Every finding on record at Forest Haven Nursing & Rehab Ctr, LLC

Based on observation and interview the facility failed to ensure the kitchen prepared and served food in accordance with professional standards for food service safety. This had the potential to affect 121 diets served from the kitchen.Findings:On 06/22/2026 at 10:25 a.m. observation of the lunch meals revealed they were serving herb baked chicken, riced dressing, squash and zucchini and chocolate and strawberry cake. Observation of the alternate foods available revealed they had a choice of pulled pork, mashed potatoes and cabbage.For the mechanical chopped meat, residents were served chopped chicken.On 06/22/2026 at 11:30 a.m. S5Production Manager began serving trays from the steam table. Observation revealed there were no steam table temperatures taken on the following food items that were served: rice dressing, mashed potatoes, pulled pork, cabbage, chopped chicken, pureed chicken, pureed rice dressing, and the pureed squash and zucchini.Further observation in the kitchen revealed S7Dietary used her bare hands to put the chocolate and strawberry cake in the blender to make the pureed dessert.During the serving of the lunch meal S6Cook made 2 grilled cheese sandwiches and used her bare hands to obtain bread out of the package and then used the same bare hands to grab cheese out of a plastic bag and place it on the bread. Further observation of S6Cook revealed she then made a chef salad with her bare hands by getting lettuce out of a plastic bag and cutting the lettuce into pieces, then got sliced turkey and used her bare hands to cut up the turkey and placed it on the lettuce, S6Cook then cut up a tomato and placed it on the salad with her bare hands and also got grated cheese out of a plastic bag with her bare hands and placed it on the salad.On 06/22/2026 at 2:00 p.m., an interview with S5Production Manager confirmed the food temperatures were not taken of the rice dressing, mashed potatoes, pulled pork, cabbage, chopped chicken, pureed chicken, pureed rice dressing, and the pureed squash and zucchini on the steam table prior to serving the lunch meal.S5Production Manager agreed that S6Cook should not have used her bare hands to make a grilled cheese sandwich and should not have used her bare hands to make the chef salad.

Based on interview and record review, the facility failed to ensure it developed a comprehensive person-centered care plan for each resident by failing to develop a care plan for catheter care for 1 (#14) of 3 residents reviewed for urinary catheters.Findings:Review of the medical record for Resident #14 revealed he was admitted on [DATE] with a diagnosis of chronic kidney disease. Review of the June 2026 Physician orders revealed Resident #14 had a urinary catheter. Review of the care plan revealed it did not address the resident's urinary catheter. On 06/23/2025 at 3:30 p.m., interview with S2DON confirmed the resident had a urinary catheter and the care plan did not address the urinary catheter of Resident #14.

Based on observation and interview, the facility failed to ensure CNAs were competent in the skill of incontinent care for 1 (#7) of 2 residents observed during incontinent care.Findings: On 06/22/2026 at 9:08 a.m. Resident #7 requested to have her brief changed. Resident #7 pushed her call light and S3CNA and S4CNA entered the room.S3CNA stated at that time she normally worked in medical records, but she was also a CNA.Observation revealed Resident #7 had urinated in her brief.Further observation revealed S4CNA obtained a new brief from Resident #7's dresser and Resident #7 stated that she was out of personal wipes.Further observation revealed S3CNA went into Resident #7's bathroom and came back with wet paper towels. Observation revealed S3CNA wiped Resident #7's perineal area with the wet paper towel and did not dry the area. Resident #7 was then turned onto her side and again S3CNA wiped the resident's buttocks with wet paper towels and did not dry the area before a new brief was put on the resident.On 06/22/2026 at 9:45 a.m., an interview with S3CNA confirmed she used wet paper towels to wipe the urine off Resident #7 and did not dry Resident #7 prior to putting a new brief on the resident.

Based on record review and interview, the facility failed to ensure the attending physician included a handwritten clinical rationale for the denial of a dose reduction of a psychotropic medication for 2 (#2, #55) of 5 residents reviewed for unnecessary medications. Findings:Resident #2Review of the medical record revealed Resident #2 was admitted on [DATE] with diagnoses which included depression and delusional disorders. Review of the physician orders revealed Resident #2 was receiving the psychotropic medication Seroquel 50 mg three times daily. Review of the Pharmaceutical Consultant Report revealed on 01/19/2026, the consultant pharmacist requested a dose reduction for Seroquel 50mg. The physician denied a dose reduction. The physician failed to provide a hand written valid clinical rationale for the denial of a dose reduction. On 06/23/2026 at 2:45 p.m., interview with S2DON confirmed the physician failed to provide a hand written valid clinical rationale for the denial of a dose reduction. Resident #55Review of the medical record revealed Resident #55 had an admission date of 03/12/2026 with diagnoses which included impulse disorder and major depression. Review of the physician orders revealed Resident #55 received Oxcarbazepine 150mg and Depakote 125mg for impulse control disorder and Sertraline 50mg for major depression. Review of the Pharmaceutical Consultant report revealed on 01/19/2026, the consultant pharmacist requested a dose reduction for medications which included Zoloft 25mg daily, Oxcarbazepine 150mg bid and Depakote 125mg bid. The physician denied the dose reductions. The physician failed to supply a hand written valid clinical rationale for the denial to conduct a dose reduction of the medications. On 06/23/2026 at 2:45 p.m., interview with S2DON confirmed the physician failed to provide a handwritten rational for the denial of a dose reduction.

Based on observations, record reviews, and interviews, the facility failed to ensure that a resident who received respiratory care was provided such care, consistent with professional standards of practice by not having signage on the outside of the resident's room to indicate oxygen was in use for 2 (#99 and #125) of 2 residents reviewed for oxygen.Findings:Review of the facility's Oxygen Administration Policy (undated) revealed the following in part:Policy:While oxygen is in use, No Smoking, signs will be posted at the entrance to the room. Procedure13. Place the No Smoking, Oxygen in Use warning sign on the resident's room door or in other appropriate location. Resident 99Review of the medical record revealed Resident #99 had an admission date of 04/14/2026.Resident #99 had diagnoses that included orthostatic hypotension, vascular dementia and heart disease.Review of the physician orders dated 06/21/2026 revealed an order for Oxygen at 1 liter per nasal cannula continuously. Observations on 06/22/2026 at 1:02 p.m., 06/23/2026 at 8:30 a.m. and 10:45 a.m. revealed Resident #99 was in the room and received Oxygen 1 liter per nasal cannula, signage was not posted outside of the resident's room door to indicate Oxygen was in use.On 06/23/2026 at 11:15 a.m. observation of Resident #99 with S2DON revealed the resident was in the room and received Oxygen at 1 liter per nasal cannula, no signage was observed outside of Resident #99's room to indicate Oxygen was in use. At this time S2DON confirmed signage to indicate Oxygen in use should have been posted on the outside of the resident's room door. Resident 125Review of the medical record for Resident #125 revealed an admission date of 06/12/2026. Resident #125 had diagnoses that included heart failure, hypotension, atrial fibrillation, pulmonary embolism, and shortness of breath. Review of the June 2026 physician orders revealed an order for Oxygen at 2 liters per nasal cannula as needed related to diagnoses of shortness of breath.Observations on 06/22/2026 at 8:30 a.m., and 10:30 a.m. revealed Resident #125 was in the bed and received Oxygen at 2 liters per nasal cannula, signage was not posted outside of the resident's room to indicate Oxygen was in use.On 06/23/2206 at 11:10 a.m. observation of Resident #125 with S2DON revealed the resident was in the room and received Oxygen at 2 liters per nasal cannula, no signage was observed outside of Resident #125's room to indicate Oxygen was in use. At this time S2DON confirmed signage to indicate Oxygen in use should have been posted on the outside of the resident's room door.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident was free from physical restraints imposed for the purpose of discipline or convenience for 1 (#112) of 2 (#58 and #112) residents reviewed for restraints. The facility failed to identify that resident #112 had a wheelchair seatbelt in place. Findings: Review of the facility's undated Physical Restraint Policy revealed the following, in part: A physical restraint is defined as any manual method or mechanical, physical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. The policy specifies that devices that are used in conjunction with a chair such as trays, tables, bars or belts that the resident cannot remove easily and prevent a resident from rising out of the chair are included as restraints. Additionally, the undated Physical Restraint Policy specified that informed consent must be obtained prior to initiation of a restraint. Before a resident is restrained, the facility must complete a pre-restraining assessment and they must demonstrate the presence of a medical symptom that requires the use of restraints, and how the use of restraints would treat the medical symptom, protect the resident's safety, and assist in reaching the highest level of physical and psychological well-being. A physician's order is also necessary for the use of physical restraints and must be very specific. Use of restraints must be included in each resident's plan of care, addressing what restraint to use, when to use it, why it is used and measures to prevent decline in status. Review of the medical record for resident #112 revealed an admitted [DATE] with diagnoses including type 2 diabetes mellitus, monoplegia of upper limb following non-traumatic subarachnoid hemorrhage affecting right dominant side, abnormalities of gait and mobility, unsteadiness of feet, and paranoid schizophrenia. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating that resident #112 was cognitively intact. Further review of the MDS revealed physical restraints were not in use for resident #112. Review of the April 2025 Physician's Orders revealed no order for a wheelchair seatbelt for resident #112. Review of resident #112's current plan of care revealed no documented evidence related to the use of a wheelchair seatbelt. Observations on 04/28/2025 at 1:29 p.m. and 04/29/2025 at 3:13 p.m. revealed resident #112 was seated in a wheelchair with a seatbelt in place and secured. On 04/30/2025 at 11:51 a.m., resident #112 was observed in the therapeutic dining area in a wheelchair. S8Restorative Certified Nursing Assistant (CNA) visually confirmed that a wheelchair seatbelt was in place and secured. On 04/30/2025 at 12:00 p.m., S2Director of Nursing (DON) was notified that resident #112 had a wheelchair seatbelt in place and secured. S2DON was also notified there was no documentation related to the use of the wheelchair seatbelt. S2DON confirmed he was unaware there was no physician order for resident #112's wheelchair seatbelt and that the resident currently had a wheelchair seatbelt in place.

Based on observation, record review, and interviews, the facility failed to ensure the resident's environment remained as free of accident hazards as is possible; and each resident received assistance devices to prevent accidents by failing to ensure a thorough investigation and appropriate interventions were initiated after each incident for 1 (#49) of 4 (#38, #49, #81, #107) sampled residents revealed for accidents. Findings: Review of the undated facility Accident/Incident Reports: Resident policy revealed the following, in part: Purpose: To assure appropriate follow-through on all accident/incidents. To study the cause of accidents and incidents and to give guidance for corrective/preventative action. Procedure: 10. Note the location and the time of the incident, the names of witnesses, and the exact circumstances of the incident. 12. Chart an objective account of the incident in the nurses' notes in the resident's medical record to include: b. Witnesses - their description of the incident. 14. Send accident/incident report to the Director of Nursing who: d. Submits accident/incident form and follow-up assessment form to Administrator, who then reviews the forms. All accident/incident reports are reviewed for causes, trends, patterns, and preventive measures. Review of the record revealed resident #49 was admitted to the facility on [DATE] with diagnoses including overactive bladder, mild vascular dementia with other behavioral disturbance, aphasia following unspecified cerebrovascular disease, muscle wasting and atrophy, lack of coordination, difficulty in walking, other reduced mobility, unsteadiness on feet, cognitive communication deficit, peripheral vascular disease, other specified depressive episodes, dementia, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 which indicated resident #39 had severe cognitive impairment. Further review revealed she required extensive - 2 person assistance with most activities of daily living and used a walker for ambulation. An observation of resident #49 on 04/28/2025 01:35 p.m. revealed she was ambulating in the hall with a rolling walker. Resident #49 had a large purple bruise and small dressing observed on the back of her right hand. An interview with resident #49 revealed she was alert but confused. Resident #49 reported she was unsure of what happened to her right hand. Review of resident #49's current care plan revealed she was at a high risk for falls related to confusion, gait/balance problems, incontinence, poor communication/comprehension, psychoactive drug use, unaware of safety needs. Further review revealed the resident used a walker for ambulation. Review of the facility Incident Accident Report dated 04/09/2025 at 6:45 a.m. revealed S6Licensed Practical Nurse (LPN) was called to resident #49's room by staff a member. There was an open area to her left lower arm. The area was round and approximately the size of a half dollar coin with no bleeding noted. The walker was found across the room against the wall. The incident was not witnessed and the resident was unable to give a description of incident. Further review revealed S7Registered Nurse (RN) followed up on the above incident on 04/10/2025. When S7RN asked the resident what happened, resident #49 pointed to the handle on the rolling walker and stated I hit my hand on that. Further review revealed the facility failed to conduct a thorough investigation by failing to obtain witness statements from staff that worked with the resident on 04/09/2025. Review of the facility Incident Accident Report dated 04/10/2025 at 6:35 a.m. revealed S6LPN was called to resident #49's room. A superficial skin tear approximately 3 centimeters (cm) round was noted on her lower right forearm surrounded with dark red and purple bruising. Bruising to the back of her right hand was also noted. Resident #49 was unable to give a description of the accident. S7RN followed up on the above incident on 04/11/2025. When she asked the resident what happened, resident #49 pointed to the handle on the rolling walker and stated I hit my hand on that. Geri-Sleeves were in place to bilateral arms. Further review revealed the facility failed to conduct a thorough investigation by failing to obtain witness statements from staff that worked with the resident on 04/10/2025. There was no documentation of the following: an appropriate intervention to address the bruising to the resident's right hand and no evaluation of the resident's walker by therapy to ensure safety. Review of the Rehabilitation Screen - Physical/Occupational Therapy dated 04/10/25 revealed she was screened for rocking with transfers and a skin tear on 04/10/2025. Therapy was not recommended for resident #49 at that time. Further review revealed there was no documentation that therapy addressed the issue regarding potential safety concerns with the resident's rolling walker handle. Review of the facility Incident Accident Report dated 04/11/2025 at 6:39 a.m. revealed S4LPN entered resident #49's room to administer morning medications. S4LPN noticed a dried skin tear to right hand and no blood noted. S4LPN also noticed dried blood noted to left side of cheek and underneath fingernails. Discoloration was noted to the back of resident #49`s right hand. Resident had been scratching her hand causing skin tear and rubbed her face with right hand causing the dried blood to the left side of her cheek. The resident's fingernails were cut to prevent further injury. Further review revealed the facility failed to conduct a thorough investigation by failing to obtain witness statements from staff that worked with the resident on 04/11/2025. Review of the Electronic Heath Record nurse's note dated 4/11/2025 at 07:40 a.m completed by S11LPN, revealed resident #49 was sitting on bench in front of the chapel as she was walking up the hallway. S11LPN stopped to talk with the resident #49 and she reached and grabbed the brakes, pushed them down (locked them) and then started to rock back and forth. Resident #49 then reached to grab the handle bar and hit her right hand on handle bar as she was pulling herself up. She shook her hand, looked at me, and laughed, It got me. A phone interview with S11LPN on 04/30/2025 at 3:30 p.m. revealed in her above nurses' note she had asked resident # 49 to demonstrate how she works the brakes on her rolling walker since she had an incident on 04/10/2025 where the resident bumped her hand on the handle of her rolling walker. S11LPN confirmed the above notation regarding resident #49 was not describing another incident and revealed the documentation was not clear. The facility failed to conduct a thorough investigation of resident #49's 04/11/2025 incident by not identifying the discrepancy with the 04/11/2025 nurses' note by S11LPN and the 04/11/2025 incident report completed by S4LPN. An interview with S2Director of Nursing (DON) on 04/30/2025 at 3:15 p.m. confirmed the following: there were no thorough investigations and no witness statements obtained regarding resident # 49's incidents on 04/09/2025, 04/10/2025, and 04/11/2025; no therapy evaluation of resident #49's rolling walker for the 04/09/2025 and 04/10/2025 incidents; and no appropriate intervention for the resident sustaining an injury to her right hand for the 04/10/2025 incident.

Based on observations, interviews, and record review, the facility failed to ensure that an indwelling catheter was not used unless there is valid justification for catheterization and the catheter was discontinued as soon as clinically warranted for 1 (#70) of 3 (#70, #68, and #78) residents reviewed for urinary catheter or urinary tract infection. Findings: Review of the facility's undated Catheterization, Urinary: In and out, indwelling and suprapubic (Male and Female) Policy revealed the following, in part: an indwelling catheter provides continuous bladder drainage in residents with a neurogenic bladder or urinary dysfunction. Examples of clinical conditions demonstrating that catheterization may be unavoidable include: . , 2. Skin wounds, pressure sores, or irritations that are being contaminated by urine, 3. Terminal illness or severe impairment, which makes bed and clothing changes uncomfortable or disruptive. The facility is expected to show evidence of any medical factors which caused the intervention. Justification of catheter use should be found on the accumulative diagnosis form, catheter justification record, physician's order sheet, physician's progress note or plan of care. Review of the medical record for resident #70 revealed an admitted [DATE] with diagnoses that included chronic obstructive pulmonary disease, morbid obesity, age-related physical debility, lymphedema, chronic pain syndrome, and chronic osteomyelitis of right ankle and foot. Review of the Medicare 5 day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated that resident #70 was cognitively intact. Further review of the MDS revealed that resident #70 was dependent on staff for activities of daily living including bed mobility, transfers, and toileting. The MDS also revealed that resident #70 had an indwelling catheter. Review of the resident #70's current Physician's Orders revealed an order dated 03/27/2025 for a 16French (FR)/10 cubic centimeters (CC) Foley catheter for urine collection related to the presence of a pressure ulcer to the sacrum. Further review of the Physician's Orders revealed that there were no orders for the treatment of a pressure injury to the sacrum for resident #70. Review of resident #70's skin assessment log revealed no documented evidence of the presence of a pressure ulcer to the sacrum. Review of resident #70's current plan of care revealed a plan to address skin conditions. The skin conditions care plan revealed no documented evidence of the presence of a pressure injury to the sacrum. Further review of the care plan addressed the use of a Foley catheter, and the indwelling catheter care plan documented the use of the catheter was due to the presence of a pressure injury to the sacrum. On 04/28/2025 at 9:40 a.m., resident #70 voiced that the indwelling catheter was in place due to bed sores. On 04/29/2025 at 8:56 a.m., an interview was conducted with resident #70 who confirmed that her wound was healed. On 04/29/2025 at 2:13 p.m., a follow-up interview was conducted with resident #70 who stated that her indwelling catheter is in place because she cannot walk. On 04/29/2025 at 9:16 a.m., an interview was conducted with S3Registered Nurse Wound Care who confirmed that resident #70 did not currently have a pressure ulcer to the sacrum. On 04/30/2025 at 3:41 p.m., S2Director of Nursing (DON) was informed that the indwelling catheter justification for resident #70 was inappropriate.

Based on observations, record reviews, and interviews, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 3 (#70, #76, #120) of 3 (#70, #76, #120) residents reviewed for respiratory care. The facility failed to ensure: 1) water in the humidifier bottle on the oxygen concentrator was changed weekly and oxygen tubing was stored properly for resident #70), 2) nebulizer hand pipe was dated and stored properly for resident #76, and 3) oxygen tubing was dated and oxygen concentrator filter was clean for resident #120. Findings: Review of the facility's undated Oxygen Administration (Concentrator or Tank) Policy revealed that humidifier bottles, cannulas, and Oxygen (O2) tubing will be changed at least once weekly and dated. Concentrator filter should be cleaned weekly or as needed as well. When not in use, cannula or mask should be placed in a plastic bag. Resident #76 Review of the record for resident #76 revealed diagnoses of hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side, bronchitis, extended spectrum beta lactamase (ESBL) resistance, apraxia following cerebral infarction, dysphagia, resistance to multiple antibiotics, and cognitive communication deficit. Review of the resident #76's current Physician's orders revealed an order dated 01/30/2025 for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 milligram (mg)/3 milliliter (ml) 1 vial inhale orally four times a day related to wheezing per handheld nebulizer for the diagnoses of wheezing. Record minutes of nebulizer treatment. Also, listen to resident's lungs with stethoscope for abnormal breath sounds after treatment. 0 = Clear lung sounds 1 = crackles, rales, rhonchi, wheezing or rub. Review of a physician order dated 10/07/2024 revealed to change nebulizer tubing, medication chamber, and mask weekly every night shift every Wednesday. On 04/28/2025 at 03:55 p.m., an observation of the bedside table in resident #76's room revealed the nebulizer hand held pipe was lying on top of the table with no cover and was not dated. On 04/29/2025 at 3:17 p.m., an observation of resident #76's nebulizer hand held pipe with S2Director of Nurses (DON) revealed the date on the nebulizer only read 4/1. S2DON said the rest of the date must have wiped off due to the nebulizer liquid. On 04/30/2025 at 9:10 a.m., an observation again of the nebulizer hand held pipe revealed it was lying on the floor uncovered. On 04/30/2025 at 9:15 a.m., an interview with S2DON confirmed the nebulizer hand held pipe should not be lying on the floor. Resident #120 Review of the record for resident #120 revealed diagnoses in part of dysphagia, aphasia, cognitive communication deficits, hypertension, type 2 diabetes, adult failure to thrive, other nonspecific abnormal finding of lung field, pneumonia on 02/12/2025 and 03/21/2025, and chronic obstructive pulmonary disease. Review of the physician orders revealed an order dated 04/08/2025 for oxygen at 2 liters per minute by nasal cannula as needed for oxygen saturation less than 94%. On 04/28/2025 at 3:53 p.m., an observation of resident #120 revealed she was wearing the oxygen per nasal cannula at 2 liters per minute. Observation of the oxygen tubing revealed there was no date on the tubing, and there was a dust build up on the filter on the back of the oxygen concentrator. Observations of the oxygen concentrator on 04/29/2025 at 11:53 a.m. and 04/29/2025 at 2:15 p.m., again revealed there was no date on the oxygen tubing and a buildup of dust was on the filter on the back of the oxygen concentrator. On 04/29/2025 at 3:16 p.m., observation of resident #120's oxygen tubing and oxygen concentrator with S2DON revealed the oxygen tubing did not have a date and there was a buildup of dust on the filter on the back of the oxygen concentrator. S2DON confirmed at that time there was no date on the oxygen tubing and the filter on the back of the oxygen concentrator had dust particles. 52271 Resident #70 Review of the medical record for resident #70 revealed an admitted [DATE] with diagnoses that included chronic obstructive pulmonary disease, morbid obesity, age-related physical debility, lymphedema, and chronic pain syndrome. Review of the Medicare 5 day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 which indicated that resident #70 was cognitively intact. Further review of the MDS revealed resident #70 had oxygen therapy. Review of the Physician's Orders revealed an order dated 03/27/2025 to change O2 tubing, nasal cannula, humidifier bottle, and clean filter weekly every night shift every Wednesday. Review of the April 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed resident #70's oxygen tubing/humidifier bottle was last changed on 04/23/2025. On 04/29/2025 at 8:56 a.m., resident #70 was observed lying in bed with nasal cannula hanging on the bed rail and the humidifier bottle was dated 04/17/2025. On 04/29/2025 at 2:13 p.m., resident #70 was observed lying in bed, and the humidifier bottle was dated 04/17/2025. On 04/30/2025 at 9:16 a.m., an interview was conducted with S6Licensed Practical Nurse (LPN) regarding nasal cannula storage, and she reported the nasal cannula should be stored in a storage bag when not in use. The surveyor and S6LPN observed resident #70's nasal cannula tubing lying on the floor in her room and she confirmed the nasal cannula tubing was not stored properly. On 04/29/2025 at 2:17 p.m., S2DON was interviewed regarding the facility policy for oxygen tubing, nasal cannula, and humidifier bottle. S2DON confirmed resident #70's respiratory equipment should be changed out every Wednesday night.

Based on observation and interview the facility failed to ensure drugs and biologicals were stored and labeled in accordance with accepted professional principles by failing to put an open date on multidose medications for residents #41, #59, #61, #77, #92 and by failing to ensure there were no expired medications available for resident use that were stored in the stock cabinet. Findings: On 04/30/2025 at 2:17 p.m. observation of medication cart 1 with S4Licensed Practical Nurse (LPN) revealed an opened Fluticasone Propionate nasal spray for resident #41 did not have an open date written on the medication container. Observation of an open bottle of artificial tears for resident 77 revealed there was no open date written on the medication container. Observation of an open bottle of Brimonidine eye drops 0.2%, for resident 92 revealed there was no open date written on the medication container. On 04/30/2025 at 2:20 p.m., an interview with S4LPN confirmed the open medications did not have an open date written on them. On 04/30/2025 at 2:45 p.m. observation of medication cart 4 with S5LPN revealed an opened Fluticasone Propionate nasal spray 50 micrograms (mcg) container for resident 59 that did not have an open date written on the medication container. Observation of an opened Nova log 70/30 flex pen for resident 61 revealed there was no open date written on the medication container. Observation of the medication stock cabinet in the front nurses' station revealed an open bottle of Vitamin D 25 micrograms (mcg) with and expiration date of 01/2025. On 04/30/2025 at 2:50 p.m., an interview with S5LPN confirmed the medications for resident 59 and 61 did not have an open date written on the medication container. S5LPN confirmed the Vitamin D 25 mcg in the stock cabinet was expired and available for resident use. On 4/30/2025 at 3:00 p.m. observation of cart 2 with S6 LPN revealed an open bottle of artificial tears with no open date written on the container. At that time an interview with S6LPN confirmed the artificial tears did not have an open date written on the medication container.

Based on observations and interviews, the facility failed to store food in accordance with professional standards for food service safety by failing to ensure that food was dated and stored properly. This deficient practice had the potential to affect all residents who received meals served from the kitchen. Findings: On 04/28/2025 at 8:50 a.m., observation revealed three bulk storage containers for sugar, flour, and cornmeal covered with clear plastic lids in the food service area. All three lids had dirt and grime build-up on the lids and the front of the containers were visibly soiled. Additionally, multiple products in the dry food storage room were open and did not have the open date documented. The undated items were: 128 ounces (oz) light corn syrup, a large bottle of blended oil, a large open box with 1/4 full bag of rice left open to air and undated. Further observation revealed a dented 6 pound 9oz can of peaches. On 04/30/2025 at 1:30 p.m., an interview with S12Dietary Manager confirmed the above areas should have had an opened date and/or should have been cleaned.

Based on observations and interviews, the facility failed to ensure that essential kitchen equipment was maintained in safe operating condition. This deficient practice had the potential to affect all residents who received meals served from the kitchen. Findings: On 04/28/2025 at 9:05 a.m., there were two large ice chests on rolling stands full of ice. The ice scoops were not stored properly and were observed uncovered on top of the ice inside of the ice chests. The deep fryer was observed to have a large amount of old grease and grime build-up on the lower compartment of the deep fryer. Both of the large capacity ovens were in need of cleaning as evidenced by the food spills and splatters on the inner and outer oven doors. The large can opener had a large amount of old food build-up and there were old food spills and splatters observed inside of the microwave. On 04/30/2025 at 1:30 p.m., an interview with S12Dietary Manager confirmed the above areas should have been cleaned.

Based on record review, observation and interview the facility failed to ensure infection control practices were maintained during wound care for 1 (#120) of 2 (#78, #120) wound care observations. Findings: Review of the record for resident 120 revealed diagnoses in part: stage 3 pressure ulcer sacral region dysphagia, aphasia, cognitive communication deficits, hypertension, type 2 diabetes, adult failure to thrive, crohn's disease of the small intestine, pneumonia, neuromuscular dysfunction of bladder, and chronic obstructive pulmonary disease. Review of the April 2025 Physician orders revealed the following active orders: 04/10/2025 Clean stage 3 pressure ulcer to sacrum with wound cleanser, pat dry with 4 by 4, apply sure prep to periwound, apply collagen then Opticell silver to wound bed, cover with border foam dressing on Monday, Wednesday, and Friday and as needed if dressing becomes soiled/dislodged until resolved. On 04/30/2025 at 11:07 a.m., an observation of wound care by S3Registered Nurse (RN), Wound Care Nurse to resident #120 was conducted in the resident`s room. Observation revealed S3RN Wound Care Nurse sprayed dermal wound cleanser onto the sacral wound from the bottle that was dated 04/19/2025 and dried the area with a 4 by 4 gauze. S3RN Wound Care Nurse then got a small piece of collagen and attempted to place it on the sacral wound but it fell off onto resident #120's brief. S3RN Wound Care Nurse then got a piece of Opticell silver and picked up the collagen that had fallen on the resident's brief and placed it back on the wound, then applied the protective wipe and then border gauze dressing. On 04/30/2025 at 11:10 a.m., an interview with S3RN Wound Care Nurse confirmed she picked up the collagen dressing off of the resident #120's brief and placed it back on the wound after it fell in resident's brief. On 04/30/2025 at 11:48 a.m. review of the findings with S2Director of Nurses (DON) acknowledged S3RN Wound Care Nurse should not have picked up the dressing from the brief and placed it on the wound.

Based on observation, interview and record review the facility failed to provide assistance for a resident who was unable to carry out activities of daily living and received the necessary services to maintain good grooming, and personal hygiene for 1(#75) of 2(#64, 75) residents investigated for ADL (activities of daily living) care. Findings: Resident #75 On 02/28/23 at 08:50 am Resident #75 was observed in her room with long dirty fingernails to both hands. On 02/28/23 at 10:30 am an observation of Resident #75 in her room revealed she had long dirty fingernails to both hands that were in need of nail care. Record review revealed Resident #75 was a [AGE] year old female admitted to the facility on [DATE] with diagnosis that included vascular dementia and cerebrovascular accident resulting in paralysis of left side. Record review revealed a completed quarterly MDS (minimum data set) assessment was completed on 02/16/2023. Review of the quarterly MDS assessment revealed in section G - Functional Status revealed Resident #75 had total dependence on staff to maintain personal hygiene. Review of care plans revealed an active care plan acknowledging Resident #75 had a self care deficit related to activities of daily living with an intervention in place that required nursing staff to keep fingernails trimmed and clean. On 02/28/23 at 12:38 pm an observation and interview was conducted with S4 LPN in the room of Resident #75. S4 LPN confirmed Resident #75 had long dirty fingernails to both hands that were in need of nail care.

Based on observation, interview and record review the facility failed to provide appropriate treatment and services to prevent further decrease in range of motion for 1 (#320) of 4(#97, 322, 1, 320) residents investigated for position/mobility. The failed practice was evidenced by facility staff failing to apply a brace to the right hand of Resident #320 as ordered per the physician. Findings: Resident #320 Record review revealed Resident #320 was a [AGE] year old female admitted to the facility on [DATE] with active diagnosis that included CVA (cerebrovascular accident), muscle wasting and contracture of right hand. Review of the POC (plan of care) revealed Resident #320 was dependent on facility staff for all ADL (activities of daily living) care. The POC also revealed Resident #320 had cognitive impairment and was unable to sit upright, stand or walk. The POC also revealed Resident #320 was dependent on staff for all activities of daily living and mobilization. Review of physician orders revealed the following active order: Apply resting hand splint to right hand for up to 23 hours/day for contracture management. May remove for bathing and to observe skin each shift to ensure integrity is intact. Review of the MAR (medication administration record) revealed the nursing staff had signed the electronic record acknowledging they had placed the splint to the right hand of Resident #320 on 03/01/23 at 05:00 am, 02/28/2023 at 05:00 pm, 02/28/2023 at 05:00 am, 02/27/2023 at 05:00 pm and 02/27/2023 at 05:00 am, 02/26/2023 at 05:00 pm, 02/26/2023 at 05:00 am, 02/25/2023 at 05:00 pm, 02/25/2023 at 05:00 am and 02/24/2023 at 05:00 pm. On 02/27/23 at 01:39 pm Resident #320 was observed in her bed with no splint placed on her right hand. On 02/28/23 at 03:08 pm Resident #320 was observed in her bed with no splint applied to her right hand. On 03/01/23 at 09:00 am Resident #320 was observed in bed with no splint observed to the right hand. On 03/01/23 at 09:45 am an interview with S5Therapy Director was conducted in her office. S5 Therapy director confirmed Resident #320 had a contracture to the right hand and a splint was ordered on 02/24/2023 for the right hand of resident #320. S5Therapy Director revealed a splint for Resident #320 had been stored in the therapy office since 02/24/2023. On 03/01/23 at 11:44 am S5 Therapy Director reported she found a second splint in Resident #320`s room in the drawer of the nightstand of Resident #320`s room. S5 Therapy Director confirmed Resident #320 did not have a splint in place to the right of Resident #320 as ordered. On 03/01/23 at 12:45 pm an interview with S2 DON (director of nursing) confirmed Resident #320 should have had the splint to the right hand in place as ordered.

Based on observation, record review, and interview, the facility failed to ensure a resident maintained acceptable parameters of nutritional status by failing to provide ordered supplements for a resident with significant weight loss for 1 (#77) of 2 (#77 and #100)residents reviewed for nutrition. Findings: Review of the medical record for resident #77 revealed the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set, dated dated dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. The resident required one person extensive assistance with eating, dressing and personal hygiene. The resident required two person extensive assistance with bed mobility, dressing and personal hygiene. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the record revealed the following note: on 03/10/2022 the Interdisciplinary Team met to discuss monthly weights and potential changes or significant weight loss or gain that may need to be addressed in their plan of care. This review revealed that the resident has experienced a significant weight loss within the past month. The present weight is documented at 122.9 pounds. The Registered Dietician, physician and responsible party have been notified of these findings and will make changes at their request. Observation on 03/13/2022 at 11:50AM, on 03/15/2022 at 11:15AM and on 03/16/2022 at 11:15AM revealed the resident received a pureed lunch tray and there was not a pudding or yogurt on the tray. An interview with S3Dietary Manager on 03/16/2022 at 12:40PM confirmed the kitchen should be providing the yogurt or pudding on resident #77's meal trays. S3Dietary Manager reported add pudding or yogurt to meal tray is on her diet card and there is also a note in the kitchen. An interview with S4Certified Nursing Assistant on 03/16/2022 at 12:45PM confirmed there was a pureed dessert on her lunch tray but not a pudding or yogurt. During an interview on 03/16/2022 at 1:40PM, S2Director of Nursing was notified that resident #77 was not provided a pudding or yogurt on her lunch trays on 03/13/2022, 03/15/2022 and 03/16/2022.

Based on record review, observations and interviews, the facility failed to ensure a resident received appropriate treatment and services to prevent further decrease in range of motion by not applying a hand roll device daily as ordered for 1 (#112) of 3 (#47, #73 and #112) residents reviewed for limited range of motion. Findings: Review of the medical record revealed the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set, dated dated dated [DATE] revealed the resident had moderately impaired cognitive skills for daily decision making. The resident required two person extensive assistance with transfers, dressing and toilet use. The resident had range of motion impairment on one side of her upper and lower extremities. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 03/13/2022 at 2:00PM and on 03/15/2022 at 10:00AM and 1:25PM revealed the resident's left hand and wrist were contracted and there was not a hand roll in place. An interview with S5Certified Nursing Assistant (CNA) on 03/16/2022 at 1:55PM revealed that the nurse or the CNA should put the hand roll in the resident's hand. During an interview on 03/16/2022 at 2:00PM, S2Director of Nursing was notified that resident #112 did not have her hand roll in her left hand on 03/13/2022 and 03/15/2022.

Based on record review and interview the facility failed to ensure the pharmacist report any irregularities to the attending physician, the facility's medical director and director of nursing. The pharmacist failed to address the facility did not monitor a [CONDITION(S)] Stimulating Hormone level for a resident receiving [MEDICATION(S)] for 1 (#64) of 5 (#38, #60, #64, #105 and #108) sampled residents reviewed for unnecessary medications. Findings: Review of the medical record for sampled resident #64 revealed an admitted [DATE] with diagnoses of [CONDITION(S)], dementia, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], pain, abnormal [CONDITION(S)] function studies, depressive disorder, hypertension, and sick sinus syndrome. Review of the 01/12/2022 significant change Minimum Data Set revealed the resident had severely impaired cognitive skills for daily decision making and required assistance with activities of daily living. Review of the March physician orders revealed an order for [MEDICATION(S)] 50 micrograms to be administered every day with a start date of 03/26/2019. Review of the careplan revealed to monitor endocrine system related to diagnoses of [CONDITION(S)]. Further review of the care plan revealed to administer the medications as ordered, obtain labs as ordered, and to notify the physician with signs and symptoms of [CONDITION(S)] or [CONDITION(S)]. Review of the medical record revealed no documented evidence of monitoring TSH ([CONDITION(S)] stimulating hormone) levels for resident #64 receiving [MEDICATION(S)] medication. Review of the monthly drug regimen reviews performed by the Pharmacist revealed no documented evidence that the pharmacist addressed the facility not monitoring the TSH level for resident #64. On 03/16/2022 at 2:15PM, S2DON (Director of Nursing) was notified that the pharmacist did not address TSH level not obtained. S2DON revealed the last TSH level obtained was 03/23/2020.

Based on record review and interview the facility failed to ensure the each resident's drug regimen must be free from unnecessary drugs. The facility failed to monitor TSH ([CONDITION(S)] Stimulating Hormone) levels for a resident receiving [MEDICATION(S)] medication for 1 (#64) of 5 (#38, #60, #64, #105 and #108) sampled residents reviewed for unnecessary medications. Findings: Review of the medical record for sampled resident #64 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 01/12/2022 significant change Minimum Data Set revealed the resident had severely impaired cognitive skills for daily decision making and required assistance with activities of daily living. Review of the March physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the careplan revealed to monitor endocrine system related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the care plan revealed to administer the medications as ordered, obtain labs as ordered, and to notify the physician with signs and symptoms of [CONDITION(S)] or [CONDITION(S)]. Review of the medical record revealed no documented evidence of monitoring TSH ([CONDITION(S)] stimulating hormone) levels for resident #64 receiving [MEDICATION(S)] medication. On 03/16/2022 at 11:35AM an interview with S2DON (Director of Nursing) confirmed a TSH level was not obtained to monitor the use of the [MEDICATION(S)] medication.

Based on record review, observation, and interview, the facility failed to ensure a resident's right to be free from sexual abuse for 1 (Resident #1) of 10 (Residents #2-#10) sampled residents reviewed. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1 on 11/20/2020 at 9:00PM when S5CNA sexually assaulted the resident anally. This sexual assault was witnessed by S6CNA when she returned Resident #1's roommate to her room. S6CNA said she looked through the opening in Resident #1's closed curtain, where the curtains meet, and saw that Resident #1 was laying on her left side in the bed facing the wall and S5CNA was hunching her from the back. S6CNA did not report the abuse until 10:10PM after their shift had ended. During the 70 minutes before S6CNA reported the abuse, S5CNA continued caring for residents in the facility. The facility implemented corrective actions prior to the State Agency's investigation thus, it was determined to be a past noncompliance citation. S1Administrator was notified of the past non-compliance Immediate Jeopardy situation on 11/25/2020 at 1:40PM. Findings: Record Review revealed Resident #1 was admitted on [DATE] and had [DIAGNOSES REDACTED]. Review of the quarterly Minimum (MDS) data set [DATE] revealed BIMS (Brief Interview Mental Status) score of 3 which represents severe cognitive impairment. The resident was totally dependent on staff for all activities of daily living. Resident #1 requires two-person physical assist with bed mobility, transfers, toileting. Resident #1 is frequently incontinent of bowel and bladder. Observations of Resident #1 on the mornings of 11/24/2020 and 11/25/2020 revealed she was sitting in her wheelchair by the bed in her room. A cushion was noted in the seat of the wheelchair. She was alert and oriented to name only. She was pleasantly confused and spoke in a soft voice. She could answer simple yes / no questions. She was calm and did not appear in any distress. She denied any pain. She was wearing geri-sleeves on both arms and had [MEDICATION NAME] 1.2 cal infusing via feeding pump at 60cc/hr. Review of the facilities incident investigation for Resident #1 revealed on 11/20/2020 at 10:10PM, S6CNA reported to S4RN (Charge Nurse) an alleged physical abuse by staff. Documentation revealed there was no apparent injury. The incident occurred in Resident #1 room. The associate involved was S5CNA. The narrative of incident and description of injuries revealed S6CNA summoned me and said I have something I have to tell you. She was crying with her mask on and was difficult to understand at first. S6CNA stated I had to wait until my partner left to be able to tell this. The guy I was working with was sexually abusing a resident. The administrator was notified immediately and came back to the facility to conduct interviews while I stayed with the resident for safety. The physician and responsible party were notified. No injuries noted. The police were notified immediately. The accused was taken into custody. On 11/21/2020 at 12:00AM, S3ADON conducted a head to toe assessment on Resident #1. Resident #1 vital signs obtained: temperature 98.6, pulse 64, respirations 17, blood pressure 98/62, and pain scale 0. The Physician was notified of the incident on 11/21/2020 at 12:05 AM. The responsible party was notified of the incident on 11/21/2020 at 12:08AM. Resident #1 went out to the emergency room for evaluation and treatment and returned to the facility. Resident #1's condition at time of incident: Adjustable bed was down. Bedfast no independent movement. Orientation: Alert, oriented only to self. Risk factors: History of Confusion/disorientation and incontinency. On 11/24/2020 at 9:25AM an interview conducted with S1Administrator revealed that on 11/20/2020 around 11:15PM she was called and notified by S4RN (Charge Nurse) that S6CNA reported that S5CNA had sexually assaulted Resident #1. S1Administator reported she instructed S4RN (Charge Nurse) to make sure Resident #1 was safe and have someone stay with her and that she would be at the facility as soon as possible. S1Adminitrator called the administrative staff that was on call S3ADON and S2DON and informed them of the alleged sexual abuse at the facility and the immediate need for them to meet her at the facility as soon as possible. S1Administrator revealed that when she got to the facility she interviewed S6CNA. S1Administrator reported that S6CNA appeared very upset, and she reported that she observed S5CNA humping Resident #1 through the opening in the curtains as she was returning Resident1's roommate back to her room. S1Administrator asked S6CNA to write a witness statement exactly what she saw. S1Administrator asked S4RN (Charge Nurse) to call S5CNA back to the facility so she could interview him. She told her to inform him that he had forgotten to complete some charting and needed to return to the facility and complete it. When S5CNA returned to the facility, S4RN (Charge Nurse) stayed with him in the front administrative office until S1Administrator and S3ADON entered the office. S1Administrator reported that at 11:11PM she interviewed S5CNA in the front administrative office with S3ADON and S4RN (Charge Nurse) present. S1Administrator reported that at first he was not very willing to answer questions, and he reported that he had completed all of his charting already. She reported that she asked him general questions about the residents that he cared for and how they were doing. She reported that she had to break down each question into very simple direct questions. She asked him if he provided care for Resident #1. He replied that he did provide care for Resident #1. She asked him what he did while in the room caring for Resident #1. She reported that he was very detailed about collecting all the supplies he needed to provide incontinent care and change her adult brief. S1Administrator reported that he was very detailed about all the steps he did: closing the curtains, picking up the floor mat, positioning the bed, cleaning her up and placing a new adult brief on her. She asked him why he was alone and why did he not go as a team while providing incontinent care for Resident #1. She reported that he just looked downward and did not answer the question. She asked him at any time while caring for Resident #1 did his pants come down. At first he said no. She reminded him that they do have video cameras throughout the facility. She then asked him again at any time while caring for Resident #1 did your pants come down. S1Administrator reported that S5CNA said that his pants may have come down because they are a little loose sometimes. She asked him if there was ever a time that his genitals ever touched her body. He did not answer the question. She asked him 2 more times was there ever a time that his genitals touched her body. He did not answer. She asked him vaginally or anally? He did not answer. She asked him 2 more times vaginally or anally? S1Administrator reported he said anally and lowered his head. She asked him if this behavior has ever happened in this room before, and he said no. She asked him if this behavior has ever happened at the facility before, and he said no. S1Administrator reported that he said he just got the urge and could not control himself. She reported that he said he knew that he would be wrote up over this. S1Admiinistrator then asked S5CNA to do a written statement. S3ADON and S4RN (Charge Nurse) stayed with S5CNA while he was writing his statement and provided him paper and pen. S1Administrator reported that she went to another office and immediately called the MD, Sheriff's Department and Resident #1 responsible parties and informed them of what had occurred. S1Administrator reported that staff stayed with S5CNA in the front administrative office until he was questioned by the 2 sheriff's officers. S1Administrator reported that Resident #1 had dementia and could not remember the incident occurring. S1Administrator reported that S3ADON performed a head to toe assessment on Resident #1 with S8LPN assisting. Review of Resident #1's nurses notes revealed the assessment done revealed no negative findings. S1Administrator revealed Resident #1 was sent out to the local Hospital ER via ambulance per Physician order. She was evaluated and also had evaluation done by SANE (Sexual Assault Nurse Examiner) nurse while in the ER. Resident #1 returned back to the facility via ambulance with no new orders. On 11/24/2020 at 9:45AM an interview conducted with S3ADON. S3ADON revealed she was the administrative staff member on call on 11/20/2020 and was called around 10:35 pm by S1Adminisrator and informed of the alleged sexual assault that had occurred at the facility and instructed to go directly to the facility. She reported that she arrived around 11:10PM. S3ADON reported that S1Administrator was already at the facility interviewing S6CNA. S3ADON reported that S5CNA was at the facility in the front administrative office with S4RN (Charge Nurse). S3ADON interview confirmed what was said during the interview with the administrator. S3ADON reported that she did a head to toe assessment on Resident #1 around midnight with S8LPN present. She reported that Resident #1 was asleep and that she could not find any negative findings. On 11/24/2020 at 10:25AM an interview conducted with S2DON. S2ADON revealed on 11/20/2020 around 10:40PM he was notified by S1Administrator of the alleged sexual assault at the facility. S2DON went directly to the facility to assist in the investigation. S2DON confirmed that S5CNA was terminated on 11/21/2020. On 11/24/2020 at 1:30PM a telephone interview conducted with S6CNA. S6CNA revealed she was recently hired on 11/17/2020. She confirmed that she had received and was aware of the facilities abuse/neglect policy when she was hired during her orientation on 11/17/2020. She reported that the first day to work was the day shift on 11/18/2020. She reported that her first evening shift was on 11/20/2020. She reported that she did work the 2p-10p shift on 11/20/2020 and was assigned to work with S5CNA. S6CNA reported that around about 8:50PM on 11/20/2020 she was assisting another CNA provide care to another resident and they were talking with the resident's roommate for a while. When S6CNA came out of their room she saw Resident#1's roommate was sitting in her wheel chair next to the Christmas tree in the hallway. She reported that she didn't know if she should be out of her room so she pushed her back into her room. S6CNA reported the door to the room was closed. She opened the door and the curtains were closed to Resident #1 area. She reported that she pushed Resident #1's roommate to her side of the room. S6CNA reported that she looked through the opening where the curtains meet and saw that Resident #1 was laying on her left side in the bed facing the wall, and S5CNA was hunching her from the back. S6CNA reported that S5CNA was having sex with her. S6CNA reported she could not believe what she saw. She reported that she was scared. S6CNA backed out of the room and peaked again through the curtain by the door before exiting the room and observed S5CNA had stopped and was in the process of pulling up his scrub pants. S6CNA reported that she did not think that S5CNA had heard or seen her. On 11/24/2020 at 2:20PM a telephone interview was conducted with S4RN (Charge Nurse). S4RN (Charge Nurse) revealed that on 11/20/2020 at 10:10PM S6CNA told her that she saw S5CNA hunching Resident #1 from behind, through the curtains earlier in the night before shift change. S6CNA told her that S5CNA did not see her. S4RN (Charge Nurse) reported that she and S3ADON were present during the entire time that S1Administrator interviewed S5CNA. S4RN (Charge Nurse) reported that S5CNA confessed to sexually assaulting Resident#1 while he was providing brief change in her room. S4RN (Charge Nurse) reported that S5CNA admitted that his penis entered Resident #1's anus and that he removed his penis before ejaculating. S4RN (Charge Nurse) reported S1Administrator instructed S5CNA to write a statement about what he had done after he gave a verbal confession. On 11/25/2020 at 9:20AM, an interview with S2DON revealed he had reviewed the video surveillance again for 11/20/2020 and did a timeline of S5CNA's movements. S2DON revealed that on 11/20/2020 at 9:06PM, S5CNA entered Resident #7 room alone with supplies to perform incontinent care alone. S2DON confirmed that Resident #7 was alone, and she was not oriented due to dementia. S5CNA exited Resident #7 room at 9:15PM with linen and trash. S2DON confirmed that a head to toe assessment was not done on Resident #7 after the administrative staff was made aware of the alleged sexual assault of Resident #1 on 11/20/2020 at 10:10 PM. On 11/30/2020 at 11:30AM, two surveyors observed the facilities surveillance video from the evening shift on 11/20/2020 and verified the timeline provided by S2DON. S1Administrator, S2DON, and S3ADON were present for our observation of the surveillance video in the administrator's office. S2DON and S3ADON both confirmed that a head to toe assessment was not done on Resident#7 after the administrative staff was made aware of the alleged sexual assault of Resident #1 on 11/20/2020 at 10:10 PM. Review of the Facilities High Risk Resident Monitoring binder for 100, 200, 300/400 and 500/600 halls revealed the binder had documentation that began on 11/25/2020 and was completed on each shift up to 11/30/2020 (present date). There were no concerns noted. Observation of peri/incontinent care by different CNAs was done on 11/30/2020 at 8:50 AM (S12CNA & S32CNA), 9:00 AM, 10:00 AM, and 10:10 AM (S27CNA & S28CNA) and no issues were noted. Observation, interview and review of the facility's policy, and training documents verified that all components of the Plan of Correction were in place. The facility has implemented the following Plan of Correction to correct the deficient practice: Plan of Correction 11/20/2020 following the report of alleged abuse. Resident observations were completed by Charge Nurse 11/20/2020 of potentially affected residents, exhibit #10. The observations continued on 11/21/2020, 11/22/2020 by licensed personnel. Corrective actions accomplished by: 11/20/2020, Exhibit #5 staff present in facility were in-serviced on process for providing personal care to residents and the abuse policy with emphasis on immediate reporting by S2DON and S3ADON. 11/20/2020, Exhibit #6 an On-shift message was sent out to all employees to present to facility and receive in-service per RN- charge nurse on process for provision of personal care and the abuse policy with emphasis on immediate reporting. These corrective measures were monitored by the Director of Nurses, the Administrator, the licensed practical nurses, and the RN-charge nurse on 11/21/2020. 11/22/2020 RN-charge nurse continued to in-service toward completion of entire staff, on abuse policy with emphasis on immediate reporting and the provision of personal care as a team. These corrective measures were monitored by the Director of Nurses, the Administrator, the licensed practical nurses, and the RN-charge nurse on 11/22/2020. 11/23/2020- Exhibit #8 RN-charge nurse completed in-service for entire staff, on abuse policy with emphasis on immediate reporting and the provision of personal care as a team. These corrective measures were monitored by the Director of nurses, the Administrator, the licensed practical nurses and the RN-charge nurse on 11/23/2020. Exhibit #4 IDT team met and compiled a list of cognitively impaired residents whom require personal care interventions for routine checks that were performed multiple times daily by the administrative nurses. Exhibit #9- The Administrator and DON conducted staff interviews related to employee's professionalism during provision of care, and to discern if any concerns were relevant to the matter. Exhibit #11A and 11B Resident interviews were conducted by Director of Nursing & Facility Administrator related to perception of safety within the facility. Exhibit #3 Cognitively impaired residents who require personal care interventions were routinely checked multiple times daily by administrative nurses. 11/24/2020, Exhibit #3 Cognitively impaired residents who require personal care interventions were routinely checked multiple times daily by administrative nurses. 11/25/2020, Exhibit #12-The IDT team met and reviewed QA concern and formulated corrective action plan. All staff in-service for acknowledgement of understanding and compliance with making rounds together as a team on female cognitively impaired residents. Floor LPNs were distributed a list of female high-risk residents that will be observed by administrative staff member or nurse during the provision of personal care once each shift times 1 month, then twice daily times 1 month, then daily times 1 month until compliance is met. Exhibit #15-There will be a binder located at each nurse's station with the list of high-risk residents that can be referenced if needed. Any new residents and current residents with a status change, requiring a provision of personal care intervention, will be updated on the high-risk list needed by the administrative nurses. Exhibit #14-Instructions sheet was added to the orientations packet for new staff members and current employees to sign signifying their compliance with working as a team during the provision of care to demented female residents. Exhibit #13-Monitors will be conducted three times weekly by the Director of Nursing and administrative nurses to ensure the facility correction is sustained by direct observation, chart audits, and audits of monitors. If a problem is detected, disciplinary action will be taken and re-education will be provided. Corrective action Exhibit #12 through Quality Assurance will be completed on 11/27/2020.