheet but I never saw any stools. I put " Y " because I saw him sitting there. When you asked he would say " yes " . He flushed the toilet many times. We didn ' t use a hat (receptacle under the toilet seat). We never tried that. I didn ' t know he had a problem with constipation. " I never thought he was constipated. He would never say whether it was small, medium or large (as the ADL form called for). On [DATE], CNA 3, explaining the ADL flow sheets which she had completed, said: " The resident was ambulatory so we asked him if he had a bowel movement today. I believe he could answer correctly. We put " Y " if he said " Yes " . When asked if she had seen any of his stools, she replied, " No " . She said, " We asked if it was small, medium or large and he would tell us. We would tell the charge nurse to check him when he focused on his stomach. " On [DATE], charge nurse, LVN 1 said, " I think if you caught him right away coming out of the bathroom, you might get an accurate response as to " yes ' or " no " . I don ' t think he would know if it was small, medium or large. " During interview on [DATE] between 2:,[DATE]:00 p.m., the facility ' s consultant pharmacist (RPH 1) stated she had started consulting at the facility in " March or [DATE]. " RPH 1 said to evaluate patient care and assess the effectiveness of drug regimens, she would review the entire resident ' s record including, physicians orders, current medication administration records, activities of daily living flow sheets, care plans, laboratory results, physician and nursing notes and weekly summaries. RPH 1 said she was aware of clozapine-induced constipation. RPH 1 was not aware that Resident 1 had suffered from chronic constipation and could not remember whether she had seen the facility ' s care plan identifying constipation as a problem. In the surveyor ' s presence, RPH 1 reviewed Resident 1 ' s medication list and the facility ' s care plan for Resident 1 ' s constipation. RPH 1 stated that since Resident 1 was on multiple psychoactive medications that could cause constipation and on four medications to prevent and treat constipation, he required close monitoring to evaluate the efficacy of his bowel regimen. RPH 1 said she had relied on the charge nurse to inform her of if Patient 1 had any problems with constipation and occasionally reviewed the weekly nurses ' summaries. RPH 1 could not remember if she had reviewed Resident 1 ' s nursing assistant daily flow sheets to determine whether Resident 1 was having bowel movements. Review on [DATE] with RPH 1, of the weekly nurses summaries dated [DATE], showed that licensed nurses had recorded that Resident 1 could control his bowels for toileting, and staff heard bowel sounds (heard when a stethoscope was placed on the belly, of movement of gases and digested foods in the intestine). Licensed nurses recorded that Resident 1 had a soft abdomen. According to <http://www.merck.com/mmpe/sec02/ch011/ch011h.html>: " On physical examination, bowel obstruction presents with the symptoms of, " vomiting ... dilated loops of bowel are palpable ...lower abdominal cramps are unproductive of feces ...the abdomen is distended with loud borborygmi (a rumbling or gurgling sound caused by the movement of gas in the intestines). " In contrast to the weekly nurses ' summary, two days later, on [DATE], Resident 1 died and the primary cause of death was bowel obstruction of both the small and large intestine. The small intestine showed, " dilated loops of bowel ... " The large bowel had, " extensive fecal impaction ... hard fixed fecal debris throughout the colon. " Continued review of Resident 1 ' s medical record nursing assistant daily flow sheets, for January and February 2010, showed the facility had not followed the instructions to document the size of the bowel movement for Resident 1. RPH 1 said the size of the bowel movement was important to determine whether Resident 1 was constipated. Consistently small bowel movements may indicate that Resident 1 was constipated. RPH 1 said the nursing assistant daily flow sheets did not contain sufficient information regarding Resident 1 ' s bowel movements to determine whether he was constipated or not. The facility did not provide adequate monitoring of Resident 1 ' s risk for constipation as the nurses ' weekly summary and nursing assistant daily flow sheets did not tell whether Resident 1 had met the goals of the care plan of having three sufficient bowel movements per week. Therefore, the facility failed to recognize the fecal impaction which led to Resident 1 ' s death. Resident 1 had a history of [REDACTED]. Staff never verified that he actually moved his bowels. There was no assessment of the amount, color, shape or consistency of his stools. This contributed to his sudden death which was attributed to complications of chronic constipation.