The Haven of Paris

Inspectors wroteBased on interview and record review the facility failed repeatedly, to obtain/purchase a resident's medication from the resident's preferred pharmacy in accordance with the resident /resident representatives' choice. This failure affects one of three residents (R5) reviewed for medication procurement on the sample list of 14.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by another resident for two of four residents (R1 and R8) reviewed for abuse in the sample of fourteen residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement fall interventions for R4 and R6 who have a history of repeated falls. R4 and R6 are two of four residents reviewed for falls/accidents on the sample list of 18.

Inspectors wroteBased on interview and record review the facility failed to protect a resident's right to for privacy. This failure affected two of three residents (R1, R6) reviewed for quality of care on the sample list of six. Findings Include: The facility's Resident rights Guideline policy dated October 2023 documents the facility will treat each resident with respect and dignity, and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. All residents have the right to equal access to quality care regardless of a diagnosis, severity of a condition, or payment source. Each resident has the right to privacy and confidentiality as well as a safe environment for themselves and their personal possessions. [...]

Inspectors wroteBased on interview and record review the facility failed to provide adequate supervision for a resident who wanders. This failure affected one of three residents (R2) reviewed for quality of care on the sample list of six. Findings Include: The facility's undated Nursing Services Policy documents it is the policy of the facility that each resident shall receive nursing care and supervision to obtain and maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessments, plan of care, physician's orders and accepted standards of nursing practice. It is the facility's responsibility to ensure that each resident is provided nursing care and supervision based on their needs. Staff are to provide care in a manner in which the resident is treated with respect, dignity and afforded privacy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to document wound assessments for two (R2, R3) of three residents reviewed on a sample list of five residents.1. R2's Care Plan, Undated, documents on 8/2/24 high risk for pressure ulcers was added, and on 10/9/24, actual pressure ulcers of sacrum, right ischium, left heel, right lateral ankle, right heel, left dorsum foot, left gluteal fold and left gluteus was added. R2's Care Plan also documents Pressure Ulcers to be assessed weekly by licensed nurse, monitor for signs of infection daily, increased warmth, redness, swelling, pain, drainage, and odor. Notify physician if not healing. R2's Treatment Administration Record (TAR) dated November and December 2025 documents order for daily foot checks related to a history of ulcers. Document color, temperature, edema, and pedal pulses. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure sufficient lighting in a resident's bedroom and failed to provide adequate supervision for a restless resident with dementia. These failures resulted in a fall for one (R6) of three residents reviewed for accidents, causing a brain bleed and skin tears to the right shoulder, right hand, and right forearm on the total sample list of 17.

Inspectors wroteBased on interview and record review, the facility failed to promptly honor a resident's request to be transferred to the emergency room for one resident (R4) of one resident reviewed for Resident's Rights in the sample list of 17.

Inspectors wroteBased on interview and record review, the facility failed to ensure consistent monitoring and documentation of bowel movements for residents requiring bowel management, resulting in constipation for one resident (R4) of three residents reviewed for bowel management in the sample list of 17.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement interventions and provide supervision to prevent a wandering resident from entering other resident's rooms invading resident privacy, disturbing the environment, taking assistive devices, and making inappropriate comments for five (R1, R5, R6, R7, R8) of five residents reviewed for accidents on a sample list of eight. This failure resulted in R1 falling on two separate occasions when R2 took R1's walker and sustaining a laceration to the knee requiring six sutures, a laceration to the left hand and a hematoma to the scalp.

Inspectors wroteBased observation, interview, and record review the facility failed to protect the resident's right to be free from physical abuse by another resident. This failure affects two of four residents (R2 R3) reviewed for abuse in the sample list of eight. The facility's undated Abuse Prevention Policy documents that the facility affirms the right of their residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse neglect, exploitation, misappropriation of property and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision for a resident with Lewy Body Dementia to prevent a fall for one (R1) of three residents reviewed for falls on a sample list of three. This failure resulted in R1 falling to the ground and sustaining an acute fracture of the left hip.

Inspectors wroteBased on interview, and record review the facility failed to schedule a prompt appointment for physician ordered diagnostic Magnetic Resonance Imagining (MRI) of R2's right hip post-fall, and failed to obtain the results of the MRI in a timely manner. These failures resulted in R2's sustaining continued severe pain, and delay in surgical repair of a hip fracture. R2 is one of three residents reviewed for falls on the sample list of three.

Inspectors wroteFailures at this level required more than one deficient practice statement: A. Based on observation, interview, and record review, the facility failed to provide a safe environment by leaving a normally secured bathroom door ajar, effectively failing to supervise R1, a resident with a diagnosis of dementia, to prevent a traumatic fall. This failure resulted in R1 falling and striking their head, sustaining a hematoma, a rib fracture with a partially collapsed lung, and two brain bleeds requiring emergency hospitalization and treatment at two separate hospitals. R1 was one of three residents reviewed for falls in a sample of three. B. Based on observation, interview and record review the facility failed to maintain a shower chair, in safe operable condition, which resulted in R2's fall with a hip fracture that required surgical repair. [...]

Inspectors wroteBased on interview and record review, the facility failed repeatedly to maintain complete and accurate medical records for one of three (R2) residents reviewed for falls/ medical records on the sample list of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post an accurate notice for the location of the survey results book and failed to identify the survey book. This failure has the potential to affect all 81 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe and implement controlled temperature safeguards for potentially hazardous foods served to residents to prevent food borne illness (R30), failed to prevent the potential for physical cross-contamination of stored food, and failed to maintain sanitary dietary service floor areas. These failures have the potential to affect all 81 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain residents' rights to dignity by failing to keep urinary catheter collection bags inside of a privacy cover. This failure affects two residents (R1, R12) of five reviewed for dignity in the sample list of 30.

Inspectors wroteBased on observation, interview and record review the facility repeatedly failed to maintain nebulizer respiratory equipment in a clean sanitary manner, change oxygen nasal canula and tubing in a timely manner, provide an oxygen humidification water bottle, failed to obtain an oxygen administration order, and failed to care plan respiratory status, interventions for the monitoring of oxygen administration, and for safe and sanitary practices for R43. The facility also failed to provide an oxygen humidification water bottle for (R64). These failures affected two of three residents (R43 and R64) reviewed for respiratory care and medication administration on the sample list of 30.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow pharmacy instruction for the administration of physician ordered medication, for two of seven resident (R3 and R43) reviewed during medication observation. The facility had three medication errors, out of 32 opportunities, resulting in an 9.38 percent medication error rate.

Inspectors wroteBased on observation, interview and record review the facility failed to store (R55's) Scheduled IV, Narcotic Controlled Substance in a locked refrigerator compartment to prevent the potential for drug diversion, and failed to ensure (R2 and R8's) opened, insulin injection pens were properly labeled, by the dispensing pharmacy with directions for safe administration. These failures affected three residents (R2, R8 and R55) reviewed during medication storage observation and are included on the sample list of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure enhanced barrier precautions were utilized for residents with indwelling urinary catheters. This failure affects two residents (R1, R12) of five reviewed for infection control in the sample list of 30.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a supply of a house-stock probiotic medication (to prevent antibiotic -associated diarrhea, and protect against Clostridium-difficle infection that can develop after antibiotic use,) for a resident (R43) currently on an intravenous antibiotic medication for Extended-Spectrum Beta-Lactamase (ESBL), (antibiotic resistant bacterial infection) of a wound. R43 is one of seven resident reviewed during medication administration, on the sample list of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a full-time director of nurses to oversee and coordinate nursing services provided within the facility. This failure has the potential to affect all 83 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to notify residents Family Representatives/Power of Attorney of Physical Abuse allegations for five of nine residents (R3 - R7) reviewed for abuse on the sample list of 18.

Inspectors wroteBased on interview and record review, the facility failed to protect residents' right to be free from witness, resident to resident physical abuse. This failure affects four of nine residents (R3, R4, R5 and R6), reviewed for abuse on the sample list of 18.

Inspectors wroteBased on interview and record review, the facility failed repeatedly to operationalize their abuse prevention policy by failing to notify the Ombudsman of abuse allegations. This failure affected seven of nine residents (R3 -R7) reviewed for abuse on the sample list of 18.

Inspectors wroteBased interview and record review, the facility failed to report allegations of resident to resident physical abuse, staff to resident physical abuse, and injuries of unknown origin to the police department and physician, in accordance with the facility policy. This failure affected five of nine residents (R3-R7) reviewed for abuse on the sample list of 18.

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation by failing to interview families that are frequently in the facility, and other residents residing in the facility, that may have knowledge of alleged abuse. This failure had the potential to affect five of nine residents (R3- R7) reviewed for abuse on the sample list of 18.

Inspectors wroteBased on interview and record review, the facility failed to timely review and revise care plans for four of nine residents ( R3, R4, R5, and R6) reviewed for abuse on the sample list of 18.

Inspectors wroteBased on interview and record review, the facility failed repeatedly to maintain complete and accurate medical records for one of nine residents ( R6) reviewed for abuse/injury of unknown origin on the sample list of 18.

Inspectors wroteBased on record review and interview the facility repeatedly failed to report changes in condition to a provider, for a resident with hypotension. These repeated failures resulted in a delay in treatment and hospitalization to stabilize residents blood pressure. This failure affected one of three residents (R1) reviewed for a change in condition on the sample list of three.

Inspectors wroteBased on record review and interview the facility failed repeatedly, to notify a provider of blood pressure measurements, that were below normal range, for one of three resident (R1) reviewed for change in condition on the sample list of three.

Inspectors wroteBased on interview and record review the facility failed to report an Injury of Unknown Origin timely for one (R4) resident out of three residents reviewed for Injuries of Unknown Origin in a sample list of seven residents.

Inspectors wroteBased on interview and record review the facility failed to complete a thorough investigation of an Injury of Unknown Origin for one (R4) resident out of three residents reviewed for Injuries of Unknown Origin in a sample list of seven residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was provided adequate assistance and safe equipment, to prevent a fall during a shower. This failure affects one of three residents (R3) reviewed for falls on the sample list of four.

Inspectors wroteBased on record review and interview the facility failed to maintain a resident's complete and accurate medical record after a fall in the shower room. This failure affects one of three residents (R3) reviewed for falls on the sample list of four.

Inspectors wroteBased on interview and record review the facility failed to notify a resident's physician of signs of a potential wound infection subsequently delaying treatment resulting in Cellulitis of the wound. This failure affected one of three residents (R1) reviewed for Wound Treatments on the sample list of three. Findings Include: The Acute Change of Condition policy dated 1/23/23 documents the facility will identify and treat residents with an acute change of condition. The nursing staff will collect pertinent details to report to the physician. The nursing staff will contact the physician based on the urgency of the situation. The physician will help identify and authorize appropriate treatments. [...]

Inspectors wroteBased on interview and record review the facility failed to notify a resident's physician of signs of a wound infection. This failure affected one of three residents (R1) reviewed for Physician Notification on the sample list of three. Findings Include: The Acute Change of Condition policy dated 1/23/23 documents the facility will identify and treat residents with an acute change of condition. The nursing staff will collect pertinent details to report to the physician. The nursing staff will contact the physician based on the urgency of the situation. The physician will help identify and authorize appropriate treatments. R1's Medical Diagnosis List dated April 2025 documents R1 is diagnosed with Atherosclerotic Heart Disease, Diabetes Mellitus Type II, Dementia, and Local Infections of the Skin and Subcutaneous Tissue. [...]

Inspectors wroteBased on interview and record review the facility failed to complete weekly pressure wound assessments/measurements for one of three residents (R1) reviewed for Wound Assessments on the sample list of three. Findings Include: The Pressure Ulcer policy dated 8/31/23 documents it is the responsibility of the Charge Nurse or Designee to measure and document on the pressure areas weekly, monitor for healing progress, and ensure appropriate treatments are in use. Documentation of the pressure ulcer must occur upon identification and at least once a week until healed. The assessment is to include wound characteristics, presence of granulation tissue or necrotic tissue, treatment and response to treatment, prevention techniques used, and any updated for the physician or resident/family of any regression of the wound. [...]

Inspectors wroteBased on interview and record review the facility failed to follow their bedbug prevention policy to ensure the identification and removal of bedbugs from the facility. This failure has the potential to affect all 82 residents who reside in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a safe, clean and homelike environment for 28 (R1, R2, R3, & R7-R31) of 28 residents reviewed for a homelike environment from a total sample list of 31 residents.

Inspectors wroteBased on interview and record review the facility failed to ensure that two (R4, R5) of three residents reviewed for physical abuse were free from physical abuse from a total sample list of 31 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store a Schedule II Controlled medication (Morphine Sulfate) in a locked location by leaving the medication on top of the medication cart in plain view, unsupervised, and readily accessible to wandering residents on a dementia care unit. This failure resulted in facility staff observing R1 at the medication cart with the bottle of Morphine placed to R1's lips, when staff removed the bottle, no medication remained in the bottle and then staff later observed R1 unresponsive with a decreased respiration rate followed by staff administering Narcan (an emergency medication that rapidly reverses life-threatening opioid overdoses) and sending R1 to the hospital emergency room for evaluation and treatment. [...]

Inspectors wroteBased on interview and record review the facility failed to administer one (R4) resident's physician ordered Insulin for eight days and failed to notify R4's Physician of medication error out of three residents reviewed for Quality of Care in a sample list of ten residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow two (R4, R9) residents physician ordered diets, and failed to initiate a nutritional careplan for one resident (R4) out of three residents reviewed for Dietary Services in a sample list of ten residents.

Inspectors wroteBased on interview and record review, the facility failed to report a resident's change of condition to the nurse prior to obtaining a COVID-19 test and failed to ensure qualified staff conducted COVID 19 testing for one of three residents (R2) reviewed for a change in condition in the sample list of four.

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on observation, interview and record review the facility failed to protect a resident's right to be free from restricted access from areas of the facility without clinical justification. These failures affect one (R9) out of three residents reviewed for seclusion in a sample list of 16 residents. These failures resulted in R9 expressing fear of being yelled at by staff and threats of room move to a locked down Dementia unit if R9 walked the length of her own hallway.

Inspectors wroteBased on interview and record review the facility failed to protect one (R9) resident's right to be free from mental abuse by a staff member (V1) out of three residents reviewed for mental abuse in a sample list of 16 residents. This failure resulted in R9 being yelled at and threatened by staff, crying, expressing humiliation, and fear of participating in activities.

Inspectors wroteBased on observation, interview and record review the facility failed to provide privacy for one (R5) resident during incontinence care out of three residents reviewed for incontinence care in a sample list of 16 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to honor two (R11, R16) resident's right to refuse treatment out of three residents reviewed for electronic monitoring device systems in a sample list of 16 residents.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of mental abuse of one (R9) resident by a staff member to the Physician, Ombudsman and State Agency timely. These failures affect one (R9) out of three residents reviewed for abuse in a sample list of 16 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination during incontinence care and failed to provide timely incontinence care for one (R12) resident out of three residents reviewed for incontinence care in a sample list of 16 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain safe functioning equipment. These failures affect two residents (R3, R5) out of three residents reviewed for equipment in a sample list of 16 residents.

Inspectors wroteBased on interview and record review the facility failed to protect a resident's (R8) right to be free from verbal and physical abuse by another resident (R1), and failed to protect a resident's (R1) right to be free from verbal abuse by a staff member. These failures affects three (R1, R8, R9) of nine residents reviewed for abuse in the sample list of nine.

Inspectors wroteBased on observation, interview and record review the facility failed to complete skin assessments and provide hygienic wound care for one of three residents (R1) reviewed for wound care from a total sample list of eight residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a working resident room call light, resulting in a fall for one (R5) of three residents reviewed for falls from a total sample list of eight residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide hygienic perineal and catheter care for one (R1) of three residents reviewed for perineal and catheter care from a total sample list of eight residents.

Inspectors wroteBased on interview and record review the facility failed to develop a pressure ulcer care plan for one (R1) of four residents reviewed for pressure ulcers on the sample list of four.

Inspectors wroteBased on observation, interview and record review the facility failed to monitor and prevent a wound from worsening, failed to prevent new wounds from developing, failed to implement pressure reducing interventions and failed to complete treatments as ordered for three of three residents (R1, R2, R3) reviewed for pressure ulcers in the sample list of three. This failure resulted in R1 requiring hospitaliztion. for a maggot infestation of R1's wound.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent potential cross contamination during a pressure ulcer dressing change for R2 and R3 and failed to complete effective hand washing in a contact isolation room for two of two residents (R2, R3) reviewed for infection control in the sample list of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the potential for cross-contamination and foodborne illness, by failing to maintain the facility commercial can opener and commercial plate warmer/storage wells in a sanitary manner, free of food-like debris and rust. The facility also failed to maintain dishware and glassware in a clean, sanitary manner free from dust, paint and caulking chips. The facility also failed to wear hair covering while preparing food. These failure affects all 85 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to have the required documentation in their Facility Assessment. This failure has the potential to affect all 85 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to trend the facility's monthly infections. This failure has the potential to affect all 85 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to development and implement a facility-wide antibiotic stewardship program. This failure has the potential to affect all 85 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to obtain consent for psychotropic medication use for five of five residents (R46, R55, R44, R36, R68) reviewed for psychotropic medications in the sample list of 29.

Inspectors wroteBased on observation, interview and record review the facility failed to protect the resident rights' to be free from verbal abuse by a visitor and another resident. These failures affect five of seven residents (R17, R55, R31, R40, R77) reviewed for abuse on the sample list of 29.

Inspectors wroteBased on observation, interview, and record review the facility failed to transcribe pressure ulcer treatment orders onto the Treatment Administration Record, document wound dressing changes, notify the physician of a dislodged wound graft, implement pressure relieving interventions, assess wounds weekly, and prevent cross contamination during wound treatment administration for residents. Theses failures affect three of three residents (R14, R46, R230) reviewed for pressure ulcers in the sample list of 29.

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on interview and record review the facility failed to implement fall prevention interventions to prevent falls/injuries for one of three residents (R39) reviewed for falls in the sample list of 29.

Inspectors wroteBased on interview and record review the facility failed to develop a policy for medication regimen reviews (MRRs), repeatedly failed to maintain pharmacy recommendation documentation, and follow up on pharmacy recommendations for three of five residents (R46, R55, R70) reviewed for unnecessary medications in the sample list of 29.

Inspectors wroteBased on interview and record review the facility failed to complete psychotropic medication assessments, ensure appropriate diagnosis or behaviors to warrant the use of an antipsychotic, attempt gradual dose reductions (GDRs), and identify/track specific targeted behaviors for five of five residents (R55, R70, R36, R46, R68) reviewed for psychotropic medications in the sample list of 29.

Inspectors wroteBased on interview and record review the facility repeatedly failed to administer an antibiotic as ordered for one of one resident (R73) reviewed for following Physician's Orders in the sample list 29.

Inspectors wroteBased on interview and record review, the facility failed to offer residents Influenza and Pneumococcal immunizations annually or upon admission and failed to provide educational material and consents for these vaccinations. This failure has the potential to affect all 85 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to promote dignity following meals for one of 28 residents (R132) reviewed for dignity in the sample list of 29.

Inspectors wroteBased on interview and record review, the facility failed to provide required Medicare Beneficiary Notices to residents whose Medicare Part A coverage was ending. This failure affects two residents (R78 and R384) out of three reviewed for beneficiary notices on a sample list of 29.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement restraint reduction interventions, and failed to have consents and assessments for the use of body pillow restraints, for one of one resident (R61) reviewed for restraints in the sample list of 29.

Inspectors wroteBased on interview and record review, the facility failed to document a resident's required discharge summary and recapitulation of stay. This failure affects one resident (R78) out of one reviewed for discharge on a sample list of 29.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent tension to male urethra during urinary catheter care by failing to remove the catheter tubing from a residents leg mounted anchor during care and failed to stabilize catheter tubing during cleansing for one of one resident (R73) reviewed for catheter care in the sample list of 29.

Inspectors wroteBased on observation and interview, the facility failed to post the required name, addresses, and telephone numbers for the state Protection and Advocacy Network in the facility. This failure has the potential to affect all 85 residents residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to post their required daily nurse staffing information. This failure has the potential to affect all 85 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to implement post-fall interventions for two of three residents (R2 and R3) reviewed for falls on the sample list of three.

Inspectors wroteBased on interview and record review the facility failed to report a resident incident to the physician for one (R1) of three residents reviewed for skin injuries in the sample list of six.

Inspectors wroteBased on interview and record review the facility failed to properly transfer a resident (R1). R1 is one of six residents reviewed for accidents/incidents in the sample list of six.

Inspectors wroteBased on observation, interview and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for one (R1) of three residents reviewed for skin injuries in the sample list of six.

Inspectors wroteBased on interview and record review the facility failed to protect the residents' right to be free from physical abuse by another resident. This failure affected one of three residents (R2) reviewed for abuse in the sample of three. Findings Include: The facility's undated Abuse Prevention Policy documents the facility affirms the right of it's residents to be free from abuse or mistreatment. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means. Physical abuse includes hitting, slapping, pinching, and kicking. The Verification of Incident Investigation/Administrative Summary dated 1/25/24 documents on 1/25/24 at 10:40 AM R1 physically assaulted R2. V7 Therapy Staff witnessed the incident. V7's statement dated 1/25/24 documents V7 witnessed R1 standing up and out of his wheelchair (no alarm sounded). [...]

Inspectors wroteBased on interview and record review the facility failed to prevent staff to resident mental abuse and failed to immediately suspend alleged perpetrators in order to prevent further staff to resident mental abuse. This failure affects three of four residents (R2, R3, R4) reviewed for abuse. This failure resulted in R2, R3, and R4 being subjected to mental abuse by two Certified Nurses Assistants (CNAs) (V9, V14) engaging in sexual behavior in residents' rooms. The Immediate Jeopardy began on 12/15/23 when V9 CNA and V14 CNA engaged in sexual groping in front of R4. V1 Administrator was notified of the Immediate Jeopardy on 1/09/24 at 2:20 PM. [...]

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate alleged mental abuse and failed to suspend alleged perpetrators. This failure has the potential to affect all 74 residents residing in the facility. Findings Include: 1. On 1/7/24 at 1:00 PM V11 Certified Nurse's Assistant (CNA) stated on 12/15/23 at approximately 9:20 AM V11 observed V14 CNA standing right behind V9 CNA, rubbing on V9's bottom when V9 was assisting R4 with a shower. V11 is unsure if R4 understood what was going on but V11 stated R4 could see both V9 and V14. V11 stated she did not report this to V1 Administrator. 2. On 1/7/24 at 11:06 AM V4 Registered Nurse (RN) stated on 1/2/24, V5 CNA and V11 CNA called her to R3's room. R3 reported to V4 that two female CNAs had been kissing in his room and doing sexual things in front of him on three different occasions. [...]

Inspectors wroteBased on interview and record review the facility failed to report one incident of potential mental abuse immediately to the Administrator and failed to report two incidents of potential mental abuse to the State Survey Agency. This failure affects three of four residents (R2, R3, R4) reviewed for abuse in the sample of four. Findings Include: 1. On 1/7/24 at 1:00 PM V11 Certified Nurse's Assistant (CNA) stated on 12/15/23 at approximately 9:20 AM V11 observed V14 CNA standing right behind V9 CNA, rubbing on V9's bottom when V9 was assisting R4 with a shower. V11 is unsure if R4 understood what was going on but V11 stated R4 could see both V9 and V14. V11 stated she did not report this to V1 Administrator. 2. On 1/7/24 at 11:06 AM V4 Registered Nurse (RN) stated on 1/2/24, V5 CNA and V11 CNA called her to R3's room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the potential for fire and burn hazards by installing portable space heaters in resident rooms throughout the facility and intentionally labeling working emergency exit doors with signs declaring the doors do not open, are out of order, and should not be used to discourage or prevent use by exit-seeking residents. These failures affect all 74 residents residing in the facility. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 11/28/2023 when facility staff first placed portable space heaters in resident rooms throughout the facility. V1 (Administrator) was notified of the Immediate Jeopardy on 12/29/2023 at 3:43PM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store nutritional supplement. This failure has the potential to affect all 74 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure required personnel attended the facility's Quality Assessment and Assurance (QAA) committee meetings. This failure has the potential to affect all 74 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a resident's room at a comfortable temperature. This failure affected one of three residents (R62) reviewed for comfortable room temperatures on the sample list of 74. Findings Include: R62's Medical Diagnoses list dated January 2024 documents R62 is diagnosed with Acute and Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, Bipolar Disorder, Heart Failure, Anemia, Anxiety, and Pain. R62's Minimum Data Set, dated [DATE] documents R62 is completely cognitively intact. R62's Transfer Evaluation dated 12/5/23 documents R62 requires a mechanical lift and staff assistance for transfers and mobility. R62's Care Plan dated 11/29/23 documents R62 requires assistance with transferring, toileting, dressing, personal hygiene, bathing, and bed mobility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide showers to dependent residents. This failure affected three of three residents (R8, R9, R62) reviewed for showers on the sample list of 74. Findings Include: The facility's Bathing Policy dated 4/25/22 documents showers must be offered per resident preference at least twice per week and documented when completed. On 1/3/24 at 1:50 PM the North Hall shower room's temperature measured 56 degrees Fahrenheit by the State Agency thermometer. On 1/3/24 at 1:52 PM the South Hall shower room's temperature measured 51 degrees Fahrenheit by the State Agency thermometer. 1. R8's Medical Diagnoses list dated January 2024 documents R8 is diagnosed with Cerebral Palsy, Autonomic Neuropathy Disease, Post Traumatic Stress Disorder, Anxiety, Insomnia, Pain in Right Knee, and Chronic Pain. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their abuse prevention and employee background check policies by not performing and documenting any employee background screening. This failure has the potential to affect all 74 residents in the facility.

Inspectors wroteBased on record review and interviews the facility failed to provide Resident Council with responses, actions, and rationale taken regarding their concerns for the months of August, September, and October 2023. This failure affects five residents (R4-R8) reviewed for lack of staff.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision in conducting and documenting visual checks of a resident with a known history to initiate an unwitnessed exit from the facility. This failure affects one resident (R1) out of a sample of three reviewed for a risk of unwitnessed exits.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow resident care plan fall interventions for three (R10, R48, R59) residents. The facility also failed to provide safe feeding assistance for one (R23) resident on swallowing precautions while eating and facility failed to securely store a pressurized Oxygen tank for one resident (R6). These failures affect five residents (R6, R10, R23, R48, R59) out of eight residents reviewed for Accidents. These failures resulted in R10 sustaining a Right front of scalp Hematoma and R59 sustaining Right sided 10th, 11th Rib Fractures and a Hematoma.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store frozen foods in an order to protect from cross-contamination, failed to maintain kitchen equipment in a sanitary manner, and failed to maintain a kitchen appliance to operate as designed for sanitation. These failures have the potential to affect all 69 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to conduct one of four required quarterly Quality Assurance Committee meetings and failed to include required members such as the Director of Nursing and the Infection Preventionist. These failures have the potential to affect all 69 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to label and date residents' medications when opened. This failure affects four residents (R13, R30, R38, R41) reviewed during medication storage on the sample list of 34.

Inspectors wroteBased on interview and record review the facility failed to offer, administer and/or obtain declinations for Pneumococcal Conjugate Vaccination (PCV) 13, 15 or 20 and/or Pneumococcal Polysaccharide Vaccine (PPSV) 23 for four residents (R26, R28, R33, R60) out of five residents reviewed for Vaccinations in a sample list of 34 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the dignity of one (R26) resident was maintained by not providing timely incontinence care, grooming/personal hygiene, and bed linens for a resident. This failure affects one (R26) resident reviewed for dignity in a sample list of 34 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide privacy during a resident's Insulin administration. This failure affected one of 13 residents (R219) reviewed for privacy during medication administration on the sample list of 34.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop a Comprehensive Care Plan for two of twenty residents (R43, R49) reviewed for Comprehensive Care Plans in the sample list of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure wound treatments and dressing changes were completed as ordered per the physician and per the resident's plan of care for a resident with Lymphedema and open skin wounds. This failure affects one resident (R6) out of two reviewed for skin conditions on the sample list of 34.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide palatable protein during breakfast and failed to have a substitute available for resident consumption. This failure affects one on five residents (R49) reviewed for nutrition on the sample list of 34.