South Park East

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow the posted menu and provide bread for 1 of 1 meal observation. During the noon meal observation on 05/04/26, cook #1 served 38 trays without any bread or bread sticks, even though the menu for that meal listed ravioli, Italian blend vegetables, bread sticks, and dessert. The dietary manager later stated that no bread had been served, but the cook was supposed to provide plain bread because the stove and oven were not working. On 05/06/26, cook #1 stated bread was not served because there was no way to toast it and said they had never had the stove break before, so they did not know what to do.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Provide and implement an infection prevention and control program. Based on record review and interview, the facility failed to have a water management program to prevent the growth and detection of Legionella. The facility had policies titled Legionella Surveillance and Detection and Legionella Water Management Program, both revised July 2017, which described a commitment to prevention, detection, and control of waterborne contaminants and outlined elements of a water management program, including a detailed description and diagram of the water system, identification of areas where Legionella could grow and spread, specific control measures, and annual review. However, review of infection control records from 12/01/25 through 05/07/26 did not show any residents diagnosed with Legionella, and on 05/07/26 the maintenance director could not provide documentation for the water management program. On 05/08/26, the maintenance director stated there was no map or drawing of the facility, no system in place to assess the water system, and no measures in place to monitor for Legionella, and stated they were not aware an assessment or monitoring program was needed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an allegation of abuse within 2 hours to the OSDH for Resident #22. Resident #22 had diagnoses including dementia, depression, and psychosis. A CMA documented that Resident #22 stated someone of the opposite sex had just tried to rape them, and the CMA stated they immediately reported the allegation to the nurse and administrator. The DON later stated the allegation should have been reported within 2 hours, but it was instead included with another investigation involving Resident #30. The administrator stated Resident #22 was reported to adult protective services within 2 hours, but not to the OSDH within 2 hours. The facility also failed to complete and submit a final report within 5 days for an allegation involving Resident #30. Resident #30 had a quarterly assessment showing a BIMS score of 6, indicating severe cognitive impairment for daily decision making. The initial incident report stated Resident #30 reported that someone had touched their breast, and a staff member was suspended pending investigation. The investigation record did not show a final report had been submitted to the OSDH for that incident, and the DON stated the final results were placed on the Form 283 for Resident #22 instead of being sent separately for Resident #30. The administrator stated final reports were to be sent to the OSDH within 5 days and acknowledged the final report for Resident #30 should not have been sent on the report for Resident #22.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a quarterly assessment accurately reflected Resident #30’s wandering behavior. Resident #30 was admitted with a diagnosis of Alzheimer’s disease, and the admission assessment dated 11/28/25 documented wandering one to three days during the seven-day look-back period and indicated the behavior would be addressed on the care plan. However, the quarterly assessment dated 02/27/26 recorded a BIMS score of six, showing severe cognitive impairment, but stated the resident had no behaviors such as wandering or rummaging. During observation on 05/04/26, Resident #30 was seen leaving and entering other residents’ rooms, taking a pillow from one room, and telling another resident to get out of their room. The resident was also observed claiming another room as their own and directing the occupant to leave. Nurse progress notes from 11/21/25 through 05/06/26 did not document wandering behaviors. In interviews on 05/07/26, CNA #1, CNA #2, CNA #3, CMA #1, and LPN #1 each stated Resident #30 wandered into other residents’ rooms daily or every day when awake, but they did not document these behaviors. The MDS coordinator stated there were no notes documenting wandering, so it was not coded on the quarterly assessment, and staff interviews would not be used to ask about wandering.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure comprehensive care plans were developed for 2 of 14 sampled residents whose care plans were reviewed. Facility policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables was to be developed and implemented for each resident. For Resident #8, an annual assessment showed severe cognitive impairment with a BIMS score of 00, impairment in range of motion to one side of the upper and lower extremities, and receipt of range of motion services during the lookback period. The resident was also admitted to hospice services in March 2026, and family and staff stated the resident had limited range of motion and a contracture to the left hand. On observation, Resident #8 was seen sitting in a Geri-chair with the fingers on both hands curled inward and was later transported to the shower room by a hospice aide. The MDS coordinator reviewed the record and stated the resident had elected the hospice benefit but a care plan related to hospice services had not been developed. The MDS coordinator also stated the contracture and limited range of motion interventions had been on the previous care plan but were not carried over when the care plan was revised on 02/26/26. The DON stated they were not sure why the limited range of motion/contracture was not on the current care plan and that hospice may have been overlooked. For Resident #30, observations showed the resident repeatedly entered other residents’ rooms, took items such as a purse and pillow, and told other residents to leave their rooms. The admission assessment documented wandering one to three days during the seven-day look back period and stated the behavior would be addressed on the care plan, but the care plan last revised on 12/08/25 did not address wandering, entering other residents’ rooms, or attempting to keep them out of their own rooms. Staff interviews confirmed the resident wandered into other residents’ rooms daily, believed another room was theirs, and became upset when redirected, while the MDS coordinator stated the behavior was not care planned and should have been.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure inspection of u-bars was included in its regular maintenance program for Resident #38, who was identified as using a u-bar on the right side of the bed. The resident had a physician order dated 06/14/25 stating that a u-bar may be used to assist with transfers, and a quarterly assessment dated 04/17/26 showed a BIMS score of four, indicating severe cognitive impairment and the need for partial to moderate assistance for transfers from chair to bed. On 05/05/26, surveyors observed the resident’s bed with a u-bar on the right side, and later observed the resident in bed with eyes closed and the u-bar still in place. The facility’s Bed Safety policy stated that maintenance staff should inspect all beds and related equipment as part of the regular bed safety program to identify risks and problems, including potential entrapment risks. However, review of the electronic clinical record did not show that the u-bar had been inspected as part of the maintenance program. The maintenance supervisor stated that u-bars were not regularly inspected and were only installed and removed when instructed, and the administrator stated they did not know why regular inspections were not being conducted.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to complete a thorough investigation of an allegation of sexual abuse involving Resident #22, who had diagnoses including dementia, depression, and psychosis. An undated statement from CMA #2 indicated Resident #22 approached them and reported that someone of the opposite sex had just tried to rape them, and CMA #2 stated they immediately reported the allegation to the nurse and administrator. However, there was no documentation of a separate investigation into Resident #22’s allegation of attempted rape made to CMA #2. The incident report dated 04/23/26 identified Resident #30 in the narrative, and the optional page stated that staff and other residents were interviewed with one further complaint of rape attempt from Resident #22. The report was faxed to OSDH three days after Resident #30 made the allegation. The DON stated each allegation, even those found during another investigation, must be fully investigated, and that Resident #22’s allegation was investigated with Resident #30’s allegation. The ADON stated the allegation from Resident #22 should have been handled separately and investigated on its own, and the administrator stated there was no documentation that Resident #22’s allegation was investigated separately.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a significant change assessment was completed for Resident #8 when the resident elected hospice services. Record review showed a Physician's Certification for Hospice Benefit dated 03/18/26 for a terminal diagnosis of Alzheimer's disease, stating the physician's clinical judgment that the resident had a life expectancy of six months or less if the illness ran its normal course. Review of the electronic clinical record did not show that a significant change assessment had been completed when hospice was initiated. During interviews, an LPN stated the resident had received hospice services for a couple of months, the MDS coordinator stated hospice had started in March 2026 and acknowledged forgetting to complete the significant change assessment, and the DON stated they did not know why the assessment had not been completed and said it must have been overlooked.

Penalty

Inspection fine: $15,480

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect residents from sexual abuse and inappropriate touching, resulting in multiple incidents involving residents with severe cognitive impairment and dementia. Several residents with a history of sexually inappropriate behaviors were observed touching other residents inappropriately on multiple occasions. These incidents occurred despite the residents being known to have sexual dysfunction and behavioral issues, and despite previous interventions such as medication and 1:1 supervision. Documentation showed that after each incident, the involved residents were placed on 1:1 supervision, but the care plans were not always updated in a timely manner to reflect the current status or interventions. Staff interviews revealed inconsistent knowledge and implementation of abuse prevention protocols. Some CNAs and an LPN reported that their primary intervention was to redirect the resident and initiate 1:1 supervision, but they were not always aware of additional steps taken or required. There was also a lack of consistent and recent abuse education among staff, with some staff members stating they had not received abuse training in the weeks leading up to the incidents. The DON acknowledged that efforts to prevent recurrence included monitoring and attempting to keep residents separated, but there was no documentation that families were always notified of incidents involving their loved ones. Medical records and staff statements confirmed that the residents involved had severe cognitive impairment, with BIMS scores indicating significant deficits. The facility's own policy defined sexual abuse as non-consensual sexual contact of any type with a resident, and the incidents described met this definition. Despite the known risks and previous behaviors, the facility did not ensure adequate protection for all residents, as evidenced by repeated incidents of inappropriate sexual contact and insufficient updates to care plans and communication with families.

Removal Plan

• Identify total number of residents at risk for the same failed practice.
• Place affected residents on 1:1 supervision following incidents.
• Increase psychoactive medications for affected residents as ordered by the PA after incidents.
• Change resident’s room to reduce proximity to women.
• Send resident to the hospital for psychological evaluation after incident and maintain 1:1 supervision upon return.
• Maintain affected residents on 1:1 supervision after incident.
• Notify the PA of each incident and implement medication changes/interventions as directed.
• Interview all interviewable residents and assess non-interviewable residents for evidence of abuse or inappropriate/nonconsensual contact.
• Provide in-service training for all staff on abuse/neglect risk, sexual behaviors, identification of those at risk, protection measures, and dementia care, including documentation of 1:1 supervision.
• Require all current staff to complete in-service training before their next scheduled shift; no staff permitted to work until trained.
• Implement ongoing monitoring of resident behaviors to observe for potential to administer/receive abuse or neglect, including sexual abuse.
• Screen new admissions through interviews and record reviews for at-risk behaviors, including abuse/neglect and sexual behaviors.
• Care plan at-risk residents with individualized interventions, including possible 1:1 supervision and/or safe discharge, and document on baseline and regular care plans.
• Capture behaviors in behavior notes and screen daily by the DON or designee to identify behaviors that might lead to abuse/neglect, including sexual behaviors.
• Require staff to notify the DON or Administrator immediately of residents exhibiting increased sexuality or behaviors putting others at risk so immediate intervention can be placed.
• Add Psych Plus services to the facility’s service offerings.
• DON or designee to conduct daily review of all incidents and behavior notes to identify residents at risk for behaviors affecting others, including abuse/neglect and sexual behaviors.
• Continue staff training on dementia care, protective measures from abuse/neglect, behavior prevention/management, and documentation for 1:1 care, including for new hires.
• Administrator or designee to monitor abuse/neglect identification, protection from abuse/neglect, and dementia care, including behaviors that put self or others at risk.
• Daily review of allegations, incidents, and behaviors that put or potentially put self or others at risk, as well as documentation for 1:1 supervision.
• Carry information through the Quality Assurance Performance Improvement (QAPI) process.
• Ensure all residents that can be interviewed are interviewed and non-interviewable residents are assessed for evidence of abuse or inappropriate/nonconsensual contact.

Penalty

Inspection fine: $15,480

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to thoroughly investigate allegations of abuse involving five residents. Multiple incident reports documented inappropriate sexual contact between residents, including instances where one resident touched the breast of other residents. Despite these reports, there was no evidence that the facility conducted or documented safety assessments of other residents who may have been affected. Additionally, the facility did not provide or document abuse education for all staff following these incidents, as required by their own policy. Interviews with the DON revealed a lack of awareness regarding the completion of investigation summaries on incident reports and confirmed that staff education on abuse was not formally documented, but only provided verbally. The DON also stated that assessments of potentially affected residents were performed visually and not documented. These actions and omissions resulted in a failure to ensure that all alleged violations were appropriately responded to and thoroughly investigated.

Penalty

Inspection fine: $15,480

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify a resident's family of an allegation of abuse involving the resident. According to facility policy, the resident, their attending physician, and their representative are to be promptly notified of changes in the resident's condition or status. Record review showed that a resident with severe cognitive impairment and diagnoses including Alzheimer's disease and dementia was involved in an incident where another resident was observed touching them inappropriately. Although documentation indicated that the family was notified, an interview with the family revealed they were not aware of the incident or any related events. The Director of Nursing confirmed that there was only a single, unsuccessful attempt to contact the family, with no documented follow-up or successful notification.

Penalty

Inspection fine: $15,480

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to timely revise and update the care plan for a resident following multiple incidents of abuse. According to the facility's policy, care plans must be revised as information about the resident and their condition changes, and the interdisciplinary team is required to review and update the care plan when desired outcomes are not met. In this case, a resident with severe cognitive impairment and a diagnosis of sexual dysfunction was involved in several incidents of sexually inappropriate behavior, including grabbing staff and making sexual comments. Although the care plan was initially created and later revised, documentation showed that updates were not made promptly after each incident as required. Record review and staff interviews revealed that incidents occurring on specific dates were not reflected in the care plan until several days later. The MDS coordinator acknowledged that care plans were typically updated every three months and as necessary, but admitted that updates for certain incidents were delayed. The coordinator also confirmed that they were solely responsible for updating care plans and recognized that the care plan should have been updated sooner following the incidents of abuse.