Every finding on record at Southern Hills Healthcare and Rehabilitation

Based on record review and interviews, the facility failed to refer 1 (#70) of 1 resident with a new diagnosis of bipolar disorder for a level II PASARR. Findings:Review of Resident #70's medical record revealed an admit date of 10/09/2020 with the following diagnoses, including in part: generalized anxiety disorder, dementia, bipolar disorder current episode mixed severe with psychotic features (01/13/2026) and insomnia.Review of Resident #70's quarterly MDS assessment dated [DATE] revealed an active diagnosis of bipolar disorder. Review of Resident #70's medical record failed to reveal a level II PASARR referral was completed for a new diagnosis of bipolar disorder.During an interview on 04/14/2026 at 2:45 p.m. S2 Social Services reported Resident #70 had a permanent level II PASARR but was unable to produce documentation.During an interview on 04/15/2026 at 8:25 a.m. S1 DON confirmed a level II PASRR referral was not completed on Resident #70 following a new diagnosis of bipolar disorder.

Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (#33) of 2 total residents reviewed for anticoagulant medications. The facility failed to develop a care plan for Resident #33's cerebral infarction and anticoagulant therapy. Findings: Review of Resident #33's medical record revealed an admit date of 02/12/2026 with the following diagnoses, including in part: cerebral infarction and chronic obstructive pulmonary disease. Review of Resident #33's Physician's orders revealed an order dated 02/13/2026: Xarelto (anticoagulant) oral tablet 10 mg give 1 tablet by mouth in the evening related to cerebral infarction. Review of Resident #33's Comprehensive Care Plan failed to reveal a problem and approach for cerebral infarction and anticoagulant therapy. During an interview on 04/14/2026 at 12:40 p.m., S3MDS Nurse acknowledged Resident #33 had not been care planned for cerebral infarction and the use of an anticoagulant and should have been.

Based on record review and interview, the facility failed to transmit an assessment within 14 days after completion for 1 (#56) of 1 resident reviewed for resident assessments. Findings:Review of Resident #56's medical record revealed an admit date of 08/19/2024 with the following diagnoses, including in part: type 2 diabetes with hyperglycemia, heart failure unspecified and paranoid schizophrenia. Review of Resident #56's MDS Assessments revealed a quarterly assessment dated [DATE] with a status of inactivated. Further review revealed an assessment dated [DATE] with a status of annual is export ready. During an interview on 04/14/2026 at 1:30 p.m. S3 MDS Nurse reported Resident #56's assessment dated [DATE] was entered as a quarterly assessment and should have been an annual assessment. S3 MDS Nurse acknowledged the 02/24/2026 assessment had not been transmitted.

Based on record review, observation, and interviews, the facility failed to ensure a resident received adequate supervision to prevent incidents and accidents. The facility failed to ensure a resident received supervision during incontinent care for 1 (#2) of 3 (#1, #2, #3) residents reviewed for falls. The deficient practice resulted in an immediate jeopardy for Resident #2 on 04/26/2025 at approximately 5:00 a.m. when Resident #2 fell out on the left side of the bed during incontinent care when S4CNA (Certified Nursing Assistant) failed to ensure the resident was secured and safe in the bed to prevent her from falling before she turned away to retrieve an adult brief from the over bed table leaving Resident #2 unsupervised causing Resident #2's fall resulting in a fractured right femur. Resident #2 was transferred to a local ER (Emergency Room) on 04/26/2025. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a past noncompliance citation. Findings: Resident #2 was admitted to the facility on [DATE] with diagnoses, which included in part, unspecified fracture of lower end of right femur, subsequent encounter for closed fracture with routine healing, Rheumatoid arthritis, type 2 diabetes mellitus without complications, other lack of coordination, pain unspecified and unspecified abnormalities of gait and mobility. Review of Resident #2's most recent completed Quarterly MDS(Minimum Data Set) assessment dated [DATE] revealed in part, Resident #2 had a BIMS (Brief Interview Status) score of 15, which indicated Resident #2 was cognitively intact that includes normal thinking, learning, and memory abilities. Resident #2 was always incontinent of bowel and bladder and dependent on staff for ADL (activities of daily living) care. Review of Resident #2's comprehensive care plan revealed in part, Resident #2 was at risk for falls related to impaired mobility, with approaches in place prior to the fall injury. ADLs were bed mobility Resident #2 needed extensive assistance. Review of the facility's Incident Report dated 04/26/2025 at 05:00 a.m., revealed in part, S4CNA stated during Resident #2's incontinent care, she (S4CNA) turned away to retrieve an adult brief from the over bed table leaving Resident #2 unsupervised causing Resident #2's fall resulting in a fractured right femur. Resident #2 was transferred to a local ER (Emergency Room) on 04/26/2025. Review of S4CNA's signed witness statement dated 04/27/2025 revealed S4CNA documented she was changing Resident #2, Resident #2 had turned and grabbed the side rail so I (S4CNA) reached the other way to grab a diaper that was on the other side which took 2 seconds I (S4CNA) look back over Resident #2 had must got weak and let go. After the fall I (S4CNA) immediately got the nurse. Review of Resident #2's nurse's progress notes dated 04/26/2025 at 5:00 a.m. by S5LPN (licensed practical nurse) which read in part: S5LPN notified per S4CNA Resident#2 was on the floor. Upon entry of room S5LPN noted Resident #2 laying on her left side on the floor with the bed in the high position. When asked what happened S4CNA reported she was changing Resident #2 reached over to grab a diaper to put under her, turn back around and Resident #2 was on the floor. S5LPN assessed Resident #2's range of motion, pain and skin. Resident #2 complained of pain level of 8 to 10 to right knee. S5LPN noted ½ centimeter skin tear to Resident #2's jaw, blood pressure 152/93, pulse 82, respiration 18. Temp. 98.4, oxygen saturation 90%, oxygen at 2 liters continuous by way of nasal cannula. Resident #2 assisted from floor per Hoyer Lift. Resident #2 was administered 2 Tylenol 325 for pain per standing orders. At 5:08 a.m. order received from on call nurse practitioner to send Resident #2 to E.R. (emergency room). At 5:12 a.m. ambulance called, 5:19 a.m. spouse was called no answer. At 5:22 a.m. Resident #2's son was notified of incident. At 5:26 a.m. Resident #2 left facility via stretcher per ambulance to local hospital E.R. DON (Director of Nursing) notified Review of Resident #2's hospital records dated 04/26/2025, revealed she was diagnosed with a non-operative right distal femur fracture. Resident #2 is to remain in an immobilizer for 6 to 8 weeks. Observation on 05/13/2025 at 9:40 a.m. Resident #2 was alert and talkative sitting up in a wheelchair at the bedside. Resident #2 had an immobilizer to her right leg that was slightly elevated. Resident #2's fingers and hands were deformed and twisted. Resident #2's bed had a weight reduction mattress on it, bilateral assisted side rails attached properly to the bed. During an interview on 05/13/2025 at 9:50 a.m., Resident #2 reported she had slipped out of her bed on the left side when S4CNA was cleaning her up. Resident #2 reported S4CNA just wasn't paying attention, talking on that phone. When Resident #2 was asked if she used the side rails to turn and reposition herself she responded, No. Resident #2 reported she was not able to hold on to the side rails for a long time due to the arthritis in her hands. Resident #2 reported she did not have much pain in that right leg now. Resident #2 reported the pain was nothing like the pain she had when she first fell. She reported the nurses gave her something for pain and it worked. During an interview on 05/13/2025 at 12:15 p.m., S3CNA Supervisor reported she was not working when the incident occurred with Resident #2 and S4CNA. S3CNA Supervisor reported S4CNA reported to her she was providing incontinent care to Resident #2 when she turned around to get an adult brief from the over bed table and Resident #2 fell out of the bed. S3CNA Supervisor reported S4CNA reported Resident #2's bed was in a high level so that she could work. S3CNA Supervisor reported S4CNA reported to her Resident #2 was holding on to the side rails and lost her grip and fell on the floor. During an interview on 05/13/2025 at 12:35 p.m., S1Administrator reported when she was notified about the incident with Resident #2 she went to the hospital to interview her (Resident #2). S1Administrator reported Resident #2 reported she lost her grip on the side rail. S1Administrator reported Resident #2 reported she was turned on her left side when her legs and feet dragged her to the floor. S1Administrator reported Resident #2 reported S4CNA was on her cell phone. S1Administrator reported she believed Resident #2 when she said S4CNA was on her cell phone. S1Administrator reported S4CNA should not have been on her cell phone. S1Administrator reported S4CNA was sent home immediately by S2DON. During an interview on 05/13/2025 at 12:50 p.m., S4CNA reported she was providing incontinent care for Resident #2 and she had turned on her on side away from her. S4CNA reported Resident #2 was holding onto the side rail. S4CNA reported Resident #2 let go of the side rail when she turned around to get a brief from the over bed table. S4CNA reported resident #2's legs went off the bed and she fell out the bed. S4CNA reported the bed was positioned high so she could work. S4CNA reported she did not go off and leave Resident #2, she hollered for a nurse in the hall to get Resident #2's nurse to come. S4CNA reported Resident #2 complained of right knee pain. During an interview on 05/13/2025 at 3:00 p.m., S2DON reported when she was notified about the incident she sent S4CNA home immediately pending the investigation. S2DON reported they called S4CNA to come back into the facility Monday 04/28/2025 to write her statement of what happened. S2DON reported S4CNA was suspended for three days and returned to work 05/01/2025. S2DON reported S4CNA was placed on the evening shift so that she could work with another CNA and be monitored. S2DON agreed a resident's bed should never be left in a high position when staff is not right there with them providing care. S2DON agreed even if staff steps or turns away for even a second to make sure that a resident is in a safe positon and the bed is in a low position. During an interview on 05/14/2025 at 10:25 a.m., S1Administrator confirmed the corrective actions put into place were completed on 05/01/2025 and monitoring would be ongoing for three months or until compliance is achieved per QA (quality assurance) committee. During the survey, in-services records, QAPI (Quality Assessment and Performance Improvement), and monitoring tools were reviewed and it was determined the facility had implemented the following actions prior to surveyor entering the facility to correct the deficient practice. The facility implemented the following actions to correct the deficient practice beginning on 04/26/2025 with a completion date of 05/01/2025: 1. On 4/26/2025 S4CNA was sent home immediately by S2DON and suspended for 3 days. 2. On 04/26/2025, 04/27/2025 and 04/28/2025 The facility initiated in-services, QAPI, Corrective Action Plan, monitoring tools were implemented to ensure compliance with ADL care provided for Dependent Residents twice weekly times three months and CNA Evaluations were conducted with CNAs on ADL care, resident rights, reporting accurately status of resident; Resident Rights & Accident Prevention, change in condition, skin breaks, bruises and injuries. 3. On 04/26/2025, 04/27/2025 and 04/28/2025 S3CNA Supervisor in-serviced all CNAs, Nurses, and Van Driver on the facility's cell phone policy, resident ADL care, fall prevention and safety and repositioning. 4. On 04/28/2025 Interviews were conducted with interviewable residents who said they had no problems with S4CNA when she worked on their hall. 5. On 05/01/2025 Resident #2's care plan revised to require 2 person assist in transfers with the use of the Hoyer lift and one additional person to be in the room to witness everything was being done correctly. 6. On 05/01/2025 S4CNA returned to work on the evening shift instead of the night shift for closer monitoring on a different hall. S3CNA Supervisor completed additional training with S4CNA including utilizing [NAME] the Skills Mannequin, have supplies close and within reach, to never leave the resident, reposition the resident to prevent them from falling, educated on turning and repositioning, and lifting to prevent injury to the resident and yourself.

Based on interviews and record reviews the facility failed to protect the residents' right to be free from sexual abuse and psychosocial harm from another resident for 1 (Resident #36) of 2 (Resident #2 and Resident #36) residents reviewed for abuse. Resident #36 was subject to unwanted sexual contact by Resident #2. The deficient practice resulted in an Immediate Jeopardy on 09/08/2024 at 9:00 p.m. when S4 CNA (Certified Nursing Assistant) observed Resident #2 touching Resident #36's breast in the facility's unlit dining room. S5RN (Registered Nurse) asked Resident #36, who was cognitively impaired, Were you (Resident #36) being touched by Resident #2? and Resident #36 replied, Well yeah, just down here as she pointed to S5 RN's breast. S5 RN asked Resident #36 if she wanted that to happen and Resident #36 replied, No. S5 RN asked Resident #36 if she was uncomfortable and Resident #36 stated, Yes. Even though there was no significant decline in mental or physical functioning, it can be determined that the reasonable person would have experienced severe psychosocial harm as a result of the sexual abuse, since a reasonable person would not expect to be treated in this manner in his own home or a health care facility. By the facility failing to implement protective measures, there was a high likelihood that additional severe harm, injury, or death could occur to any of the 74 residents residing in the facility. S1 Administrator was notified of the Immediate Jeopardy on 02/06/2025 at 3:30 p.m. The Immediate Jeopardy was removed on 02/07/2025 at 4:45 p.m. The facility implemented an accepted Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to the exit. Findings: Review of the facility's Incident Investigation and Reporting policy with a last review date of 05/2024, revealed in part: Purpose: To provide guidance to the facility for investigation and reporting incidents of abuse, neglect, exploitation, misappropriation of property and/or other reportable incidents to LDH (Louisiana Department of Health), Health Standards Section, local law enforcement, and others as required by state and federal requirements. To ensure reporting reasonable suspicion of crimes against a resident within prescribed timeframes. 1. Each resident residing in this facility has the right to be free from any type of abuse including: verbal, sexual, mental, physical abuse, neglect, exploitation, misappropriation of resident property . Relevant terms - Sexual abuse: Is nonconsensual sexual contact of any type with a resident. Resident #2 Resident #2 was admitted to the facility on [DATE] with diagnoses, which included in part bipolar disorder, major depressive disorder-single episode severe with psychotic features, anxiety disorder, intellectual disabilities and delusional disorders. Review of Resident #2's most recent Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed in part, Resident #2 had a BIMS (Brief Interview for Mental Status) score of 09 out of 15 indicating moderate cognitive impairment. Resident #2 used antipsychotic medication on a routine basis. Resident #2 required set-up help by staff for mobility and transfers. Review of Resident #2's comprehensive care plan failed to reveal that any interventions or monitoring following the incident of sexual abuse on 09/08/2024 had been implemented. Resident #36 Resident # 36 was admitted to the facility on [DATE] with diagnoses, which included in part, unspecified dementia, moderate, with other behavioral disturbances, schizophrenia unspecified, Alzheimer's disease with late onset, and major depressive disorder, recurrent, severe. Review of Resident #36's Quarterly MDS assessment dated [DATE] revealed in part, Resident #36 had a BIMS score of 03 out of 15 indicating severely impaired cognition. Resident #36 was able to walk 150 feet with supervision and utilized a wheelchair as a mobility device. Review of Resident #36's comprehensive care plan failed to reveal protective measures had been implemented related to an incident of unwanted sexual contact by Resident #2. Review of Resident #36's medical record revealed, a nurse's note by S5 RN dated 09/08/2024 at 9:24 p.m. which read in part, S4 CNA reported to S5 RN that Resident #36 was being felt on in dining room by a male resident (Resident #2). Resident #36 found in dining room, lights off, standing in front of Resident #2's walker. When asked what was going on, Resident #2 was silent. Both residents separated. S5 RN asked, Were you (Resident #36) being touched by him (Resident #2)? Resident #36 stated, Well yeah, just down here as she (Resident #36) pointed to my (S5 RN) breast. S5 RN asked if she (Resident #36) wanted that to happen. She (Resident #36) stated, No. S5 RN asked if she (Resident #36) was uncomfortable; she (Resident #36) stated, Yes . Resident #36 sent to room, in stable condition. Review of an incident report dated 09/08/2024 at 9:00 p.m. related to Resident #2, and prepared by S5 RN revealed in part: Description: S4 CNA reported to S5 RN that Resident #2 was sitting in dining room with a female resident (Resident #36), Resident #2 grabbed her hand, pulled her close and began to feel on her breast. S4 CNA reports that she knocked on the window and Resident #2 stopped. S5 RN entered dining area; Resident #2 was sitting and Resident #36 was standing in front of him and his walker. S5 RN asked Resident #2 if he touched Resident #36's breasts. Resident #2 stated, I'm sorry, I won't do it again, I didn't mean it, I'm sorry. S5 RN explained that these actions were inappropriate and actions would have to be reported. Resident #2 continues to apologize. Resident #2 encouraged to head to bed but Resident #2 refused multiple times, Resident #2 stated, It's too early, I'm going to the TV room . Review of the facility's reportable incident list 05/01/2024 to 02/03/2025 failed to reveal a report of sexual abuse on 09/08/2024 had been submitted to the appropriate state agency for review. During an interview on 02/04/2025 at 1:00 p.m., S2 DON (Director of Nursing) reported she was unable to find any ongoing monitoring of Resident #2. S2 DON identified the staff involved in the reporting of the incident as S5 RN and S4 CNA, neither still work at the facility. S2 DON identified the victim as Resident #36. During an interview on 02/04/2025 at 4:30 p.m., S2 DON reported she had not provided in-service training to all staff on abuse and neglect following the incident with Resident #2 and should have. During a telephone interview on 02/06/2025 at 3:00 p.m., S4 CNA reported she was walking by the glassed-in dining room directly adjacent from the nurse's station and happened to notice Resident #2 and #36 in the dining room. Resident #36 was standing in front of Resident #2. She stopped to see what was going on because the lights were off and she saw Resident #2 playing with Resident #36's breast. She banged on the dining room window and called the nurse/S5 RN who immediately went in the dining room and separated them. S4 CNA reported she was not aware of any in-services done at the time or right after the incident about abuse. During an interview on 02/06/2025 at 10:50 a.m., S1 Administrator acknowledged she was not made aware of the sexual abuse incident of Resident #36 being inappropriately touched by Resident #2, until 02/04/2025. S1 Administrator reported she was out during the incident date and she had not been informed upon return. S1 Administrator acknowledged a report was never submitted to the appropriate state agency or law enforcement and should have been. During an interview on 02/06/2025 at 11:05 a.m., S2 DON reported she was working on the night of the incident and conducted an abuse in-service on 09/08/2024 with the on-site evening shift and oncoming night shift staff but had not in-serviced the day shift or remaining staff members on abuse. S2 DON acknowledged she was responsible for in-servicing the staff on the abuse/neglect policy including recognizing signs, investigations, protection, and reporting procedures and failed to ensure all staff had been in-serviced. S2 DON reported she was responsible for overseeing that interventions were put into place to protect the residents but she had not reviewed the assessments and monitoring findings and should have. S2 DON acknowledged she did not notify the Administrator of the sexual abuse allegations towards Resident #36 or report it to the appropriate state agency or law enforcement and should have. During an interview on 02/06/2025 at 11:20 a.m., S3 Corporate Nurse reported she was notified of the incident by the DON the following day 09/09/2024. S3 Corporate Nurse acknowledged S1 Administrator had never been informed of the sexual abuse incident and she should have made sure S1 Administrator was made aware. S3 Corporate Nurse reported she would be responsible to oversee the monitoring. S3 Corporate Nurse acknowledged she had not confirmed the completion of ongoing monitoring. During an interview on 02/07/2025 at 10:30 a.m., S2 DON acknowledged no interventions had been put into place for the safety of Resident #36 or all other residents related to the sexual abuse incident and should have been. During an interview on 02/06/2025 at 4:00 p.m., S1 Administrator and S3 Corporate Nurse acknowledged the facility failed to properly report the allegation of sexual abuse and appropriately monitor the situation and should have. The facility's Plan of Removal: Resident #36 and all other residents have the potential for similar outcome. Two residents were unsupervised in the facility dining room with lights off on 09/08/2024. S4 CNA witnessed in the facility dining room with lights off Resident #2 touching Resident #36's breast. Resident #2 and Resident #36 were immediately separated by S4 CNA and S5 RN. Resident #2 was placed on one-on-one supervision until NP (Nurse Practitioner) saw him 09/09/2024. On 09/08/2024 Resident #36 had body audit completed by RN with no bruising, discoloration or skin impairment. Facility will ensure on February 6, 2025 residents are free from sexual abuse to prevent the likelihood of serious injury, serious harm, serious impairment or death. On February 6, 2025 the facility conducted body audits on all twenty-five cognitively impaired female residents. On February 6 and 7, 2025 Facility interviewed 8 male and 27 female residents who were interviewable to ensure there has been no other occurrence. On February 5, 2025 facility began immediately all facility staff in-servicing on how to report allegation of abuse/suspicion of inappropriate sexual conduct and who to report the allegation of abuse/suspicion if noted. Staff will not be allowed to perform their duties until they have been properly trained by the Administrator or properly trained designee. The facility will include in Resident #2's care plan and task behaviors q (every) 2 hours to be monitored by staff. The DON or designee will review behaviors five days a week beginning 02/07/2025 with ongoing monitoring. Resident #2's plan of care has been reviewed/revised with increased supervision. Any resident that exhibits inappropriate sexual behavior will have an individualized Person-Centered Care Plan developed with the appropriate goals to address the protection of those residents deemed incapable of making consent. Beginning February 7, 2025 nursing staff will visually observe Resident #2 every two hours for increased supervision and will be ongoing. The Regional Supervisor conducted an in-service on 02/06/2025 at 5:00 p.m. with Department Head Staff to include Administrator/Abuse Coordinator, DON, Department Staff on Abuse & Neglect, Elder Justice Act, Review of corporate training video on Abuse and Neglect, State Agency and Law Enforcement. These Department heads will conduct further training of staff during monthly staff meeting. Regional Corporate Supervisors will oversee to ensure compliance. Administrator/designee began in-servicing all facility staff beginning on February 5, 2025 on how to report allegations of abuse/suspicion of any type of abuse to include inappropriate sexual conduct and who to report the allegation/suspicion if noted. Staff will not be allowed to perform their duties until they have been properly trained by the Administrator or properly trained designee. This in servicing began on February 5, 2025 at 4:00 p.m. and will continue until all staff have been in-serviced. All Residents that exhibit inappropriate sexual behavior will be monitored by all staff beginning on February 6, 2025. The facility Abuse Coordinator plans to monitor staff competency by direct observation, and continued in-servicing. All residents will be monitored for through direct observations, interviews and staff interviews 5 times per week and documenting effects on a facility QA (Quality Assurance) tool. These audits will continue until substantial compliance is achieved and monthly times two months. QA monitoring tools were initiated on February 6, 2025 and will be ongoing. On February 6, 2025 the Facility conducted an Emergency QA with the facility Medical Director's Nurse Practitioner to outline all a fore mentioned protocol. The QA will be on going until substantial compliance is achieved. Any residents that exhibit inappropriate sexual behavior will have an individualized/Person Centered Care Plan developed with the appropriate goals to address the protection of those residents deemed incapable of making consent. QAPI (Quality Assurance Performance Improvement) was initiated on February 6, 2025, along with corrective action plan and monitoring tools. QA Committee will review in next Quarterly Meeting with Medical Director in attendance to give guidance and input to QA program. Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: 02/07/2025. 44414

Based on record reviews and interviews, the facility failed to ensure an alleged violation of sexual abuse was reported immediately to the facility's administrator, to the appropriate state agency within 2 hours after the allegations were made and to local law enforcement for 1 (Resident #36) of 2 (Resident #2 and Resident #36) residents reviewed for abuse. Resident #36 was subject to unwanted sexual contact by Resident #2. The deficient practice resulted in an Immediate Jeopardy on 09/08/2024 at 9:00 p.m. when S4 CNA (Certified Nursing Assistant) observed Resident #2 touching Resident #36's breast in the facility's unlit dining room. S5 RN (Registered Nurse) asked Resident #36, who is cognitively impaired, Were you (Resident #36) being touched by Resident #2? and Resident #36 replied, Well yeah, just down here as she pointed to S5 RN's breast. S5 RN asked Resident #36 if she wanted that to happen and Resident #36 replied, No. S5 RN asked Resident #36 if she was uncomfortable and Resident #36 stated, Yes. Even though there was no significant decline in mental or physical functioning, it can be determined that the reasonable person would have experienced severe psychosocial harm as a result of the sexual abuse, since a reasonable person would not expect to be treated in this manner in his own home or a health care facility. By the facility failing to implement protective measures, there was a high likelihood that additional severe harm, injury, or death could occur to any of the 74 residents residing in the facility. S1 Administrator was notified of the Immediate Jeopardy on 02/07/2025 at 11:10 a.m. The Immediate Jeopardy was removed on 02/07/2025 at 5:15 p.m. The facility implemented an accepted Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to the exit. Findings: Review of the facility's Incident Investigation and Reporting policy with a last review date of 05/2024, revealed in part: Purpose: To provide guidance to the facility for investigation and reporting incidents of abuse, neglect, exploitation, misappropriation of property and/or other reportable incidents to LDH (Louisiana Department of Health), Health Standards Section, local law enforcement, and others as required by state and federal requirements. To ensure reporting reasonable suspicion of crimes against a resident within prescribed timeframes. 1. Each resident residing in this facility has the right to be free from any type of abuse including: verbal, sexual, mental, physical abuse, neglect, exploitation, misappropriation of resident property . Relevant terms - Sexual abuse: Is nonconsensual sexual contact of any type with a resident. 3. Abuse, Neglect .are crimes and shall be reported to proper authorities as such. In the event of any incident involving an allegation or suspicion of mistreatment, exploitation, neglect, abuse ., each occurrence will be reported immediately to the Administrator of the Facility . The Administrator shall report to the State Survey Agency and local law enforcement entities in which the facility is located, any allegation or reasonable suspicion of a crime against any resident. The administrator shall report not later than 2 hours after forming the suspicion. 5. Additional incidents that must have a thorough investigation and may require reporting, as determined by the NF (Nursing Facility) especially in consideration to abuse and/or neglect, to the state agency with the implementation of corrective action(s), and referrals, as appropriate to the appropriate authorities/agencies. 6. The facility will thoroughly investigate all alleged violations under the direct supervision of the Administrator. The facility will take all necessary steps to prevent occurrence and/or further potential abuse. 7. During and after the investigation, the residents will be protected from harm through frequent supervision by staff. Resident # 36 was admitted to the facility on [DATE] with diagnoses, which included in part, unspecified dementia, moderate, with other behavioral disturbances, schizophrenia unspecified, Alzheimer's disease with late onset, and major depressive disorder, recurrent, severe. Review of an incident report dated 09/08/2024 at 9:00 p.m. related to Resident #2, and prepared by S5 RN revealed in part: Description: S4 CNA reported to S5 RN that Resident #2 was sitting in dining room with a female resident (Resident #36), Resident #2 grabbed her hand, pulled her close and began to feel on her breast. S4 CNA reports that she knocked on the window and Resident #2 stopped. S5 RN entered dining area; Resident #2 was sitting and Resident #36 was standing in front of him and his walker. S5 RN asked Resident #2 if he touched Resident #36's breasts. Resident #2 stated, I'm sorry, I won't do it again, I didn't mean it, I'm sorry. S5 RN explained that these actions were inappropriate and actions would have to be reported. Resident #2 continues to apologize. Resident #2 encouraged to head to bed but Resident #2 refused multiple times, Resident #2 stated, It's too early, I'm going to the TV room . Review of the facility's reportable incident list 05/01/2024 to 02/03/2025 failed to reveal a report of sexual abuse on 09/08/2024 had been submitted to the appropriate state agency for review. Review of Resident #2's record failed to reveal a police report had been completed or police had been notified. During an interview on 02/06/2025 at 10:50 a.m., S1 Administrator acknowledged she was not made aware of the sexual abuse incident of Resident #36 being inappropriately touched by Resident #2, until 02/04/2025. S1 Administrator reported she was out during the incident date and she had not been informed upon return. S1 Administrator acknowledged a report was never submitted to the appropriate state agency or law enforcement and should have been. During an interview on 02/06/2025 at 11:05 a.m., S2 DON (Director of Nursing) confirmed she was working on the night of the incident. S2 DON acknowledged she did not notify the Administrator of the sexual abuse allegations towards Resident #36 by Resident #2 or report it to the appropriate state agency or law enforcement and should have. During an interview on 02/06/2025 at 11:20 a.m., S3 Corporate Nurse reported she was notified of the incident by the DON the following day 09/09/2024. S3 Corporate Nurse acknowledged S1 Administrator had never been informed of the sexual abuse incident and she should have made sure S1 Administrator was made aware. During an interview on 02/06/2025 at 4:00 p.m., S1 Administrator and S3 Corporate Nurse acknowledged the facility failed to properly report the allegation of sexual abuse. The facility's Plan of Removal: Resident #36 was the victim at the time of the event on 09/08/2024 at 9:00 p.m. The perpetrator, Resident #2 continues to reside in the facility. Resident #36 and all residents with an adverse event or incident that required reporting to the Administrator, State Agency and Law Enforcement. Education began on February 5, 2025, the Administrator began immediately in-servicing all facility staff on how to report an allegation of abuse, including the two hour time line to report with ongoing monitoring. The Regional Supervisor conducted an in-service on 02/06/2025 at 5:00 p.m. with the Administrator/Abuse Coordinator, DON, Corporate Nurse and Department Heads on timeline reporting requirements of two hours for any allegation or suspicion of adverse event or incident that requires reporting to the Administrator, State Agency and Law Enforcement. Education included Abuse & Neglect, Elder Justice Act, Review of corporate training video on Abuse and Neglect, State Agency and Law Enforcement. These Department heads will conduct further training of staff during monthly staff meeting. On February 7, 2025, nursing staff was in-serviced on a Reporting Decision Tree, which was placed at the nurse's station to give additional guidance to staff on reporting requirements. The facility Administrator will report within two hours, any allegation or suspicion of adverse event or incident that requires reporting to state agency and law enforcement. Monitoring: Regional Corporate Supervisors will oversee to ensure compliance. On February 6, 2025 the Facility conducted an Emergency QA (Quality Assurance) with the facility Medical Director's Nurse Practitioner to outline all aforementioned protocol. The QA will be on-going until substantial compliance is achieved. The facility will report within two hours any allegation or suspicion of abuse to State reporting office and Law Enforcement. QAPI (Quality Assurance Performance Improvement) was initiated on February 6, 2025, along with corrective action plan and monitoring tools. QA Committee will review in next Quarterly Meeting with the Medical Director in attendance, to give guidance and input to QA program. Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: 02/07/2025. 44414

Based on interviews and record reviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (Resident #36) of 2 (Resident #2 and Resident #36) residents reviewed for abuse. The facility failed to have an effective system in place to: 1. protect Resident #36 from sexual abuse by Resident #2 and ensure all residents were free from abuse; 2. report abuse to the appropriate state agency and law enforcement. The deficient practice resulted in an Immediate Jeopardy on 09/08/2024 at 9:00 p.m. when S4 CNA (Certified Nursing Assistant) observed Resident #2 touching Resident #36's breast in the facility's glassed-in, unlit dining room. S5 RN (Registered Nurse) asked Resident #36, who is cognitively impaired, Were you (Resident #36) being touched by Resident #2? and Resident #36 replied, Well yeah, just down here as she pointed to S5 RN's breast. S5 RN asked Resident #36 if she wanted that to happen and Resident #36 replied, No. S5 RN asked Resident #36 if she was uncomfortable and Resident #36 stated, Yes. Even though there was no significant decline in mental or physical functioning, it can be determined that the reasonable person would have experienced severe psychosocial harm as a result of the sexual abuse, since a reasonable person would not expect to be treated in this manner in his own home or a health care facility. By the facility failing to implement protective measures, there was a high likelihood that additional severe harm, injury, or death could occur to any of the 74 residents residing in the facility. S1 Administrator was notified of the Immediate Jeopardy on 02/06/2025 at 3:30 p.m. The Immediate Jeopardy was removed on 02/07/2025 at 4:45 p.m. Findings, Cross reference F600 and F609: During an interview on 02/04/2025 at 1:00 p.m., S2 DON (Director of Nursing) reported she was unable to find any monitoring of Resident #2. During an interview on 02/04/2025 at 4:30 p.m., S2 DON reported she had not provided in-service training to all staff on abuse and neglect following the incident with Resident #2 and should have. During an interview on 02/06/2025 at 10:50 a.m., S1 Administrator acknowledged she was not made aware of the sexual abuse incident of Resident #36 being inappropriately touched by Resident #2, until 02/04/2025. S1 Administrator reported she was out during the incident date and she had not been informed upon return. S1 Administrator acknowledged a report was never submitted to the appropriate state agency or law enforcement and should have been. During an interview on 02/06/2025 at 11:05 a.m., S2 DON reported she was working on the night of the incident and conducted an abuse in-service on 09/08/2024 with the on-site evening shift and oncoming night shift staff but had not in-serviced the day shift or remaining staff members on abuse. S2 DON acknowledged she was responsible for in-servicing the staff on the abuse/neglect policy including recognizing signs, investigations, protection, and reporting procedures and failed to ensure all staff had been in-serviced. S2 DON reported she was responsible for overseeing that interventions were put into place to protect the residents but she had not reviewed the assessments and monitoring findings and should have. S2 DON acknowledged she did not notify the Administrator of the sexual abuse allegations towards Resident #36 or report it to the appropriate state agency or law enforcement and should have. During an interview on 02/06/2025 at 11:20 a.m., S3 Corporate Nurse reported she was notified of the incident by the DON the following day 09/09/2024. S3 Corporate Nurse reported she should have made sure S1 Administrator was made aware of the sexual abuse incident and she did not. S3 Corporate Nurse acknowledged she was responsible for overseeing the ongoing monitoring put into place and could not confirm the findings or completion of the monitoring. During an interview on 02/07/2025 at 10:30 a.m., S2 DON acknowledged no interventions had been put into place for the safety of Resident #36 or all other residents related to the sexual abuse incident and should have been. During an interview on 02/06/2025 at 4:00 p.m., with S1 Administrator and S3 Corporate Nurse, S1Administrator acknowledged she was responsible for providing oversight of the facility's abuse/neglect policy including reporting timeframes and making sure staff was educated on the necessary steps to ensure the safety and well-being of all residents. S1 Administrator and S3 Corporate Nurse acknowledged the facility failed to properly report the allegation of sexual abuse and appropriately monitor the situation and should have. The facility implemented an accepted Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to the exit. The facility's Plan of Removal: Resident #36 and all other residents has the potential for similar outcome. On February 5, 2025 the facility began immediate all facility staff in-servicing on how to report allegation of abuse/suspicion of inappropriate sexual conduct and who to report the allegation of abuse/suspicion if noted. Staff will not be allowed to perform their duties until they have been properly trained by the Administrator or properly trained designee. The facility will include in Resident #2's care plan and task behaviors q (every) 2 hours to be monitored by staff. The DON or designee will review behaviors five days a week beginning 02/07/2025 with ongoing monitoring. Resident #2's plan of care has been reviewed/revised with increase supervision. Any resident that exhibits inappropriate sexual behavior will have an individualized Person-Centered Care Plan developed with the appropriate goals to address the protection of those residents deemed incapable of making consent. Beginning February 7, 2025 nursing staff will visually observe Resident #2 every two hours for increase supervision and will be ongoing. Beginning on February 7th Facility Administrator will conduct monthly in-services continuing to educate staff on abuse and reporting requirements. On February 7, 2025 signs will be placed in designated areas as reminder on reporting abuse and signs of abuse. All facility staff will be in-serviced immediately beginning on February 5,2025 on how to report allegation of abuse/suspicion of any type of abuse and who to report the allegation/suspicion if noted. Staff will not be allowed to perform their duties until they have been properly trained by the Administrator or properly trained designee. This in servicing began on February 5, 2025 at 4:00 p.m. and ongoing until all staff have been in-serviced. Any residents that exhibit inappropriate sexual behavior will be monitored by all staff beginning on February 6, 2025. The facility Abuse Coordinator plans to monitor staff competency by direct observation, continued in-servicing, and resident and staff interviews 5 times per week and documenting effects on a facility QA (Quality Assurance) tool. These audits will continue until substantial compliance is achieved and monthly times two months. QA monitoring tools were initiated on February 6, 2025. The Regional Supervisor conducted an in-service on 02/06/2025 at 5:00 pm with Department Head Staff to include Administrator/Abuse Coordinator, DON on Abuse &Neglect, Elder Justice Act, Review of corporate training video on Abuse and Neglect, State Agency and Law Enforcement. These Department heads will conduct further training of staff during monthly staff meeting. Regional Corporate Supervisors will oversee to ensure compliance. On February 6, 2025, the facility conducted an Emergency QA with the facility Medical Director's Nurse Practitioner to outline all a fore mentioned protocol. The QA will be ongoing until substantial compliance is achieved. Any residents that exhibit inappropriate sexual behavior will have an individualized/Person Centered Care Plan developed with the appropriate goals to address the protection of those residents deemed in capable of making consent. QAPI (Quality Assurance Performance Improvement) was initiated on February 6, 2025, along with corrective action plan and monitoring tools. QA Committee will review in next Quarterly Meeting. Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: 02/07/2025. 44414

Based on record review and interview the facility failed to notify the resident's representative and physician after an incident of sexual abuse for 1 (#36) of 2 (#2 and #36) residents reviewed for abuse. Findings: Resident # 36 was admitted to the facility on [DATE] with diagnoses, which included in part, unspecified dementia, moderate, with other behavioral disturbances, schizophrenia unspecified, Alzheimer's disease with late onset, and major depressive disorder, recurrent, severe. Review of Resident #36's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed in part, Resident #36 had a BIMS (Brief Interview of Mental Status) score of 03 out of 15 indicating severely impaired cognition. Review of Resident #36's medical record revealed, a nurse's note by S5 RN (Registered Nurse) dated 09/08/2024 at 9:24 p.m. which read in part, S4 CNA (Certified Nursing Assistant) reported to S5 RN that Resident #36 was being felt on in dining room by a male resident (Resident #2). Further review Resident #36's medical record failed to reveal Resident #36's representative or physician had been notified of the incident of sexual abuse on 09/08/2024. During an interview on 02/06/2025 at 1:30 p.m., S2 DON (Director of Nursing) acknowledged the incident of abuse had not been reported to Resident #36's representative and should have been. During an interview on 02/06/2025 at 2:30 p.m., S2 DON reported she could not produce documentation that Resident #36's physician was notified of the incident of sexual abuse towards Resident #36 and should have been. During a telephone interview on 02/06/2025 at 3:00 p.m., Resident #36's representative reported she has never been notified of any inappropriate resident to resident interactions towards Resident #36.

Based on record reviews, observations, and interviews the facility failed to develop and implement a comprehensive person-centered care plan for 2 (#22, #326) out of 18 sampled residents reviewed. The facility failed to ensure a physician's order was in place for Resident #22's wander guard alarm device and for the maintenance/monitoring and/or discontinuation of Resident #326's PICC (Peripherally Inserted Central Catheter) line. Findings: Resident #22 Review of Resident #22's medical record revealed an admitted [DATE] with diagnoses that included, in part, Alzheimer's disease, anxiety disorder, and chronic kidney disease. Review of Resident #22's physician orders failed to reveal an order for wander guard alarm device. Review of Resident #22's annual MDS (minimum data set) assessment dated [DATE] revealed in part, Resident #22 had a BIMS (brief interview for mental status) score of 03, indicating severely impaired cognition. Review of Resident #22's current care plan revealed Resident #22 was an elopement risk, wanderer, and had impaired safety awareness. Resident #22 has a wander/elopement alarm device to ankle. Observation on 02/04/2024 at 10:30 a.m. revealed resident #22 sitting in common area on a couch in close proximity to the nurses' station with walker at side and wander-guard alarm device noted to right ankle. During an interview on 02/06/2024 at 12:40 p.m., S2 DON (Director of Nursing) acknowledged Resident #22 did not have a physician's order in place for the use of wander guard alarm device and should have. Resident #326 Review of the facility's General Central Venous Policies and Procedures policy dated October 2016 revealed in part: These procedures pertain to the access and maintenance of central venous catheters . These include peripherally inserted central catheters, tunneled catheters ., and implanted ports. B. Peripherally Inserted Central Catheters (PICCS) PICC line indications: Limited Peripheral venous access Additional recommendations for routine maintenance and care: Flushing: use of heparin flushes and the recommended concentration and frequency of flushing are determined in accordance with manufacturer's instructions and per the physician's orders . Review of Resident #326 medical record revealed an admitted [DATE] with diagnoses that included in part spinal stenosis, fusion of spine, Parkinson's disease, Type 2 diabetes and UTI (urinary tract infection). Review of Resident #326's physician orders failed to reveal an order for the maintenance/monitoring and/or discontinuation of Resident #326's PICC line. Review of Resident #326's admit nurse's note by S16 LPN (Licensed Practical Nurse) dated 01/30/2025 at 3:03 p.m. revealed in part, Resident #326 has a midline in upper left arm and an IV (intravenous) in lower left arm. During an interview on 02/06/2025 at 4:05 p.m., S2 DON reported Resident #326 was admitted with a PICC line for 1 dose of antibiotic. S2 DON acknowledged a physician's order was not in place to maintain, monitor and/or discontinue PICC line and should have been.

Based on record reviews, observations, and interviews, the facility failed to ensure correct use and maintenance of bed rails by ensuring 3 (#13, #50, #51) out of 3 residents reviewed for bed rails were assessed for the risk of entrapment from bed rails and 1 (#51) out of 3 residents nurse data collection and screening for bed rails was completed correctly. Findings: Review of facility's Physical Restraints/Devices Policy (revision date 03/2024) revealed: Purpose: to ensure that the resident is given the least restrictive options to care. To ensure resident safety and promote wellbeing. Potential reasons for using a physical restraint: 1. to improve the resident's mobility and independent function. 2. to treat resident's medical symptoms 3. in an emergency to restrict movement to protect the resident during treatment and diagnostic procedures. 4. to prevent the resident from injuring himself or others. Side rails: 4. Ensure that there is not a gap between the mattress and the side rail, as per facility policy. 8. Document all appropriate information in the clinical record. Resident #13 Review of Resident #13's face sheet revealed an initial admitted on 05/08/2024 and a re-entry admitted on 10/21/2024 with a medical diagnosis but not limited to unspecified glaucoma. Review of Resident #13's February 2025 Physician orders revealed an order dated 09/11/2024: may have assist rails for bed mobility and positioning Review of Resident #13's care plan revealed resident's current safety devices and special equipment included assist rails times two for bed mobility and positioning related to decreased strength to promote comfort and independence of bed mobility with interventions to assist rails times two half rails to assist with bed mobility and positioning to promote comfort and independence. Review of Resident #13's State Operational MDS (Minimum Data Set) assessment revealed Resident #13 required extensive assistance with two person physical assist with bed mobility. Review of Resident #13's device/physical restraint consent for bedrails revealed a verbal consent was received on 11/01/2024. Review of Resident #13's medical record failed to reveal any assessments for entrapment after assist rails were applied. Observation on 02/03/2025 at 10:38 a.m. revealed Resident #13 had raised assist rails to both sides of the bed. Observation on 02/03/2025 at 10:31 a.m. revealed Resident #13 had raised assist rails to both sides of the bed. Resident #50 Review of Resident #50's face sheet revealed an initial admitted on 03/14/2024 and an re-entry admitted on 09/25/2024 with the following medical diagnoses but not limited to schizoaffective disorder and hypertension. Review of Resident #50's February 2025 Physician orders dated 09/11/2024 revealed may have assist rails for bed mobility and positioning. Review of Resident #50's Care Plan revealed a focus on current safety devices and special equipment assist rails times two for bed mobility and positioning related to decreased strength to promote comfort and independence of bed mobility with interventions for assist rail times 2 for bed mobility and repositioning to promote comfort and independence Review of Resident #50's State Operational MDS assessment revealed Resident #50 required limited assistance with one person physical assist with bed mobility. Review of Resident #50's Device/Physical Restraint Consent for bed rails was signed and dated by Resident #50's representative on 11/01/2024. Review of Resident #50's medical record failed to reveal any assessments for entrapment after assist rails were applied. Observation on 02/03/2025 at 10:31 a.m. revealed Resident #50 had raised assist rails to both sides of the bed. Observation on 02/06/2025 at 9:46 a.m. revealed Resident #50 had raised assist rails to both sides of the bed. Resident #51 Review of Resident #51's face sheet revealed an initial admissiom date on 08/02/2023 and a re-entry admission on 09/19/2024 with the following medical diagnoses but not limited to cerebral infarction, unspecified dementia, unspecified abnormalities of gait and mobility, lack of coordination, muscle weakness, primary generalized (osteo) arthritis, muscle wasting and atrophy, cognitive communication deficit, and delusional disorders. Review of Resident #51's February 2025 Physician order dated 01/21/2025 revealed may have assist rails for bed mobility and positioning. Review of Resident #51's State Operation MDS assessment dated [DATE] revealed Resident #51 required extensive assistance with one person physical assist with bed mobility. Review of Resident #51's Care Plan revealed resident current safety devices and special equipment assist rails times 2 for bed mobility and positioning related to decreased strength to promote comfort and independence of bed mobility with interventions to assist rails times two. Review of Resident #51's Device/Physical restraint consent for bed rails was signed and dated by Resident #51 on 11/11/2024. Review of Resident #51's restraint necessity/positioning device dated 10/04/2024 revealed Resident #51 did not currently have a device (bed/side rail) in use. Observation on 02/03/2025 at 10:48 a.m. revealed Resident #51 had raised quarter side rails to both sides of the bed. Observation on 02/06/2025 at 10:05 a.m. revealed Resident #51 had raised quarter side rails to both sides of the bed. During an interview on 02/06/2025 at 9:55 a.m. S1 Administrator reported maintenance checks beds for risk for entrapment. S1 Administrator reported she did not know whether maintenance had performed the assessment for risk for entrapment. During an interview on 02/06/2025 at 11:30 a.m. S8 Maintenance reported residents with bed rails should be assessed monthly for risk for entrapment. S8 Maintenance reported residents #13, #50, #51's bedrails have not been assessed for risk for entrapment. During an interview on 02/07/2025 at 5:30 p.m. S1 Administrator reviewed Resident #51's restraint necessity/positioning device form and confirmed Resident #51's restraint necessity/positioning device form was incorrect and should reveal Resident #51 had side rails in use.

Based on review of personnel records and an interview the facility failed to ensure an annual performance review was completed for 1 (S11) of 5 (S11, S12, S13, S14, & S15) CNAs (Certified Nurse Assistant) at least once every 12 months. Findings: Review of S11 CNA's personnel record revealed a hire date 02/03/2017 and a re-hire date 10/28/2021. Review of S11 CNA's personnel record failed to reveal a 2024 annual performance review was completed. During an interview on 02/06/2025 at 8:40 a.m. S9 Human Resources reviewed S11 CNA's personnel file and confirmed an annual performance review had not been completed for 2024.

Based on record reviews, observation, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure Enhanced Barrier Precautions (EBP) were in place for 1 (#326) of 1 (#326) resident reviewed for antibiotic use. Findings: Review of the facility's Enhanced Barrier Precautions policy with a revision date of 03/2024 revealed in part: Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. EBPs (Enhanced barrier precautions) involve gown and glove use during high-contact resident care activities for residents know to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices). EBPs are indicated for residents with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. Signs are intended to signal to individuals entering the room the specific actions they should take to protect themselves and the resident. To do this effectively, the sign must contain information about the type of Precautions and the recommended PPE (personnel protection equipment) to be worn when caring for the resident. Facilities should ensure PPE and alcohol-based hand rub are readily accessible to staff. Resident #326 was admitted to the facility on [DATE] with the following diagnoses not limited to spinal stenosis, fusion of spine, Type 2 Diabetes, and UTI (Urinary tract infection) . Review of Resident #326's physician orders revealed in part: 01/31/2025 surgical site: posterior middle neck. Clean with wound cleanser and apply island dressing. Monitor for any s/s (signs and symptoms) of infection or increased drainage. 01/31/2025 Ertapenem sodium solution reconstituted 1 gm (gram), use 1 gm intravenously at bedtime for infection related to spinal stenosis, cervical region for 1 day. Review of Resident #326's medical record revealed a progress note by S17 Nurse Practitioner dated 01/31/2025 which revealed in part: . seen today status post hospitalization for posterior cervical fusion decompression . Resident #326 was also found to have UTI and culture grew ESBL (Extended Spectrum Beta-Lactamase) Klebsiella. Patient was seen in consultation with Infectious Disease and was ordered for Ertapenem 1gm IV (intravenous) every 24 hours for 5 days. Last dose 01/31/2025. Review of Resident #326's medical record revealed an admit nurse's note by S16 LPN (Licensed Practical Nurse) dated 01/30/2025 at 3:03 p.m. which revealed in part, Resident #326 has a midline in upper left arm and an IV in lower left arm. Observation on 02/03/2025 at 8:00 a.m. revealed a midline catheter site to left upper arm. Further observation failed to reveal appropriate signage for EBPs and available PPE supplies for use. During an interview on 02/03/2025 at 8:00 a.m., Resident #326 reported he had just had neck surgery and IV access was from when he was in the hospital. During an interview on 02/03/2025 at 1:00 p.m., S2 DON (Director of Nursing) acknowledged Resident #326 had a midline peripheral central catheter in place to left upper arm and a surgical wound to his neck and should have been placed on EBP. S2 DON further acknowledged EBP signage was not in place and PPE was not readily available for staff to use and should be.

Based on record review and interview, the facility failed to ensure the care plan had been revised for 1 (Resident #2) of 18 sampled residents. The facility failed to update Resident #2's care plan to include increased monitoring/supervision after an incident of resident to resident abuse. Findings Resident #2 was admitted to the facility on [DATE] with diagnoses, which included in part bipolar disorder, major depressive disorder-single episode severe with psychotic features, anxiety disorder, intellectual disabilities and delusional disorders. Review of Resident #2's most recent quarterly MDS (Minimum data Set) assessment dated [DATE] revealed in part, Resident #2 had a BIMS (Brief Interview of Mental Status) score of 09 out of 15 indicating moderate cognitive impairment. Resident #2 used antipsychotic medication on a routine basis. Review of Resident #2's comprehensive care plan failed to reveal Resident #2's care plan had been updated to include increased monitoring/supervision after a resident to resident incident on 09/08/2024 when Resident #2 sexually abused another resident. During an interview on 02/04/2025 at 1:00 p.m., S2 DON (Director of Nursing) reported she was unable to find any monitoring of Resident #2. During an interview on 02/07/2025 at 10:30 a.m., S2 DON acknowledged Resident #2's care plan had not been updated to include increased monitoring and supervision after the 09/08/2024 incident and should have been.

Based on observations, interview, and record review, the facility failed to ensure that a resident with a urinary catheter received appropriate care and services to prevent urinary tract infections by having the urinary catheter tubing on the floor for 1 (#70) of 1 (#70) resident reviewed for urinary catheters. Findings: Review of Resident #70's medical record revealed an admitted [DATE] with diagnoses that include in part cerebral infarction, essential hypertension, symbolic dysfunctions, dementia with behavioral disturbance, benign prostatic hyperplasia with lower urinary tract symptoms and delusional disorders. Review of Resident #70's physician orders revealed an order dated 10/29/2024; catheter type 16; French 5 bulb size. Review of Resident #70's Minimum Data Set assessment dated [DATE] revealed the resident #70 is rarely or never understood. Resident #70 is totally dependent for toileting, has an indwelling catheter, and is frequently incontinent of bowel. Observation on 02/03/2025 at 8:30 a.m. revealed Resident #70 lying in bed with Foley catheter bag sitting on the floor. Observation on 02/03/2025 at 3:00 p.m. with S2 DON revealed Resident #70's Foley catheter bag sitting on the floor. S2 DON confirmed the Foley catheter bag should not be on the floor. During an interview on 02/04/2025 at 10:54 a.m. S3 Corporate Nurse acknowledged that is basic standard of care that the Foley catheter bag should not be on the floor.

Based on record review, observations, and interview, the facility failed to ensure appropriate treatment and services to prevent potential complications from enteral feeding not infusing at the ordered rate ordered for 1 (#18) out of 1 (#18) residents reviewed for tube feedings. Findings Review of Resident #18's medical diagnoses revealed the following, but not limited to moderate protein calorie malnutrition, dysphagia, atrial fibrillation, and Parkinson's disease. Review of Resident #18's MDS (Minimum Data Set) assessment dated [DATE] revealed Resident #18 received 51% or more of total calories through feeding tube and 501cc (cubic centimeters)/day or more of average fluid intake per day through feeding tube. Resident #18's Physician order dated 12/17/2024 revealed every shift related to encounter for attention to gastrostomy Isosource 1.5 at 45ml/hr (milliliter/hour) for 20 hours to deliver 1620 calories, 73 grams of protein, 1080 total volume. Observation on 02/03/2025 at 9:52 a.m. revealed Resident #18's enteral feeding pump infusing Isosource 1.5 at 60 ml/hr to percutaneous endoscopic gastrostomy (peg) tube. Observation on 02/03/2025 at 3:00 p.m. revealed Resident #18's enteral feeding pump was infusing Isosource 1.5 at 60 ml/hour to peg tube. During an interview on 02/03/2025 at 3:19 p.m. with S6 LPN (Licensed Practical Nurse) Resident #18's enteral feeding pump was infusing at a rate of 60 ml/hr and should have been running at 45 ml/hr.

Based on record review and an interview, the facility failed to ensure the required members were present for quarterly Quality Assessment and Assurance (QAA) meetings reviewed since last annual survey. Findings: Review of the facility's Quality Assessment and Assurance Committee Summary sign-in sheet since the last annual survey with S1 Administrator revealed the QAA committee meeting on 10/09/2024 had signatures of the Administrator, DON (Director of Nursing), Medical Director and a Nurse Practitioner. During an interview on 2/07/2025 at 5:30 p.m. S1 Administrator confirmed the required members were not present during the QAA committee meeting on 10/09/2024.

Based on record review and interview, the facility failed to ensure a discharge assessment was completed for 1 (#65) of 3 (#12, #45, #65) residents reviewed for resident assessment. Findings: Review of Resident #65's medical record revealed resident was admitted to the facility on [DATE] and discharged on [DATE]. Review of Resident #65's MDS (minimum data set) assessments failed to reveal a discharge MDS assessment was completed. During an interview on 01/24/2024 at 8:40 a.m. S2 MDS Nurse confirmed Resident #65 did not have a discharge MDS assessment completed and should have.

Based on record review and interview, the facility failed to ensure resident MDS (minimum data set) assessments were transmitted within the required timeframe for 1 (#12) of 3 (#12, #45, #65) residents reviewed for resident assessment. Findings: Review of Resident #12's MDS assessments revealed a Quarterly MDS dated [DATE] with a status of rejected. During an interview on 01/24/2024 at 8:40 a.m. S2 MDS Nurse reported Resident #12's Quarterly MDS assessment dated [DATE] had not been retransmitted to CMS (Centers for Medicare and Medicaid Services) and should have been.

Based on observations, interviews and record review, the facility failed to maintain an effective pest control program by having evidence of insects in 5 rooms (R-B, R-C, R-D, R-F, R-G) of 59 resident rooms and 4 hallways (Hall A, Hall E, Hall H, Hall I) of 5 hallways observed for insects/pests. This had the potential to affect any of the 76 residents currently residing in the facility. Findings: Observation on 12/18/2023 at 7:30 a.m. revealed a live roach crawling into Hall E. During an interview on 12/18/2023 at 7:30 a.m. S5 Social Services verified the roach in the hallway and reported we have some roaches from time to time. Observation on 12/19/2023 of resident rooms and hallways between 7:45 a.m. and 11:00 a.m. revealed: One live roach crawling on Hall A with multiple dead roaches on the hallway. Hall I with 4 dead roaches in various points in the hallway. R-B with multiple dead roaches in the room. R-C with multiple live roaches on the floor. R-D with multiple dead roaches and roach parts on the floor. Hall E with 1 live roach crawling on the floor and multiple dead roaches. R-F with multiple dead roaches. R-G with multiple dead roaches. Hall H with multiple dead roaches. During an interview on 12/19/2023 at 8:00 a.m. S2 Maintenance Director confirmed the facility had an issue with roaches. During an interview on 12/19/2023 at 8:25 a.m. S3 CNA (Certified Nurse Aide) reported we do have a problem with bugs. During an interview on 12/19/2023 at 8:45 a.m. S4 CNA Hall I reported there is a roach problem all over the building and they never really go away. During an interview on 12/19/2023 at 9:25 a.m. S6 Housekeeping reported there are bugs in the building, ants and roaches, some live and some dead. During an interview on 12/19/2023 at 9:50 a.m. S1 Administrator confirmed she was aware of pests/roaches in the building. Review of the Infection Control Pest and Housekeeping Policies dated 8/2021 revealed the following: - Infection Control Pest/Vermin Policy Statement: This facility will have an effective pest control program to prevent rodent, vermin, or insect infestation. - Housekeeping Policy Statement: All efforts are made to maintain this facility free of insects and rodents.

Based on record review and interview the facility failed to ensure residents were free from unnecessary medication use for 1 (#4) of 5 (#1, #2, #3, #4, #5) sampled residents. The facility failed to ensure Resident #4 was monitored for side effects and behaviors for antidepressant medication. Findings: Review of Resident #4's medical record revealed Resident #4 was admitted to the facility on [DATE] and had diagnoses that included, in part, anxiety disorder unspecified, depression unspecified, acute and chronic diastolic (congestive) heart failure, Type 2 diabetes mellitus, hypothyroidism, essential (primary) hypertension, and chronic obstructive pulmonary disease. Review of Resident #4's physician orders revealed a 09/23/2022 physician order for Cymbalta 60mg (milligram) capsule give one by mouth daily. Review of Resident #4's June 2023 and July 2023 Medication Administration Record (MAR) failed to reveal monitoring for side effects and behaviors had been conducted for Resident #4 who was receiving Cymbalta. Review of Resident #4's care plan revealed a potential for injury related to antipsychotic medications with interventions that included, in part, medications as ordered, observe for effectiveness of medication, observe for side effects of medications, and monitor for side effects. During an interview on 07/26/2023 at 12:25 p.m. S2 LPN (Licensed Practical Nurse) reviewed Resident #4's June 2023 and July 2023 MAR and verified there was no documentation that monitoring for behaviors and side effects had been conducted. During an interview on 07/26/2023 at 12:30 p.m. S1 Corporate Nurse reviewed Resident #4's June 2023 and July 2023 MAR and confirmed there was no documentation that monitoring for behaviors and side effects had been conducted.

Based on interview and record review, the facility failed to ensure a resident was free from sexual abuse for 1 (Resident #1) of 5 (Residents #1-5) sampled residents reviewed by failing to protect a female resident from an aggressive male resident who continued inappropriate, nonconsensual sexual contact. The deficient practice resulted in an Immediate Jeopardy situation for Resident #1 on 08/26/2021 at approximately 1:15 PM when S4 COTA (Certified Occupational Therapy Assistant) found Resident #1, who was incapable of consenting to a sexual relationship, being touched inappropriately by Resident #2 near the nurses' station. Resident #2 was observed by S4 COTA with his hands between Resident #1's legs on her genital area. S4 COTA moved Resident #2 to another location and reported it to the nurses' station staff and then to S3 LPN (Licensed Practical Nurse). On 08/30/2021 at approximately 7:30 AM, S6 DM (Dietary Manager) observed Resident #2 grab Resident #1's breast in front of the nurses' station. S6 DM notified S3 LPN who moved Resident #2 to the dining room. At approximately 8:00 AM on 08/30/2021, S5 ADON (Assistant Director of Nurses) observed Resident #2 grab Resident #1's breast again in front of the nurses' station. S5 ADON moved Resident #2 to his room and then assessed Resident #1. The immediate jeopardy situation ended at 5:55 PM on 08/30/2021 when Resident #2 left the facility for admission to a behavioral hospital. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility's Resident Abuse Policy revealed, in part, the following: Policy: Conduct detrimental to resident care that results in neglect or abuse of any resident is strictly prohibited. Procedures: A. Resident abuse is considered a critical offense and will be treated as such in the discipline process. B. An employee who knows about resident abuse or neglect or exploitation and fails to report it to his/her supervisor or a member of management may also face immediate termination and/or fines and imprisonment or all three. The same consequences could apply if the employee gives a false report. C. Any charge of resident abuse shall be investigated by the Administrator or his designee . D. In cases involving resident abuse, where required by law, the facility administrator shall notify the proper authorities. Review of the facility's Incident Investigation & Reporting form revealed, in part, the following: 1. Each resident residing in this facility has the right to be free from any type of abuse including: verbal, sexual, mental, physical abuse, neglect, exploitation, misappropriation of resident property Training on workplace violence and abuse prevention and reporting on suspected crimes under the Elder Justice Act will be included in orientation of new employees and at least annually thereafter 2. Sexual abuse: Is nonconsensual sexual contact of any type with a resident . 3. Abuse, neglect, misappropriation of resident property and exploitation are crimes and shall be reported to proper authorities as such. In the event of any incident involving an allegation or suspicion of mistreatment, exploitation, neglect, abuse, misappropriation or other crime, as well as injuries of unknown origin, elopement, and/or adverse events, each occurrence will be reported immediately to the Administrator of the facility . 4. 5. 6. 7. During and after the investigation, the residents will be protected from harm through frequent supervision by staff. In the case of resident-to-resident suspected abuse, the parties will remain separated from one another until the investigation has been completed Resident #1 Review of Resident #1's record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed the BIMS (brief interview for mental status) was coded 0 indicating the resident was rarely or never understood. Further review of the MDS revealed Resident #1 required extensive assistance by two person physical assist with bed mobility, transferring, and toileting and extensive assistance by one person assist with eating. Review of Resident #1's nurses' notes revealed the following entry: 08/30/2021 at 11:51 AM-Writer just spoke with Responsible Party, _____, about another male resident in the facility groping on his mom's breasts Resident #2 Review of Resident #2's record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's MDS dated [DATE] revealed a BIMS score of 6, which indicated severe cognitive impairment. Review of Resident #2's nurses' notes revealed, in part, the following entries: 07/21/2021 at 12:49 PM-S8 CNA (Certified Nursing Assistant) notified writer that resident went up to another resident and stated, Let me put it in your butt. Come on down to my room. CNA stated that she told him that was not nice. When writer returned to nurses' station, writer noted resident telling the other resident, Come on to my room. Let's get in the bed I have money to pay you. Writer educated resident that this was inappropriate to speak that way to others. 08/30/2021 at 11:11 AM-Writer witnessed resident (Resident #2) this AM back his wheelchair up next to a female resident of the facility and began groping on the resident's breasts. Dietary Manager also witnessed this resident on a different occasion this AM groping on the same female resident's breast. This female Resident is unable to defend herself due to decreased cognitive awareness. Resident was immediately removed from the area and placed on 1 on 1 observation. 08/30/2021 at 2:04 PM-Late entry reflecting 08/26/2021. Around 1:15 PM Writer was walking back to nurses' station and was told by employees that resident (Resident #2) was touching (Resident #1) on/between legs. Writer educated resident that he was not allowed to touch anyone without their permission. Writer assisted resident from in front of nurses' station to room ___ to look at TV. Writer informed oncoming nurse of Resident's actions and informed S7 LPN to continue to monitor resident for behaviors. 08/30/2021 at 2:10 PM-Around 0730 writer was in dining room passing meds. Writer noticed S6 DM waiving through the window. Came to see what S6 DM wanted. Writer was informed that resident (Resident #2) was observed touching (Resident #1) on her breast. Writer informed resident that he cannot touch on others without permission. Resident stated why not and started laughing. Writer educated resident that the situation is not funny and that is inappropriate to touch others without permission. Writer assisted resident to dining room to monitor. 08/30/2021 at 6:03 PM Resident (Resident #2) out to (Behavioral Hospital) via (ambulance) at 5:55 PM. Called RP to inform her of time resident left facility. In an interview on 09/14/2021 at 11:50 AM, S4 COTA reported on 08/26/2021, she observed Resident #2 with his hand between Resident #1's legs on her genital area. S4 COTA reported she moved Resident #2 to a different area and notified the nursing staff at the nurses' station. She reported the staff at the nurses' station told her to report it to the nurse and she confirmed she reported it to S3 LPN. S4 COTA reported on 08/30/2021, she overheard S6 Dietary Manager reporting to someone at the nurses' station that Resident #2 was acting inappropriately and then she looked and observed Resident #2's hand on Resident #1's chest area. S4 COTA reported staff moved him to a different location. In an interview on 09/14/2021 at 2:50 PM, S6 Dietary Manager reported on 08/30/2021 at approximately 7:30AM standing at the nurses' station and observing Resident #2 groping Resident #1's breast. She reported he had a hand full of it. She reported she could see S3 LPN in the dining room passing medications so she waved at her through the window to come. S6 DM reported telling S3 LPN who then moved Resident #2 to the dining room. In an interview on 09/14/2021 at 3:50 PM, S5 ADON reported on 08/30/2021 at approximately 8:00 AM, she observed Resident #2 back his wheelchair up to the wall next to Resident #1 and grab her breast. S5 ADON reported she moved him away to another area and let S1 Administrator know after putting Resident #2 on 1 on 1 observation. In an interview on 09/14/2021 at 4:05 PM, S2 DON reported on 08/30/2021, S6 DM saw Resident #2 grabbing Resident #1's breast. She reported S6 DM reported it to S3 LPN who moved Resident #2 to the dining room for breakfast. S2 DON reported after breakfast, Resident #2 was back out front at the nurses' station area by the wall near Resident #1. S2 DON reported a short time later S5 ADON saw him grab Resident #1's breast again after breakfast. In an interview on 09/15/2021 at 9:20 AM, S1 Administrator reported she first became aware of the sexual abuse on 08/30/2021 right after the 10 AM morning meeting when S5 ADON reported it to her and the DON. S1 Administrator and S2 DON confirmed Resident #2 had touched Resident #1 inappropriately on 08/26/2021 and twice on 08/30/2021. Review of facility records revealed the facility had implemented the following actions to correct the deficient practice: 1. On 08/30/2021 at approximately 8 AM, S5 ADON witnessed male resident back his wheelchair next to female resident and began touching her breast. S5 ADON immediately took male resident to his room and then brought female resident to her room, performed a complete body audit, after body audit completed with no abnormal findings, S5 ADON notified Administrator and DON of the occurrence. S2 DON went to male resident room and brought him to her office for one on one observation. Administrator notified police that came to the facility-police officer did not leave facility until male resident was transported to behavioral facility. 2. S2 DON performed a body audit on any female resident that did not have the ability to express to the staff if anyone had physically touched them in an inappropriate manner, these were initiated and completed on 08/31/2021. Administrator interviewed a random sample of any female resident that did have the ability to express to the staff if anyone had physically touched them in an inappropriate manner, these were initiated and completed on 08/30/2021. As a result of the resident sample no other residents indicated any sexual abuse. 3. S2 DON in serviced all staff on 08/30/2021 and 08/31/2021 regarding policy on reporting abuse of any kind immediately to Administrator. Male resident (Resident #2) remained one on one until 08/30/2021 at 5:55 PM when ambulance service picked resident up from facility with a Physician Emergency Certificate in hand-male resident was taken to ___ Behavioral Hospital. LPN that was made aware of the inappropriate touching by the male resident was sent home pending outcome of investigation and subsequently terminated. This LPN has not worked in facility since the date of the incident, (08/30/2021). 4. S2 DON performance of body audits completed on 08/31/2021 done on any resident that could not express any inappropriate touching; Administrator interviewed random sample of female residents completed on 08/31/2021 that were able to express themselves-nothing found on body audits, nothing negative discovered during interviews. Administrator and DON conducted a resident council meeting on 09/15/2021 with approximately 15 residents in attendance to discuss abuse and reporting of such. Each of the residents knew to report anything they witness to the Administrator and/or DON. In service conducted on 08/30/2021 and 08/31/2021 with all staff about reporting any type of abuse to Administrator immediately. 5. 08/30/2021 at 5:55 PM male resident was transported from facility to an inpatient behavioral hospital, to date remains discharged from this facility. In services completed 08/31/2021.