Shawnee Gardens Healthcare & Rehab Center

F-F600) and 19 Level of Harm - Actual harm female residents at risk.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 11 175267 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175267 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shawnee Gardens Healthcare & Rehab Center 6416 Long Street Shawnee, KS 66216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Level of Harm - Minimal harm or potential for actual harm 45668

Residents Affected - Few The facility identified a census of 117 residents. The sample included eight residents with two reviewed for behavioral services. Based on observation, record review, and interviews, the facility to implement effective behavioral monitoring and interventions related to Resident (R) 1's ongoing sexual behaviors toward female residents. This deficient practice placed Resident R1 at risk for continued behavioral episodes and unmet care needs.

Findings Included:

- The Medical Diagnosis section within Resident R1's Electronic Medical Records (EMR) included diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and a history of sexual behaviors related to psychiatric illness.

Resident R1's Quarterly Minimum Data Set (MDS) completed 12/15/24 noted a Brief Interview for Mental Status (BIMS) score of 12 indicating mild cognitive impairment. The MDS noted he had verbal and physical aggression one to three days weekly. The MDS noted he had rejection of care behaviors one to three days weekly. The MDS noted he was independent with transfers, bed mobility, bathing, toileting, and walking. Resident R1's MDS noted no sexual behaviors.

Resident R1's Cognitive Loss Care Area Assessment (CAA) completed 06/11/24 noted he had impaired cognition related to his medical diagnoses. The CAA noted he required reorientation, reminders, and reassurance to make sense of things. The CAA noted a care plan was implemented with interventions and monitoring to reduce the risks.

Resident R1's Behavioral Symptoms CAA was not triggered.

Resident R1's Care Plan initiated on 10/25/23 noted he was admitted to the long-term care unit due to his medical diagnoses. The plan noted he exhibited sexually inappropriate behaviors related to his psychiatric illness (03/04/24). The plan instructed staff to explain and reinforce to Resident R1 why his behaviors were inappropriate or unacceptable (03/04/24). The plan instructed staff to educate and collaborate with Resident R1 to find successful coping and interaction strategies (03/04/24). The plan instructed staff to administer and monitor his medication's side effects and effectiveness (03/04/24). The plan revealed that Resident R1 was moved to another unit due to exhibiting sexually inappropriate behaviors (02/08/24). The plan lacked information related to his sexual behaviors towards female residents, required supervision around female residents, and required monitoring while out of his room as noted in progress notes. The plan lacked specific triggers and coping strategies needed to prevent his sexual behaviors.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 175267 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175267 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shawnee Gardens Healthcare & Rehab Center 6416 Long Street Shawnee, KS 66216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 Resident R1's EMR under Progress Notes revealed a Nursing Note completed on 03/04/24. The note revealed direct care staff observed Resident R1 as he sat on a female resident's rollator walker seat. The note revealed that Resident R1 had Level of Harm - Minimal harm or his head between the female resident's breasts as she pushed him down the hallway for lunch. The note potential for actual harm indicated staff separated the residents and asked them to sit away from the female residents during meals.

The note revealed that Resident R1 was to be supervised at all times while outside of his room and around other Residents Affected - Few residents.

Resident R1's EMR under Progress Notes revealed a Nursing Note completed on 07/10/24. The note revealed direct care reported they observed Resident R1 seated in the dining room next to Resident R2 (severely cognitively impaired resident). The note revealed that Resident R1 and Resident R2 were inappropriately touching each other. The note indicated Resident R2 was immediately moved away from Resident R1 and both residents were kept separated for the rest of the shift.

Resident R1's EMR under Progress Notes revealed a Nursing Note completed on 07/14/24. The note revealed that Resident R1 walked up to a female resident and began patting her on the shoulder. The note revealed the resident became distressed and attempted to push his hand away from her. The note revealed staff had to ask Resident R1 to leave the female resident alone.

Resident R1's EMR under Progress Notes revealed a Nursing Note completed on 12/07/24. The note revealed that Resident R1 punched a female resident hand as she attempted to throw food at him. The note revealed she was moved to another table.

Resident R1's EMR under Progress Notes revealed a Nursing Note completed on 02/02/25. The note revealed staff observed Resident R1 approach a female resident while she lay in the common area recliner. The note revealed that Resident R1 began touching the female resident's outer arm. The note revealed the female resident attempted to push his arm away and Resident R1 resisted. The note revealed that Resident R1 pushed the female resident's arm downward and continued touching her arm. The note revealed staff immediately separated both residents. The note indicated staff sat with the female resident during meal service due to concerns for her safety.

A Facility Incident Report #3462 completed on 02/08/25 revealed that Resident R1 was observed by staff touching Resident R2's breast and buttocks during meal service. The report indicated that Resident R1 was moved away from Resident R2 and placed on one-on-one supervision.

Resident R1's EMR under Progress Notes revealed a Nursing Note completed on 02/08/25. The note revealed Resident R1 was moved off the secured unit and moved to the Sunflower Hall. No information related to Resident R1's sexual behavior episode on 02/08/25 was completed in his progress notes.

Resident R1's EMR under Tasks revealed no entries related to behavioral monitoring.

Resident R1's EMR under Treatment Administration Report (TAR) revealed no monitoring related to his sexual behaviors or noting of his previous sexual behavioral episodes.

Resident R1's EMR under Medication Administration Report (MAR) revealed psychotropic medication monitoring for behaviors but lacked monitoring related to his sexual behaviors or noting of his previous sexual behavioral episodes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 175267 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175267 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shawnee Gardens Healthcare & Rehab Center 6416 Long Street Shawnee, KS 66216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 On 02/19/25 at 11:55 AM, Resident R1 walked from his room to the 2nd-floor dining area without staff assistance or supervision. Level of Harm - Minimal harm or potential for actual harm On 02/19/25 at 11:03 AM, Certified Nurse's Aide (CNA) M stated Resident R1 was independently mobile and could ambulate without staff assistance. She stated he sometimes used a wheelchair or cane. She stated she was Residents Affected - Few aware of his history of touching females and staff were to monitor his behaviors and document them under

the Tasks section of the EMR. She stated care plan should note he was not to be left alone around female or attempt to enter their rooms. She stated she was expected to report all potential behaviors to the nurse.

On 02/19/25 at 01:04 PM, Licensed Nurse (LN) G stated the care plan should identify specific behaviors and interventions each resident. He stated Resident R1 had behavioral monitoring and preventative interventions in place to prevent his behaviors.

On 02/19/25 at 02:40 PM, Administrative Nurse D stated Resident R1 was immediately separated from Resident R2 and placed

on one-on-one supervision. She stated that Resident R1 was moved to the Sunflower Hall. She stated that Resident R1 had medication changes occurring and was not a risk to the females in the new hallway. She stated staff were expected to monitor Resident R1's behaviors and document them under the Psychotropic Medication Monitoring section of his MAR. She stated events should be documented there. She stated staff were expected to immediately separate the suspected perpetrator from all potential victims.

The facility's ADL Care of Dementia Unit Residents policy revised 10/2019 indicated staff will ensure the appropriate supervision, and ongoing behavioral monitoring for cognitively impaired residents to maintain the highest level of functioning. The plan indicated care plan intervention will be monitored on an ongoing basis for effectiveness and updated as needed.

The facility failed to implement effective behavioral monitoring and interventions related to Resident R1's ongoing sexual behaviors toward female residents. This deficient practice placed Resident R1 at risk for continued behavioral episodes and unmet care needs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 175267

F-F610)

A Facility Incident Report #3462 completed on 02/08/25 revealed that Resident R1 was observed by staff touching Resident R2's breast and buttocks during meal service. The report indicated that Resident R1 was moved away from Resident R2 and placed on one-on-one supervision.

A Staff Witness Statement completed 02/08/25 revealed that Resident R1 sat at the dining room table next to Resident R2. The statement revealed staff witnessed Resident R1 grope Resident R2's nipples and pulled her breast downward. The statement indicated that Resident R2 was visibly upset and reported to staff she felt like she was being held against her will. The statement indicated that Resident R2 continued to verbalize she was scared. The statement indicated Resident R1 was supervised for the remainder of the evening.

On 02/19/25 at 11:10 AM, Resident R2 sat in walked around the locked memory care unit. Resident R2 was unable to recall the incident that occurred on 02/08/25.

On 02/19/25 at 11:55 AM, Resident R1 walked from his room to the 2nd-floor dining area without staff assistance or supervision.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 11 175267 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175267 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shawnee Gardens Healthcare & Rehab Center 6416 Long Street Shawnee, KS 66216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 On 02/19/25 at 11:03 AM, Certified Nurse Aide (CNA) M stated cognitively impaired residents should be monitored closely due to the potential risk of injuries and abuse. CNA M stated residents with noted Level of Harm - Immediate behaviors should be monitored closely around other residents and said male residents with sexual behaviors jeopardy to resident health or should not be left unsupervised around female residents. CNA M stated Resident R1 should not be seated next to or safety be around female residents unsupervised.

Residents Affected - Few On 02/19/25 at 01:04 PM, Licensed Nurse (LN) G stated Resident R1 was recently moved from the locked unit due to sexual behaviors towards females. LN G stated the direct care staff documented behavioral monitoring under

the Tasks section of the EMR. LN G stated Resident R1 recently moved to the unit, so he was not sure if the monitoring section was under Tasks for the resident. LN G stated staff were expected to keep an eye on Resident R1 while he was out walking around. LN G stated all staff had access to the care plan and the care plans should reflect his repeated behaviors toward females, monitoring, coping strategies, and interventions to prevent his behaviors. LN G said suspected abuse allegations were reported immediately to the director of nursing and facility administrator. LN G stated staff would immediately separate the perpetrator from other residents and ensure everyone was safe.

On 02/19/25 at 02:40 PM, Administrative Nurse D stated Resident R1 was immediately separated from Resident R2 and placed

on one-on-one supervision. Administrative Nurse D stated Resident R1 was moved to another hall. Administrative Nurse D said Resident R1 had medication changes occurring and was not a risk to the females in the new hallway. Administrative Nurse D said she expected staff to monitor Resident R1's behaviors and document them under the Psychotropic Medication Monitoring section of his MAR. She stated events should be documented there.

She stated staff were expected to immediately separate the suspected perpetrator from all potential victims.

The facility's Abuse, Neglect, and Exploitation policy revised 11/2017 indicated the facility will provide safety and dignity for all residents by implementing proper procedures for enforcing resident rights. The policy noted

the facility will protect residents of suspected abuse and all potentially affected residents from incidents of abuse.

The facility failed to ensure cognitively impaired Resident R2 remained free from abuse when the facility failed to prevent an episode of resident-to-resident sexual abuse. This placed Resident R2 at risk for ongoing and/or unidentified abuse and mistreatment based on the reasonable person concept, this deficient practice resulted in feelings of fear for Resident R2 and placed Resident R2 at risk for further psychosocial harm, intimidation, and neglect.

The facility failed to identify and implement preventative interventions related to Resident (R)1's sexual behaviors upon moving him to a new unit. This deficient practice placed 19 female residents at risk for sexual abuse.

On 02/19/25 at 03:31 PM, Administrative Staff A was provided a copy of the IJ template and notified of the facility's failure to prevent the sexual abuse of Resident R2, the facility additionally placed 19 other female residents at risk for sexual abuse after moving Resident R1 to another unit without addressing his sexual behaviors.

The facility provided an acceptable plan for the removal of the immediacy on 02/19/25 at 04:30PM which included the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 11 175267 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175267 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shawnee Gardens Healthcare & Rehab Center 6416 Long Street Shawnee, KS 66216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 1. Resident R1 was immediately placed on one-on-one supervision until psychiatric evaluation can be completed. 02/19/25 Level of Harm - Immediate jeopardy to resident health or 2. The facility identified all at-risk residents on the new unit. 02/19/25 safety 3. Staff were provided in-service upon hire, annually, and post-allegation on abuse, neglect, and exploitation Residents Affected - Few with comprehensive testing. 02/19/25

4. Safe survey conducted on female residents of new unit. 02/19/25

5. Psychiatric evaluation will be completed.

The Surveyor verified the implementation of the IJ removal plan while onsite on 02/19/25 at 04:45 PM. The deficient practice remained at a G after removal of the immediacy based on reasonable person concept.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 11 175267 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175267 B. Wing 02/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shawnee Gardens Healthcare & Rehab Center 6416 Long Street Shawnee, KS 66216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations.

Level of Harm - Actual harm 45668

Residents Affected - Few The facility identified a census of 117 residents, with eight residents sampled, including two residents reviewed for abuse. Based on observation, record review, and interviews, the facility failed to implement effective preventative interventions related to Resident (R)1's sexual behaviors to protect the female residents in the facility including Resident R2 (See