Every finding on record at Rest Haven Health and Rehabilitation

Based on resident and staff interview, record review, and facility policy review, the facility failed to ensure a resident's right to be treated with dignity and respect was honored for one (1) of three (3) residents sampled. Resident #1.Findings Include:Review of the facility policy, Resident Rights and Dignity Management, review date 9/2025, under Standard revealed that It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality An interview with Administrator (ADM) on 01/15/26 at 9:25 AM, revealed that Resident #1 came into his office on 12/30/25 at approximately 1:40 PM and reported that Certified Nursing Assistant (CNA) #1 had been rude and disrespectful to her and told her to shut up. Administrator revealed that he watched the video camera footage and confirmed that it was true. He revealed that camera footage revealed that on 12/30/25 at 1:15 PM, Resident #1 was observed yelling down the hall for staff to take her to the restroom and CNA #1 stated they were getting on his nerves with this impatient stuff, and a few words later told her to Shut up. ADM revealed that Resident #1 was impatient and could be impulsive sometimes, but the staff had to understand how to deal with her and treat her with respect. He also agreed that CNA #1 failed to treat Resident #1 with dignity and respect and that was her right. He revealed that he called CNA #1 into the office and suspended him immediately and during the investigation CNA #1 resigned.An observation of video camera footage with ADM on 01/15/26 at 9:35 AM revealed that on 12/30/25 at 1:15 PM, Resident #1 was sitting in her wheelchair asking for help to go to the restroom. A male staff member, who ADM identified as CNA #1, approached Resident #1, spoke to her using a rude tone and told the resident to Shut up and after a few other words from Resident #1, he stated to her again, Hush your mouth. CNA #1 then walked away from Resident #1 and two other staff members assisted her. An interview on 01/15/26 at 10:40 AM with Assistant Director of Nursing (ADON), revealed that Resident #1 was very impulsive and often demanding, wanting what she asked for right then. ADON revealed that Resident #1 would often press her call light and go immediately out into the hall to find someone to help her. ADON revealed that they had issues with her being impatient about going to the bathroom because she was a two-person assist with a lift. She revealed that they could not always stop immediately what they were doing with other residents to attend to her needs and that upset her. ADON revealed that CNA #1 should never have approached Resident #1 with that behavior like he did, that he should have stepped away from the situation and allowed someone else to take over. She also revealed that Resident #1 does know how to push them to anger but they should always treat the resident with dignity and respect regardless because that was her right that should have been honored. An interview on 01/15/26 at 11:00 AM with Resident #1, revealed that on 12/30/25, there was an incident where a CNA failed to treat her with dignity and respect. She revealed that she pressed the call light for someone to come in and help her to the bathroom. Resident #1 revealed that she did not have patience, and when she wanted something, she wanted it right then. She revealed that when she pressed her call light, she wheeled herself out into the hall and asked CNA #1 to take her to the bathroom. Resident #1 revealed that she and CNA #1 had words, and he told her to shut up and she stated, I guess I said something he didn't like. Resident #1 revealed that two other CNAs came in and took her to the restroom after that, and she confirmed that she went straight to ADM office and reported it. She also revealed that CNA #1 was normally kind and stated, I love him to death because he doesn't make me wait. She also revealed that she and CNA #1 always picked on each other and stated, He's a very good aid but he must have been having a bad day. Resident #1 revealed that she felt safe there and she hated that CNA #1 was no longer there.A phone interview on 01/15/26 at 11:45 AM with CNA #1, revealed that he resigned his position at the facility after the verbal altercation he had with Resident #1. He revealed that on 12/30/25, Resident #1 was on one of her [NAME], was upset and yelling out in the hall for someone to take her to the bathroom. He revealed that Resident #1 was not assigned to him that day, but he agreed to assist her to the bathroom when he finished taking care of the resident he was with. CNA #1 revealed that two other CNAs had asked her 15 minutes prior to that time if she needed to go to the bathroom and she declined. He revealed that when he walked up to Resident #1, she was mouthing off and he confirmed that he told her to shut up. He revealed that he got the lift and brought it into her room and she continued mouthing off at him. CNA #1 confirmed that he told her to shut up and to hush her mouth and that it was unprofessional of him to do so. He revealed that he should have walked away and let someone else take over. CNA #1 stated that he was sorry for the way he handled the situation and he should have treated her with respect and dignity and not been rude to her. He revealed that she reported it to the Administrator, and ADM sent him home pending the investigation and he turned in his resignation.Record review of an In-Service on Customer Service, Resident Rights, and Abuse was completed on 08/13/25 and 08/15/25 and CNA #1 attended.Record review of CNA #1's Record of Counseling dated 12/30/25 documented that he was suspended pending investigation of the alleged verbal abuse towards a resident.Record review of Resident #1's admission Record revealed an admission date of 03/13/20 and that she had diagnoses that included Type 2 Diabetes Mellitus and Unspecified Sequelae of Cerebral Infarction.Record review of Resident #1's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/19/25 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 15 which indicated that she had no cognitive deficits.

Based on observation, staff interviews, record review and facility policy review, the facility failed to ensure the residents' environment was maintained in a homelike and sanitary manner as evidenced by the presence of a black substance in the grout lines of the shower stall wall tile, missing wall paint behind beds (Resident #17 and Resident #27) and torn bathroom flooring (Resident #4) for four (4) of 35 resident and facility rooms observed. The facility received F584 on the last annual survey therefore the scope and severity was raised to E. Findings Include: Review of the facility policy titled “Shower and Tub Room Cleaning” revised 1/16 revealed under, “Procedure Description: This procedure will remove soap scum, dirt and debris from these areas providing a safe and sanitary place for the residents to bathe.” Also revealed under, “Procedure: … 2. Shower stall walls need to be cleaned daily using cloth and spray bottle of disinfectant solution. It may be necessary to use a scrub brush and diluted all purpose cleaner or tub/tile cleaner on walls monthly to remove residue from grout and corners.” Review of the facility policy titled Homelike Environment revised 5/22 revealed under, Standard: Residents are provided a safe, clean, comfortable and homelike environment.On 9/2/25 at 10:23 AM, an observation of the shower room revealed that the lower shower wall tiles in the left stall were covered with a thick black substance along the grout lines and extended approximately five (5) to six (6) tiles up from the floor, reaching higher in the back two corners. The right shower wall tiles were the same and covered with a black substance in the crevices of the grout lines and extended approximately four (4) tiles up from the floor. Shower Room An observation of the shower stalls with Housekeeping Staff #2 on 9/2/25 at 10:28 AM confirmed the black substance in the grout lines of the tile. She stated, It looks like mold, and revealed that a member of housekeeping was responsible for cleaning the showers and acknowledged that the condition was not a sanitary environment for residents. She confirmed that she cleaned the showers every evening at the end of the day with Clorox and water. She stated she did not have any products to clean the tile thoroughly to remove the buildup and stated, It looked like that when I came here, and acknowledged she had not tried to clean the walls with a scrub brush to remove the buildup and the black substance. An observation and interview with the Administrator on 9/2/25 at 10:39 AM confirmed the showers should be cleaned thoroughly each day, including the walls, to remove any buildup and mold. He revealed that residents should have a clean, sanitary environment so infections do not spread. Resident #4 During an observation on 9/2/25, at 12:22 PM, it was noted that the linoleum flooring in Resident #4's bathroom had a torn area measuring approximately four (4) inches by five (5) inches, which exposed the concrete floor beneath. During an observation and interview on 9/4/25, at 8:55 AM, with the Maintenance Director and Director of Nursing (DON), both confirmed the presence of the torn area and acknowledged that it constituted a potential fall risk for residents, stating they were unaware of the damage prior to the observation. Record review of Resident #4’s “admission Record” revealed the resident was admitted to the facility on [DATE], with a medical diagnosis that included Chronic Obstructive Pulmonary Disease (COPD). Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/9/25, revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating Resident #4 is moderately cognitively impaired. Resident #17 During an observation on 9/2/25, at 1:48 PM, it was noted that there was a large area on the wall behind the headboard of Resident #17’s bed that measured approximately three (3) feet by four (4) feet, exhibiting scratched and damaged paint. On 9/4/25, at 8:43 AM, an observation and interview with the Maintenance Director and DON, both individuals confirmed that the damaged area on the wall should have already been repainted, acknowledging that it detracts from the quality of the living environment for the resident. Record review of Resident #17 ’s “admission Record” revealed the resident was admitted to the facility on [DATE], with a medical diagnosis that included Other Seizures. Record review of the MDS with an ARD of 8/13/25, revealed a BIMS score of 14, indicating Resident #17 is cognitively intact. Resident #27 During an observation on 9/2/25, at 12:22 PM, it was noted that there was a large area on the wall behind the headboard of Resident #27’s bed that measured approximately three (3) feet by four (4) feet, exhibiting scratched and damaged paint. On 9/4/25, at 8:53 AM, an observation and interview with the Maintenance Director and DON, both individuals confirmed that the damaged area on the wall should have already been repainted, acknowledging that it detracts from the quality of the living environment for the resident. Record review of Resident #27 ’s “admission Record” revealed the resident was admitted to the facility on [DATE], with a medical diagnosis that included Parkinson’s Disease. Record review of the MDS with an ARD of 5/30/25, revealed a BIMS score of 14, indicating Resident #27 is cognitively intact.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to develop the comprehensive care plan for one (1) of 18 sampled residents. (Resident #17) F656 was cited during the last annual survey, therefore the scope and severity was raised to E. Findings include:Review of the facility policy titled, Resident Centered Care Planning: Baseline Care Plan, dated 4/2025 outlines the standard: The facility shall develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Record review of Resident #17's Activities of Daily Living (ADLs) Care Plan date initiated 11/30/23 revealed, Interventions/Tasks did not include nail care.An observation and interview on 9/2/25 at 10:53 AM, with Resident # 17 revealed her fingernails were one-half inch in length, jagged, and had a brown substance underneath. Resident #17 expressed a desire to have her nails trimmed, stating she preferred them to be trimmed short. An interview on 9/3/25 at 11:09 AM, with Licensed Practical Nurse (LPN) #1 stated Resident #17's fingernails should have been trimmed by the nursing staff. She further verbalized the resident was at an increased risk for infection and skin tears due to having long, dirty jagged fingernails. An interview on 9/3/2025 at 11:35 AM, with the Minimum Data Set (MDS) Coordinator, she confirmed that the ADL care plan did not include nail care and was not fully developed. She verbalized that the care plan should have been developed to direct the care needed for the resident.Record review of the admission Record indicated that the facility admitted Resident #17 on 2/28/2023, with a medical diagnosis that included Other Seizures. A record review of the MDS with an Assessment Reference Date (ARD) of 8/13/25, revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 14 which indicated Resident #17 was cognitively intact.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide Activities of Daily Living (ADL) care to maintain personal hygiene for one (1) of 18 sampled residents. (Resident #17) F677 was cited during the last annual survey, therefore the scope/severity was raised to E. Findings include:Review of the facility policy titled, Resident Hygiene: Care of Fingernails/Toenails, with a review date of 6/22 outlines the purpose of providing nail care: To clean the nail bed, to keep nails trimmed and to prevent infections. During an observation and interview on 9/2/25 at 10:53 AM, Resident # 17 revealed her fingernails were one-half inch in length, jagged, and had a brown substance underneath. Resident #17 expressed a desire to have her nails trimmed, stating she preferred them to be trimmed short. During an interview on 9/3/25 at 11:09 AM, Licensed Practical Nurse (LPN) #1 stated Resident #17's fingernails should have been trimmed by the nursing staff. She further verbalized the resident was at an increased risk for infection and skin tears due to having long, dirty jagged fingernails. During an interview on 9/3/2025 at 11:16 AM, with the Director of Nursing (DON), she confirmed that usually nailcare is performed during bath time by the Certified Nursing Assistants (CNAs) for non-diabetic residents. She acknowledged that long, dirty, jagged fingernails increased the risk of infections. The DON expressed her expectations that residents' nails should be kept clean and trimmed as necessary. Record review of the admission Record indicated that the facility admitted Resident #17 on 2/28/2023, with a medical diagnosis that included Other Seizures. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/13/25, revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 14 which indicated Resident #17 was cognitively intact.

Based on observation, record review, facility policy review and staff interview, the facility failed to implement Enhanced Barrier Precautions (EBPs) as per Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines for one (1) of one (1) resident (Resident #16) observed during Percutaneous Endoscopic Gastrostomy (PEG) medication administration. The nurse did not don appropriate personal protective equipment (PPE) before handling the PEG tube, creating the potential for cross-contamination and infection spread. F880 was cited during the last annual survey, therefore the scope and severity was raised to E. Findings Include:Review of facility policy titled Enhanced Barrier Precautions, with a revision date of 5/2024, revealed, Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a multi-drug resistant organism (MDRO) as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). On 9/3/25 at 9:10 AM, an observation of medication administration via (by) PEG tube with Resident #16, observed Licensed Practical Nurse (LPN) #1 not using Enhanced Barrier Precautions and the nurse did not wear a gown while administering medications to a resident at high risk for infections. An interview on 9/3/25, at 9:30 AM with LPN#1, she stated she forgot to wear her gown and that PPE was available and accessible to staff. She was able to verbalize that the purpose of wearing a gown would be to reduce infection risk when coming in and out of the resident's room. An interview with the Director of Nursing (DON) on 9/3/25 at 11:00 AM, regarding EBP, stated that LPN#1 usually wears her gown and was probably nervous. She confirmed that she should have worn a gown to administer peg medications. She stated that the policy on EBP was in place and education was provided for staff and that an EBP sign was posted at resident's door to remind the staff to wear PPE. Record review of the admission Record revealed that the facility admitted Resident #16 on 8/07/25 with a medical diagnosis that included Pneumonia unspecified organism and Gastrostomy Status.

Based on observation, record review, staff and family interviews, record review, and facility policy review the facility failed to identify a bed rail as a physical restraint, failed to accurately assess the resident for the use of a bed rail, and failed to ensure that the bed rail did not pose a risk of injury from falls for one (1) of 18 sampled residents. Resident #35Findings Include: Review of the facility policy titled Physical Restraints revealed under, Physical Restraint Standards: The goal of this facility is to ensure that each resident attains and maintains his/her highest practical level of function and well-being in an environment that limits restraint use to circumstances in which the medical symptoms of the resident warrant the use of the least restrictive restraint . An observation of Resident #35 on 9/2/25 at 2:45 PM revealed she was lying in bed with her eyes closed, and the bed was against the wall on her left side, with a full-length bed rail that was located on her right side, and a bed alarm was also in use. The resident was lying on a concave with raised edges mattress. Record review of Resident #35's Bed Rail Use Screening Form dated 6/23/25 revealed under, Recommended Type Bedrail 1/4 (one-quarter) length side rails were indicated. An interview with the Assistant Director of Nursing (ADON) on 9/3/25 at 11:28 AM confirmed Resident #35's side rail assessment was not accurate. She explained that the resident had the full-length side rail already in place when she started working at the facility several months ago. The ADON stated the resident had the bed rail because a family member requested it to prevent the resident from falling. She revealed the resident tried to get out of the bed and sometimes scooted to the end of the bed trying to get up. Record review of Resident #35's Bed Rails Informed Consent for Use dated 5/3/24 revealed under, Reason Bed Rail(s) Being Considered: Resident/Resident representative (RR) requested for safety. Also revealed under, Type of Rails: Right upper and lower. An interview with the Director of Nursing (DON) on 9/3/25 at 3:48 PM revealed Resident #35's bed rail was applied because a family member was adamant about applying it due to frequent falls. She stated the family member signed the consent and understood the risk and that it could pose harm to the resident. An interview with a family member for Resident #35 on 9/4/25 at 10:36 AM revealed she knew the bed rail was a restraint and stated that was the purpose of the rail, to keep her mother in bed. She revealed a couple weeks ago the resident fell from the bed while trying to climb over the bed rail but was not hurt. Record review of Resident #35's Fall with Injury Report dated 8/13/2025 revealed under, Incident Description: Resident was hollering out Momma this Nurse and CNA (certified nurse aide) headed to room, resident was falling to the floor. Also revealed under, Immediate Action Taken: Head to toe assessment performed with abrasion noted to center of the back. An interview with the DON on 9/4/25 at 11:02 AM revealed Resident #35 did fall while trying to crawl over the bed rail and acknowledged the rail posed a greater risk for injures to the resident. She confirmed a restraint assessment was not done and acknowledged that positioning the bed against the wall, using a concave mattress along with a bed alarm and bed rail was restraining the resident from getting up easily. She confirmed this was done for family convenience related to falls rather than the safety of the resident and that the resident had not been screened properly for the restraints. Record review of the admission Record revealed the facility admitted Resident #35 on 9/21/24 with a medical diagnosis of Chronic Diastolic (Congestive) Heart Failure. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/10/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 3, which indicated Resident #35 was severely cognitively impaired.

Based on record review, staff interviews, and facility policy review, the facility failed to timely complete quarterly minimum data sets (MDS) within the time frame specified by Centers for Medicare and Medicaid Services (CMS) for three (3) of 21 minimum data sets reviewed. Resident #20, #41, #53Findings Include: Review of the facility policy titled “MDS/RAI (Resident Assessment Instrument) Standard” unrevised, revealed under, “Standard: This facility makes a comprehensive assessment of each resident’s needs, strengths, goals, life history and preferences using the RAI specified by CMS.” Resident #20 Record review of Resident #20’s Quarterly MDS with an Assessment Reference Date (ARD) of 7/26/25 revealed under section Z0500, the assessment had not been completed. Record review of the admission Record revealed the facility admitted Resident #20 on 7/10/25 with a medical diagnosis of hyperkalemia. Resident #41 Record review of Resident #41’s Quarterly MDS with an ARD of 8/2/25, revealed under section Z0500, the assessment had not been completed. Record review of the admission Record revealed the facility admitted Resident #41 on 11/15/24, with a medical diagnosis of Disorder of Bone Density and Structure, Anemia, and Peripheral Vascular Disease. Resident #53 Record review of Resident #53’s Quarterly MDS with an ARD of 7/27/25 revealed under section Z0500, the assessment was not completed. Record review of the admission Record revealed the facility admitted Resident #53 on 7/08/25 with medical diagnoses that included Severe Sepsis with Septic Shock. An interview with the MDS Nurse on 9/3/25 at 3:15 PM confirmed Resident #20, #41, and #53’s quarterly assessments were completed late. She explained that she had been out sick and fell behind in getting the assessment completed. The MDS Nurse stated the assessments should be closed and submitted timely to have accurate information on the residents and for payment purposes. An interview with the DON on 9/3/25 at 3:23 PM revealed her expectations were for the MDS assessment to be completed and submitted within the designated timeframe specified by CMS. She explained that she did not review the assessment to ensure they were completed timely.

Based on record review, staff interviews, and facility policy review, the facility failed to timely encode and transmit a discharge Minimum Data Set (MDS) as required by the Centers for Medicare and Medicaid Services (CMS) guidelines for one (1) of twenty-one (21) MDS reviewed. Resident #58.Findings Include:Review of the facility policy titled MDS/RAI (Resident Assessment Instrument) Standard unrevised, revealed under, Standard: This facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences using the resident assessment instrument (RAI) specified by CMS.Record review of Resident #58's Discharge MDS with an Assessment Reference Data (ARD) of 6/6/25 revealed under section Z0500, an assessment completion date of 8/6/25, which indicated the assessment was completed late.Record review of the MDS Final Validation Report revealed Resident #58's Discharge MDS was accepted by CMS on 8/20/25 with a warning message that read, Assessment completed late: Z0500B (assessment completion date) is more than 14 days after A2300 ARD. An interview with the MDS Nurse on 9/3/25 at 3:15 PM confirmed Resident #58's discharge assessment was completed late. She explained that she had been out sick and fell behind in getting the assessment completed. The MDS Nurse stated the assessments should be closed and submitted timely to have accurate information on the residents and for payment purposes. An interview with the Director of Nursing (DON) on 9/3/25 at 3:23 PM revealed her expectations were for the MDS assessment to be completed and submitted within the designated timeframe specified by CMS. She explained that she did not review the assessment to ensure they were completed timely. Record review of the admission Record revealed the facility admitted Resident #58 on 1/22/25 with medical diagnoses that included Anorexia and Repeated Falls.

Based on staff and resident interview, record review, and facility policy review, the facility failed to ensure each resident was treated with dignity and respect for seven (7) of 16 residents sampled. Residents #3, #4, #5, #6, #7, #9, and #10. Findings include: Record review of facility policy titled, Resident Rights and Dignity Management - Dignity dated 5/22, revealed, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality. 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights at all times. 5. When interacting with a resident, pay attention to the resident as an individual. 9. Speak respectfully to residents . 10. Respect the resident's living space and personal possessions. 14. 'Treated with dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. 15. Staff shall speak respectfully to the residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his room number, diagnosis or care needs. 20. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed. 21. Staff shall treat cognitively impaired residents with dignity and sensitivity. Record review of facility policy titled, Resident Rights and Dignity Management - Resident Rights dated 5/2022, revealed, Employees shall treat all residents with kindness, respect and dignity. Record review revealed that the State Agency (SA) received an anonymous complaint that stated that Certified Nursing Assistant (CNA) #1 was verbally and mentally abusing residents and the staff had reported it many times to the Administrator but nothing had been done. Resident #3 An interview with Resident #3 on 11/18/24 at 10:30 AM, revealed CNA #1 had a bad attitude problem. She stated several weeks ago, CNA #1 came into her room and had pushed the lift towards her and she had to stop it with her foot to keep it from hitting her. She stated she told the CNA to be careful, but she acted like she did not even care. She stated the facility was her home and she had the right to feel cared for and to not have to deal with a grumpy worker with a mean attitude. She stated she had talked to the Social Worker and the Administrator about this. Record review of the Admission Record revealed the facility admitted Resident #3 on 7/20/17. Record review of Resident #3's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/22/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Resident #4 An interview on 11/18/24 at 10:45 AM, with Resident #4 revealed, We have one CNA here that is a wild one and her name is (proper name for CNA #1). She stated when she has asked her to do things for her that she would often ignore her or make rude comments like What do you want now. She stated she did not feel that it was at the level of abuse and was not afraid of here, but she felt that her rights as a resident to be treated with dignity and respect were not honored by this CNA. She stated she had talked with the Social Worker in the past about these concerns with CNA#1. Record review of the Admission Record revealed the facility admitted Resident #4 on 7/26/23. Record review of Resident #4's MDS with ARD of 11/5/24 revealed a BIMS score of 15 which indicated the resident was cognitively intact. Resident #5 During an interview on 11/18/24 at 10:48 AM, Resident #5 stated CNA #1 had a bad attitude and had been rude and disrespectful to her. She stated, It might just be her way, but I don't like to be talked to like that. She also stated that Respect was not in (proper name removed) CNA #1's repertoire. She stated, I tell the staff that I might be old but there is not a damn thing wrong with my mind. She stated that she did not feel that this was verbal abuse but being treated disrespectfully in her own home did go against her rights as a resident of the facility. Record review of Admission Record revealed the facility admitted Resident #5 on 3/25/16. Record review of Resident #5's MDS with ARD of 10/28/24 revealed a BIMS score of 15 which indicated the resident was cognitively intact. Resident #6 During an interview on 11/18/24 at 11:15 AM, Resident #6 revealed some staff are just awful and will not listen to him. He stated, They just do what they want to do. He stated he told them to Give me their ear and listen to what I'm trying to tell them instead of doing what you want to do for me. He stated he had told CNA #1 and others that I'm going to the boss and tell him, and they tell him to go ahead and tell him and they will tell on me too. He also stated that CNA #1 told him he needed to go somewhere else since he could do some of his own care, and he told her this was his home, and he had the right to be there. He stated he had mentioned these concerns to the Social Worker and to the Administrator. He stated he did not feel abused, but he did feel very disrespected by CNA #1. Record review of Admission Record revealed Resident #6 was admitted to the facility on [DATE]. Record review of Resident #6's MDS with ARD of 10/21/24 revealed a BIMS score of 13 which indicated the resident was cognitively intact. Resident #7 During an interview on 11/18/24 at 11:30 AM, Resident #7 revealed that CNA #1 Smarts off to me all the time. He stated he did not remember what was said each time, but did know she was very rude and mean, not abusive, but definitely not nice. He stated she also put his meal tray down roughly and it fell on him. He stated that she also complained a lot about having to reposition him and adjust his bed with the manual crank. Record review of Admission Record revealed the facility admitted Resident #7 on 4/17/24. Record review of Resident #7's MDS with ARD of 10/4/24 revealed a BIMS score of 8 which indicated the resident had moderate cognitive impairment. Resident #9 During an interview on 11/19/24 at 2:00 PM, Resident #9 revealed some of the staff had been disrespectful to her. She stated she had pressed the call light for assistance and a staff member came in and asked what she needed now in a rude and mean way and then made comments about how the room smelled awful. She stated she could not help that she could not control her bowels or bladder and for the staff to say that was very disrespectful to her and it was not treating her with dignity. She stated she had the right to be treated with dignity and respect and making comments like that was not acceptable. Record review of Admission Record revealed the facility admitted Resident #9 on 2/12/18. Record review of Resident #9's MDS with ARD of 9/13/24 revealed a BIMS score of 15 which indicated the resident was cognitively intact. Resident #10 An interview on 11/19/24 at 2:10 PM, with Resident #10 revealed some of the staff had bad attitudes and treated him and other residents disrespectfully. He stated one nurse was rude and he felt that she always questioned what he said he needed. He stated he received the care needed but at times it was with attitude and those with bad attitudes either need to be respectful or go home. Record review of Admission Record revealed the facility admitted Resident #10 on 7/25/24. Record review of Resident #10's MDS with ARD of 9/27/24 revealed a BIMS score of 12 which indicated the resident had moderate cognitive impairment. Record review of the Grievance Log for the past six (6) months did not reveal any of the concerns voiced by these residents. Interview on 11/18/24 at 11:45 AM, with CNA # 2 stated CNA #1 was loud and her voice carried. Interview on 11/18/24 at 11:55 AM, with the Registered Nurse (RN) supervisor, stated she works both rotations, so she is aware of most of the staff and CNA #1 is thorough and gets the job done but she is loud and sounds blunt when talking and does not have a friendly tone. Interview on 11/18/24 at 1:40 PM, with CNA #3, stated at one time, CNA #1 was kinda shaky with the way she would talk, not abusive, but rude. She stated she is loud and rough and sounds mean and disrespectful but she had been trying to talk softer and kinder and she has made a complete turnaround. CNA #3 stated that CNA #1 would do good care for her residents but not with a friendly attitude. Interview on 11/18/24 at 1:48 PM, with Licensed Practical Nurse (LPN) #1 stated she works with CNA #1 almost every shift since they are on the same rotation and she had never heard her say anything that was mean or disrespectful to a resident, but that she does have a higher volume of speech. Interview on 11/19/24 at 10:50 AM, with CNA #1 confirmed that she has a loud voice, and it carries and she knows she sometimes sounds grumpy, but that is the way her voice is. She stated that she takes care of her residents and tries to do what she can for them to meet their needs. She acknowledged that she may appear rough and loud, but she tries to do her job in a good way and that she just thinks her voice is loud. During an interview on 11/19/24 at 3:00 PM, the Director of Nursing (DON) confirmed that each resident has the right to be treated with dignity and respect and the facility failed to ensure that each resident's rights were honored. During an interview on 11/19/24 at 4:00 PM, the Administrator stated each resident deserves to be treated with dignity and respect and he confirmed that there were several residents that were not treated with dignity and respect and the facility failed to honor each of these resident's rights. He stated that the facility had recently investigated an allegation of abuse with CNA #1 but was not able to substantiate the allegation and it had been reported to the State Agency. He stated that the CNA was suspended while the investigation was going on but it was not related to these concerns. He confirmed that there was a witness to this recent allegation and that it just didn't occur after the statements were gathered.

Based on observation, staff interview, record review and facility policy review the facility failed to prevent the possibility of accidents and hazards for a resident who was an elopement risk by failing to monitor placement and function of a wander guard (Resident #1) and failure to secure smoking supplies for one (1) of three (3) days of survey. Findings Include Record review of the facility policy titled, Wandering/Elopement Risk with a revision date of 11/2017 revealed STANDARD It is the standard of this facility to identify those residents at risk for wandering/elopement and to take the appropriate steps to minimize the risk of elopement . The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering . of 10/2017 revealed STANDARD This facility provides a safe and healthy environment for residents .including safety as related to smoking. Safety protections apply to smoking and non-smoking residents .Standard Explanation and Compliance Guidelines .13. Smoking material will be maintained and secured by nursing staff . Resident #1 An observation on 04/23/24 at 12:49 PM, revealed Resident #1 was wearing a wander guard bracelet on his left wrist. Record review of Resident #1's Elopement Evaluation dated 3/11/24 revealed the resident has a history of elopement or attempted elopement and wanders. Record review of Resident #1's Order Summary Report with active orders as of 4/24/24 revealed there was not an order for a wander guard bracelet. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/11/24 revealed in Section P the resident was coded for a wander/elopement alarm that was used daily. An interview on 4/23/24 at 1:30 PM, with Registered Nurse (RN) #1 revealed that Resident #1 wears a wander guard because he has dementia and gets confused sometimes. She stated he says he wants to go home and does wander, but he has never eloped. An interview, observation, and record review on 4/24/24 at 4:30 PM, with Licensed Practical Nurse (LPN) #7 confirmed that Resident #1 had a wander guard bracelet on his left wrist. She stated he had worn it for a long time. She stated that anyone that has a wander guard bracelet should have an order and then it will show on either the Electronic Medication Administration Record (EMAR) or Electronic Treatment Administration Record (ETAR) to monitor it every shift. A record review of the resident's physician's orders with LPN #7 confirmed that Resident #1 did not have an order for a wander guard, and it was not triggered on the residents EMAR or ETAR to check for functioning or placement of the wander guard bracelet each shift. An interview and record review on 4/24/24 at 4:40 PM, with LPN #3 confirmed that Resident #1's wander guard bracelet had not been monitored each shift to make sure it was still on the resident and functioning. An interview on 4/25/24 at 8:20 AM with the Director of Nurses (DON), revealed it was her expectation that Resident #1's physicians order would have been put in the resident's record and triggered for the staff to monitor the resident's wander guard placement and function. She stated the residents order for a wander guard dropped off in December 2023 after he returned from a hospital stay. She confirmed a residents wander guard needs to be monitored for placement and function to prevent an elopement. Record review of Resident #1's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Schizoaffective Disorder, Bipolar Type. Smoking: An observation on 4/23/24 at 6:38 AM, revealed the smoking supply closet on the resident hall that held residents smoking supplies was unlocked. Observed a sign on the smoking supply closet door Keep this door locked at all times. An interview and observation on 4/23/24 at 6:45 AM, with Housekeeping Staff #2 confirmed the smoking supply closet was unlocked and stated they are supposed to keep that door locked at all times. Housekeeping Staff #2 stated the key is kept behind the nurse's desk. An interview and observation on 4/23/24 at 6:50 AM, with Licensed Practical Nurse (LPN) #6 confirmed that the resident smoking supply closet was unlocked, held resident's smoking supplies including at least one lighter and that it was supposed to always be locked for safety. An interview on 4/23/24 at 6:55 AM, with Registered Nurse (RN) #1 confirmed that the residents smoking supply closet was supposed to be locked at all times and the key is kept behind the nurse's station. She revealed that the purpose of keeping the smoking supply closet locked was to prevent residents from having access to the smoking supplies and the lighter. She stated there is at least one lighter in there. If the residents got a hold of the supplies they'd be smoking in the rooms and we have oxygen in the building, so it's a safety issue. Record review of the List of Resident on Designated Smoking list undated, revealed there were 9 active smokers listed. An interview with Administrator on 4/25/24 at 11:00 AM, confirmed that the smoking supplies should always be locked up to prevent the residents from having access to the smoking supplies including the lighter for safety issues and that was the facilities policy.

Based on record review and staff interview, the facility's Quality Assessment and Assurance Committee (QAA) failed to maintain implemented procedures and monitor the interventions the committee put in place following the recertification survey of 2/2/2023. This was for a deficiency recited during a recertification and complaint survey on 4/23/2024 in the area of F695 Respiratory/Tracheostomy Care and Suctioning. The continued failure of the facility during two State Surveys of record shows a pattern of the facility to sustain an effective QAA program. This was for one (1) of eight (8) deficient practice citations. Findings Included: This citation is cross-referenced to: F695 Review of the facility policy titled Quality Assurance and Performance Improvement with a revision date of 8/2023 revealed Standard: It is the standard of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Focused Rounds: Focused Rounds are intended to discover areas of concern before they become a problem for the facility. Focused Rounds take the form of short checklist devoted to specific practices and concerns and are conducted on a regular basis . An interview with the Administrator (ADM) on 4/25/2024 at 9:05 AM, revealed he was not aware that the nebulizer mask was not being stored appropriately and was a concern for the facility again. He revealed the interdisciplinary team (IDT) did discuss this in QAPI (Quality Assurance and Performance Improvement) after the facility was cited on this in February 2023. He revealed they implemented measures to ensure this did not happen again. The ADM explained that they made rounds to ensure all the nebulizers were stored in a bag, and they did in-services with the staff. He revealed the plan failed because they have a lot of new staff. He revealed the nurses should have been trained on hire that respiratory equipment was to be placed in a bag. The ADM revealed his expectation was for that information to be relayed to the new staff, but he stated, it must have fallen through. Record review of the Facility's Plan of Correction (POC) dated 3/10/2023 revealed under, 3. Education on Respiratory Management was provided to Nursing staff in person by our Nurse Educator on 2/03/2023 and assigned via (proper name) on 2/03/2023 with a completion date of 2/10/2023. Education on Infection Control was provided to clinical staff in person on 2/03/2023 by Nurse Educator and Via (proper name) on 2/03/2023 with a completion date of 2/10/2023. 4. Unit Manager/register nurse Supervisors to make daily audits using the Oxygen/Nebulizer audit form for 30 days beginning 2/03/2023 to ensure of proper storage of respiratory equipment. The Director of nursing /Nurse Educator will complete 5 audits using the Oxygen/Nebulizer audit form weekly x 4 weeks beginning 2/10/2023 then 5 audits biweekly for 60 days to ensure proper storage of respiratory equipment. The monitoring we have in place for this deficiency will be discussed at our monthly Quality Assurance and Performance Improvement meeting on 3/9/23 and then monthly for 2 months completing on 5/9/23. Review of the facility's Quality Assurance and Performance Improvement (QAPI) Meeting Notes dated 3/9/2023 revealed . Conclusions and Recommendations: . Plan of correction discussed with audit tools in place to monitor with no issues noted.

Based on observation, resident and staff interview, and facility policy review, the facility failed to perform nail care for a resident that needed assistance, as evidence by long thick fingernails for one (1) of two (2) residents reviewed for activities of daily living (ADLs). Resident #24 Findings Include: Review of the facility policy titled Care of Fingernails/Toenails with a revision date of 06/2022 revealed under, Purpose: The purpose of this procedure is to clean the nail bed, to keep nails trimmed and to prevent infections. Nail care includes cleaning and trimming as needed. Proper nail care can aid in the prevention of skin problems around the nail bed. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his/her skin (unless medically contraindicated). Resident #24 An observation and interview on 4/23/2024 at 9:50 AM, with Resident #24, revealed long thick discolored fingernails on the left hand that measured approximately three-eights (3/8) inch in length from the tip of the fingers. The nails on the right hand measured approximately one-fourth (1/4) inch in length. The resident expressed he would like his nails cut. An observation and interview with Licensed Practical Nurse (LPN) #6 on 4/23/2024 at 2:20 PM, confirmed Resident #24's nails needed cutting. She revealed a Registered Nurse (RN) must cut his nails because he was a diabetic. An observation and interview with Registered Nurse (RN) #1 on 4/23/2024 at 2:39 PM, revealed she was responsible for trimming the diabetic nails. She confirmed Resident #24's nails were long, and he could scratch himself and cause skin concerns. An interview with the Director of Nursing (DON) on 4/24/2024 at 8:14 AM revealed the Registered Nurse (RN) on duty was responsible for doing nail care for the diabetics every Tuesday, and it should be documented on the Medication Administration Record (MAR). She confirmed Resident #24 did not have this task on his MAR. She confirmed that the long nails were an infection and a personal hygiene concern.

Based on observation, staff interviews, and facility policy review, the facility failed to prevent the possibility of the spread of infection as evidenced by failing to utilize proper hand hygiene and maintaining a clean barrier for one (1) of five (5) care observations. Resident #13 Findings include: Review of the facility policy titled, Infection Control Standard with a revised date of 05-2023 revealed, STANDARD It is our standard to assume that patients are potentially infected or colonized with an organism that could be transmitted during the course of providing patient care services and therefore our facility applies the Standard Precautions infection control practices . 1. Hand Hygiene: a. During the delivery of patient care services, avoid unnecessary touching of surfaces in close proximity to the resident to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces . e. Staff must perform hand hygiene (even if gloves are used): iii .After contact with .nonintact skin, or wound dressing, visibly contaminated surfaces or after contact with objects in the resident's room . v . If hands shall be moving from a contaminated-body site to a clean-body site during resident care . Observation of wound care treatment for Resident #13 on 4/23/24 at 2:45 PM revealed Licensed Practical Nurse (LPN) #4 washed her hands applied clean gloves and assisted Certified Nurse Aide (CNA) #2 with turning Resident #13 to her left side. LPN #4 began removing the resident's brief and then cleaned the wound to her right buttock with wound cleanser and then applied the wound treatment without changing out her gloves and washing her hands. When the wound treatment to the right buttock was completed two unopened packages of abdominal (ABD) pads fell off the overbed table onto the floor, LPN #4 retrieved the unopened ABD packages off the floor while wearing her soiled gloves and placed the unopened ABD pads back on the clean barrier tray contaminating the clean barrier tray. LPN #4 then removed her gloves, washed her hands, and applied clean gloves. LPN #4 assisted CNA #2 with turning Resident #13 to her right-side, LPN #4 did not change her soiled gloves and proceeded to administer wound treatment to Resident #13's left outer thigh. An interview on 4/23/24 at 3:10 PM, LPN #4 confirmed she did not practice infection control measures by failing to change her gloves during wound treatment to both of the resident's wounds. She confirmed when she picked up the ABD packages from the floor while wearing her soiled gloves and laying them on the clean barrier that she contaminated her clean barrier. She confirmed that not practicing proper infection control measures could potentially cause an infection in the wound. During an interview on 4/23/24 at 3:45 PM, the Director of Nurses (DON) with LPN #4 present confirmed their policy regarding wound treatment is to make sure and change gloves and wash hands between soiled dressing and clean dressing care and confirmed by not doing so is an infection control issue and could delay healing. A record review of Resident #13's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Pressure ulcer of right buttock and Type 2 Diabetes Mellitus with Hyperglycemia.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to ensure medications were stored appropriately and not left in the resident's room for one (1) of 15 sampled residents. Resident #31 Findings include: A review of the facility policy, titled 4.1 Storage of Medication with a date of 01/23 revealed, 4.1 STORAGE OF MEDICATION Policy: .The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . Procedures . 1. Medications are to remain in these containers and stored in a controlled environment. This may include such containers as medication carts, medication rooms, medication cabinets, or other suitable containers An observation and interview on 4/23/24 at 7:00 AM, revealed a prescription-labeled box of Latanoprost Solution eye drops and a prescription-labeled box of Cosopt Ophthalmic solution with medications inside of boxes sitting on Resident #31's overbed table. Licensed Practical Nurse (LPN) #1 entered the room and asked the resident, Why are these medications lying on your bedside table? Resident #31 revealed someone left them there. LPN #1 confirmed the medications were supposed to be locked up in the medication cart because the residents are not supposed to have medications in their rooms and revealed, the eye drop medication was given last night and should have been locked back up in the medication cart. An interview on 4/23/24 at 7:20 AM, Resident #31 revealed the nurse left the eye drops in here last night. In an interview on 4/23/24 at 2:22 PM, the Director of Nurses (DON) confirmed she was made aware of the eye medication left on the overbed table and revealed that is a no no. The DON stated, the nurses know that is not supposed to happen, all medication is to be kept locked up in the medication cart. She revealed a wandering resident could enter a resident's room and take the medications. A record review of Resident #31's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Heart Failure and Chronic Kidney Disease, Stage 3. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/14/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #31 was cognitively intact.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide appropriate care and services for respiratory care, as evidenced by, failing to label and store an aerosol nebulizer mask device for one (1) of three (3) nebulizers in the facility. Resident #28 Findings Include: This citation is cross reference to: F867 Record review of the facility policy titled Respiratory System Management with a revision date of 1/2003 revealed Procedure, In Order: . 17. Rinse the nebulizer and mouthpiece. Shake to air dry and store in a plastic bag that is labeled with the resident's name and room number. Nebulizer and mouth piece may also be stored in the machine if storage shelf is available. 18. Change nebulizer set up-weekly. An observation and interview with Resident #28 on 4/23/2024 at 9:04 AM, revealed he was sitting on the edge of the bed. A nebulizer machine was sitting on a bedside table, with the nebulizer mask lying across the lower bed. The tubing and mask were undated, and the mask was unbagged. The resident revealed he used the nebulizer mask every day for his breathing and was not aware of a storage bag for the nebulizer mask. An observation of Resident #28's room on 4/23/2024 at 2:10 PM, revealed a nebulizer machine sitting on top of a bedside table with the nebulizer mask secured in an upright position on the side. The mask was not bagged, and the tubing had a piece of tape attached with a date of 4/23/2024. Record review of the Order Summary Report with active orders as of 4/24/24 revealed orders dated 3/21/24 for Arformoterol Tartrate Inhalation Nebulization Solution and Ipratropium Bromide Inhalation Solution for Chronic obstructive pulmonary disease. An observation and interview with Licensed Practical Nurse (LPN) #6 on 4/23/2024 at 2:25 PM, confirmed the nebulizer mask did not have a cover to protect it. She revealed the mask should be placed in a bag to prevent it from getting contaminated. She revealed she just changed out the nebulizer set-up and dated it. An interview with Registered Nurse (RN) #1 on 4/23/2024 at 2:42 PM, revealed the nebulizer mask should be stored in a plastic bag to prevent the formation of bacteria in the mask and the bag, mask and tubing should be changed out weekly and dated. An interview with the Director of Nursing (DON) on 4/24/2024 at 8:12 AM, revealed the nebulizer mask was to be placed in a bag when not in use to prevent infection. She revealed the bag, tubing, and mask were changed out weekly on the night shift and her expectation was for staff to do this and apply the date. Record review of the Admission Record revealed the facility admitted Resident #28 on 1/27/23 with medical diagnoses that included Chronic obstructive pulmonary disease and Schizophrenia.

Based on observation and staff and resident interviews the facility failed to provide a safe clean environment as evidenced by a wheelchair with a torn armrest, a dirty oxygen concentrator, an overbed table with tattered and torn edging and overbed tables with a thick black substance on the metal base for three (3) of 44 residents rooms observed. Resident #13, Resident #31, and Resident #39 Findings include: An interview with the Administrator on 4/25/24 at 9:23 AM, revealed the facility did not have a policy addressing repairing and cleaning equipment. Resident #13 An observation and interview on 4/23/24 at 6:50 AM, revealed Resident #13 lying in bed with her overbed table pulled up to her. The overbed table edging was off around the table with exposed chipped wood. The metal base of the overbed table had a thick black substance. Resident #13 stated, I need a new table. It's been like this for a long time. During an interview and observation on 4/24/24 at 9:00 AM, Licensed Practical Nurse (LPN) #3 confirmed Resident #13's overbed table needed to be replaced because the edging around the table was tattered and torn and revealed the torn edging could cause a skin tear. Resident #31 An observation on 4/23/24 at 7:25 AM and again at 3:45 PM, revealed Resident #31's oxygen concentrator sitting by her bed with a brown and gray substance down the front and on top of the oxygen concentrator. Resident #31's overbed table had a thick brown and black substance on the metal base. During an observation and interview on 4/24/24 at 9:05 AM, LPN #3 revealed the cleaning of the oxygen concentrators is the responsibility of the nursing department but stated, really anyone who sees it can clean it. She confirmed that the oxygen concentrator was dirty and needed to be cleaned and that the metal base on the overbed table needed to be cleaned and revealed housekeeping usually does that. She revealed the metal base looks like it has rust, but it does need cleaning. Resident #39 Observation on 4/23/24 at 8:05 AM, revealed Resident #39 sitting in the dining room in a wheelchair with the left side armrest vinyl tattered and torn with jagged edges exposed where the resident's arm rested on the armrest Observation on 4/23/24 at 9:44 AM, revealed Resident #39's overbed table had a thick black substance scattered on the metal base. An interview and observation on 4/24/24 at 9:25 AM, Certified Nurse Aide (CNA) #1 revealed it is the CNA's responsibility to report any wheelchairs that are in disrepair to the Maintenance Director. She confirmed Resident #39's left armrest on his wheelchair needed to be repaired and revealed she had not reported the wheelchair to anyone. She confirmed the metal base on his overbed table was dirty and needed to be cleaned. She revealed housekeeping is responsible for cleaning the rooms. An observation and interview on 4/24/24 at 9:30 AM the Housekeeping Supervisor revealed that the nursing department is usually responsible for cleaning the oxygen concentrators and the housekeeping department is responsible for cleaning the overbed tables. She confirmed that the overbed tables for Resident #13, Resident #31, and Resident #39 had a thick substance on the metal base and the edging on Resident #13's overbed tabletop was torn and needed to be replaced. She revealed we can try and clean the metal bases on the overbed tables, but I think it's thick rust or old paint peeling. She confirmed the overbed tables looked bad and she would see what she could do to clean them. An observation and interview on 4/24/24 at 10:09 AM, the Administrator confirmed the left armrest on Resident #39's wheelchair was torn and tattered and needed to be repaired. He confirmed the overbed tables for Resident #13, Resident #31 and Resident #39 were in disrepair and needed to be either be cleaned, resurfaced, or replaced. He confirmed the tables did not look good.

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for a resident with an elopement bracelet (Resident #1) and a resident requiring nail care (Resident #24) for two (2) of 15 sampled residents reviewed during survey. Findings Include: Review of the facility policy titled Comprehensive Care Plan with a revision date of 3/2019 revealed under, Standard: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Record review of Resident #1's Care Plans, undated revealed Focus: (Proper name of Resident #1) is an elopement risk/wanderer .Interventions .Wanderguard at all times for safety . The care plan did not include any interventions to monitor the residents wanderguard bracelet. An observation on 04/23/24 at 12:49 PM revealed Resident #1 was wearing a wander guard bracelet on his left wrist. Record review of Resident #1's Elopement Evaluation dated 3/11/24 revealed the resident has a history of elopement or attempted elopement and wanders. Record review revealed that there was not any monitoring of the wander guard each shift on the Treatment Administration Record (TAR) or Medication Administration Record (MAR). Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/11/24 revealed in Section P the resident was coded for a wander/elopement alarm that was used daily. During an interview on 4/23/24 at 1:30 PM, with Registered Nurse (RN) #1 revealed Resident #1 wears a wanderguard because he has dementia and gets confused sometimes. She stated he says he wants to go home and does wander, but he has never eloped. During an interview on 4/25/24 at 8:20 AM, with the Director of Nurses (DON) revealed that it was her expectation that Resident #1's care plan would be implemented correctly because the purpose of the care plan was for staff to know what care the resident needs. She stated that the resident had gone out to the hospital and had returned and she thinks that the monitoring of the wander guard just got left off of his TAR. An interview on 4/25/24 at 9:00 AM, with Registered Nurse #1 confirmed Resident #1's care plan was not followed because the wander guard was not being monitored. Resident #24 Record review of Resident #24's care plan with an initiated date of 2/9/24 revealed Focus The resident has an ADL (Activities of Daily Living) self care performance deficit r/t (related to Dementia .Interventions . Personal Hygiene/Oral Care: The Resident requires (1) staff participation with personal hygiene and oral care . During an observation of Resident #24, on 4/23/2024 at 9:50 AM, revealed long thick discolored fingernails on the left hand that measured approximately three-eights (3/8) inch in length from the tip of the fingers. Also observed, the right fingernails measured approximately one-fourth (1/4) inch in length. During an observation and interview on 4/23/2024 at 2:39 PM, with Registered Nurse (RN) #1, confirmed Resident #24's nails were long and needed cutting. During an interview with the Director of Nursing (DON) on 4/25/2024 at 8:16 AM, revealed the purpose of the care plan was for the staff to know how to care for the resident. She revealed the personal hygiene care plan covered nail care and confirmed it was not done. 47874

Based on observation, staff and resident interview, record review and facility policy review, the facility failed to ensure residents were free from verbal abuse for five (5) of 10 residents reviewed for abuse. Residents #1, Resident #2, Resident #5, Resident #6 and Resident #7. Findings Include Review of the facility policy titled, Freedom of Abuse, Neglect and Exploitation with a revision date of 11/2019 revealed .Standard Statement : This facility shall not condone any acts of resident mistreatment, neglect, verbal, .or mental abuse . Resident #1 An observation and interview on 2/7/24 at 7:40 PM, with Resident #1 revealed there was one Certified Nurse Assistant (CNA) that had talked ugly to her and other residents. She stated one night recently she was sleeping, and her arm hit the top of her overbed table and knocked a drink off and spilled it on the floor. She revealed that when she used her call light and CNA #1 came to her room. She told her what had happened and the CNA told her that she told her she wasn't cleaning that up. CNA #1 went and got a towel and brought it back and told her to get up and clean it up. She stated that she could not get herself out of bed to do that and that made her cry. She revealed CNA #1 did end up cleaning the spill. She stated she reported this incident to the Administrator and the Director of Nurses (DON). Record review of Resident #1 Admission Record revealed the resident was admitted to the facility on [DATE] with a medical diagnosis that included Urinary Tract Infection. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/17/24 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicates the resident is cognitively intact. Resident #2 An interview and observation on 2/8/24 at 8:45 AM, with Resident #2 he stated the only problem he has had was with CNA #1 on the night shift, is that she is young. Resident #2 stated , I just don't think she knows how to talk to people, because she talks short and ugly to people at times. He revealed that normally the day shift makes his bed, but one day they forgot, and he was trying to make it up around 6:30 PM that night and had asked CNA #1 to help him. He stated that she told him she was passing snacks, and it would have to wait. He stated that he asked her if passing snacks was more important than helping him get his bed made so he could lay down and as she walked out of his room she said, Make it yourself. Record review of Resident #2's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure. Record review of Resident #2's MDS with an ARD of 11/14/23 revealed in Section C a BIMS score of 15, which indicates the resident is cognitively intact. Resident #5 An interview and observation on 2/8/24 at 8:30 AM, with Resident #5 revealed some of the CNA's talk ugly to her and one time they cussed at her. Resident #5 stated but I don't remember their names. Record review of Resident #5 Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Acute or Chronic Systolic (Congestive) Heart Failure. Record review of Resident #5's MDS with an ARD of 10/30/23 revealed in Section C a BIMS score of 14, which indicates the resident is cognitively intact. Resident #6 An interview on 2/8/24 at 10:50 AM, with Registered Nurse (RN) #2 revealed that Resident #6 had reported to her last week that CNA #1, the aide on the night shift talks ugly and treats her ugly and that she reported this to the DON and informed the resident that she could talk with the Social Worker about it the next day. An interview on 2/8/24 at 12:00 PM, with Resident #6 she stated that her only issue has been with CNA #1 on the night shift and that she talks ugly to her and tells her to stay off her call light so much at night. She stated that CNA #1 threatens her and says they will send her to behavioral health if she does not do what they tell her to do. She stated that she has reported this issue to the DON and RN #2 and stated, Please tell me you are going to do something about this. Record review of a note dated 2/3/24 at 15:26 (3:26 PM) revealed Type: eMAR-Medication Administration Note revealed (Proper name of CNA #1) and the other girl that works with her. They are thick as thieves, and they always threaten they are gonna get me sent off to behavioral. I don't know why they treat me like they do .DON was aware . Record review of Resident #6's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus with other Diabetic Neurological Complications. Record review of Resident #6's MDS with an ARD of 1/18/24 revealed in Section C a BIMS score of 13, which indicates the resident is cognitively intact. Resident #7 An observation and interview on 2/7/24 at 7:50 PM, with CNA #1, CNA #2 and CNA #3 revealed that they were the three CNA's working the night shift and they revealed they have had in-services on abuse. During this interview while in the hallway, Resident #7 was self-propelling her wheelchair and when she passed, she stated to the CNA's, I need to go to the bathroom. CNA #1 responded quickly to the resident, Well you're gonna have to wait until I get done talking. An interview on 2/7/24 at 8:00 PM, with RN #1, was informed of the manner and tone that CNA #1 had used in response to Resident #7. RN #1 confirmed that could be verbal abuse to a resident. She stated That is not an appropriate way to talk to residents. An interview on 2/7/24 at 8:05 PM, with CNA #1 she confirmed that she had told Resident #7 she would have to wait until she was done talking when the resident asked to be helped to the bathroom. She stated that she did not mean it to sound rude and admits that she has been in-serviced on verbal abuse. She revealed that she had only had one complaint from a resident about her and that one complaint was from Resident #1. She had complained that I had knocked a drink off of her table, but I did not do that. She did it, but I did cleaned it up and I told the Director of Nursing (DON) that I cleaned it up. An interview on 2/8/24 at 11:40 AM, with Licensed Practical Nurse (LPN)/Social Services confirmed that she had some complaints on CNA #1 talking ugly to the residents and that Resident #7 filed a formal grievance around the first of January that CNA #1 had refused to get her up that morning and talked ugly to her. She stated that on 1/7/24 Resident #2 came to her office to complain about CNA #1, and she asked him if he could wait to let her get the DON and the Administrator in there so they could hear, and he agreed. She revealed that the DON and the Administrator came to her office and the resident revealed that CNA #1 was passing snacks around 6:30 PM and when he asked her to help him make his bed, she told him she was busy passing snacks. She stated that the resident told them that he asked her if passing snacks that early was as important as helping him make his bed and then as she walked out of the room, she rudely told the resident to make it up himself. She revealed that Resident #1 complained to her on 2/6/24 about CNA #1 and that the resident complained that she had accidentally spilled her drink and CNA #1 told her You going to get that up. She stated that she asked the resident if she wanted to talk with the DON or the Administrator and the resident stated no that she already had, and they were going to take care of it. An interview on 2/8/24 at 12:30 PM, with Resident #7 confirmed that CNA #1 told her she would Have to wait until she was done talking when she told her she needed to go to the bathroom last night. She stated that CNA #1 was rude but that wasn't the first time, and she is used to it from her. She revealed that she had complained about it to a lot of people, but it does no good; nothing gets done. She revealed she just don't say anything anymore. She stated that she is supposed to go to the bathroom every 2 hours and usually goes at 4:30,and she has told CNA #1 this. CNA #1 told her that she was not coming straight to her as soon as she came on duty to take her to the bathroom, so she knows to not even ask until around the time she ask last night (around 8 PM). She confirmed that she filed a formal grievance back in January of this year, because the night CNAs that included CNA #1 came in her room around 4 AM and told her if she did not get up right then, then she would have to wait until day shift got there to get up. She stated that she was supposed to get up around 5:30 AM and they never came back to get her up. She confirmed that this had been reported to the Social Worker, Administrator, the DON, and some of the other nursing staff but could not remember their names. Record review of Resident #7 Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus without Complications. Record review of Resident #7's MDS with an ARD of 10/30/23 revealed in Section C a BIMS score of 15, which indicates the resident is cognitively intact. Record review of the Grievance/Concern/Comment Report dated 1/2/24 revealed a formal grievance was filed regarding CNAs on the night shift not getting Resident #7 out of bed as requested. An interview on 2/8/24 at 9:30 AM, with the CNA Supervisor revealed there has been one complaint from a resident back in November 2023 or December about night shift CNA #1 being rude to a resident and that she reported it to the DON and she took care of it. An interview on 2/8/24 at 10:00 AM, with CNA #4 and CNA #5 revealed that they normally work day shift but sometimes they have to help and work night shift and that some of the residents complain about a CNA on the night shift that is rude to them but would rather not mention any names. She stated that she thinks that everyone knows it and is sure it has been reported to the DON and the Administrator. An interview on 2/8/24 at 1:40 PM, with the DON confirmed that all staff receive abuse in services on hire and annually unless there is an issue and then we can do one anytime in our computer in-service system. She revealed that as far as she knows there has not been an issue in order to have to do an additional abuse in-service. She admitted that she had received a complaint on CNA #1 on 2/6/24, but that was the first complaint she had on the staff member, and she is not aware of any more complaints on other staff regarding talking disrespectfully. She stated that Resident #1 reported an issue to her on 2/6/24 that CNA #1 talked disrespectfully to her. The DON stated she came in last night and talked to CNA #1 about that issue around 6 PM. An interview on 2/8/24 at 2:00 PM, with the Administrator, DON, and LPN/Social Services confirmed they had complaints about CNA #1 talking inappropriately to some of the residents. The Administrator stated that the reports he had from Resident # 1 and Resident #2 just did not seem like verbal abuse to him. Both agreed that the reports of how the CNA spoke to Resident #7 last night and how she said it was inappropriate and disrespectful. The DON confirmed at this time that she had known about the report from Resident #1 and Resident #2. When the State Agency (SA) inquired about Resident #6 and her complaint, the DON stated yes, she came into the office and also had a complaint. The DON verified that she had three (3) residents complain about how CNA #1 talked to them. The Administrator stated that CNA #1 had been talked to last night about the complaint that came in on 2/6/24 with Resident #1. The Administrator stated he was not aware that CNA #1 had told Resident #2 to make his own bed as she walked out of his room, but LPN/Social Services confirmed that he did report that to them. The Administrator confirmed that he was aware of the grievance that Resident #7 had filed about them not getting her up when she wanted to but was not aware that either one of them had told her that if she did not get up now, then she would not get up until day shift got there. He admitted that they would have to do an investigation and more than likely let CNA #1 go. An interview on 2/8/24 at 2:20 PM, with LPN/Social Services confirmed that Resident #1 complained on 2/6/24, Resident #2 complained on 1/7/24 and Resident #7 filed a formal complaint on 1/3/24. Record review of the facility in-services from the last 6 months revealed there was an abuse in-service held in 1/2024 for all staff but was not attended by CNA #1. Record review of CNA#1 employee file revealed that she completed in-services on abuse on 9/25/23 and 12/11/23.

Based on observation, staff and resident interview, record review and facility policy review, the facility failed to resolve resident's grievances regarding allegations of verbal abuse from the staff for five (5) of 10 residents reviewed for unresolved grievances. Residents #1, Resident #2, Resident #5, Resident #6 and Resident #7. Findings Include: Review of the facility policy titled Grievance/Concern/Comments with a revision date of 12/2021 revealed under Standard .Residents and their family members may voice grievances to the facility or other agency/entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal The facility will make prompt efforts to resolve grievances. Resident #1 During an observation and interview on 2/7/24 at 7:40 PM, with Resident #1 revealed there was one Certified Nurse Assistant (CNA) that had talked ugly to her and other residents. She stated one night recently she was sleeping, and her arm hit the top of her overbed table and knocked a drink off and spilled it on the floor. She revealed that when she used her call light and CNA #1 came to her room. She told her what had happened and the CNA told her that she told her she wasn't cleaning that up. CNA #1 went and got a towel and brought it back and told her to get up and clean it up. She stated that she could not get herself out of bed to do that and that made her cry. She revealed CNA #1 did end up cleaning the spill. She stated she reported this incident to the Administrator and the Director of Nurses (DON). Record review of Resident #1 Admission Record revealed the resident was admitted to the facility on [DATE] with a medical diagnosis that included Urinary Tract Infection. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/17/24 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicates the resident is cognitively intact. Resident #2 During an interview and observation on 2/8/24 at 8:45 AM, with Resident #2 he stated the only problem he has had was with CNA #1 on the night shift, is that she is young. Resident #2 stated , I just don't think she knows how to talk to people, because she talks short and ugly to people at times. He revealed that normally the day shift makes his bed, but one day they forgot, and he was trying to make it up around 6:30 PM that night and had asked CNA #1 to help him. He stated that she told him she was passing snacks, and it would have to wait. He stated that he asked her if passing snacks was more important than helping him get his bed made so he could lay down and as she walked out of his room she said, Make it yourself. Record review of Resident #2's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure. Record review of Resident #2's MDS with an ARD of 11/14/23 revealed in Section C a BIMS score of 15, which indicates the resident is cognitively intact. Resident #5 During an interview and observation on 2/8/24 at 8:30 AM, with Resident #5 revealed some of the CNA's talk ugly to her and one time they cussed at her. Resident #5 stated but I don't remember their names. Record review of Resident #5 Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Acute or Chronic Systolic (Congestive) Heart Failure. Record review of Resident #5's MDS with an ARD of 10/30/23 revealed in Section C a BIMS score of 14, which indicates the resident is cognitively intact. Resident #6 During an interview on 2/8/24 at 10:50 AM, with Registered Nurse (RN) #2 revealed that Resident #6 had reported to her last week that CNA #1, the aide on the night shift talks ugly and treats her ugly and that she reported this to the DON and informed the resident that she could talk with the Social Worker about it the next day. During an interview on 2/8/24 at 12:00 PM, with Resident #6 she stated that her only issue has been with CNA #1 on the night shift and that she talks ugly to her and tells her to stay off her call light so much at night. She stated that CNA #1 threatens her and says they will send her to behavioral health if she does not do what they tell her to do. She stated that she has reported this issue to the DON and RN #2 and stated, Please tell me you are going to do something about this. Record review of a note dated 2/3/24 at 15:26 (3:26 PM) revealed Type: eMAR-Medication Administration Note revealed (Proper name of CNA #1) and the other girl that works with her. They are thick as thieves, and they always threaten they are gonna get me sent off to behavioral. I don't know why they treat me like they do .DON was aware . Record review of Resident #6's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus with other Diabetic Neurological Complications. Record review of Resident #6's MDS with an ARD of 1/18/24 revealed in Section C a BIMS score of 13, which indicates the resident is cognitively intact. Resident #7 During an observation and interview on 2/7/24 at 7:50 PM, with CNA #1, CNA #2 and CNA #3 revealed that they were the three CNA's working the night shift and they revealed they have had in-services on abuse. During this interview while in the hallway, Resident #7 was self-propelling her wheelchair and when she passed, she stated to the CNA's, I need to go to the bathroom. CNA #1 responded quickly to the resident, Well you're gonna have to wait until I get done talking. During an interview on 2/7/24 at 8:00 PM, with RN #1, was informed of the manner and tone that CNA #1 had used in response to Resident #7. RN #1 confirmed that could be verbal abuse to a resident. She stated That is not an appropriate way to talk to residents. During an interview on 2/7/24 at 8:05 PM, with CNA #1 she confirmed that she had told Resident #7 she would have to wait until she was done talking when the resident asked to be helped to the bathroom. She stated that she did not mean it to sound rude and admits that she has been in-serviced on verbal abuse. She revealed that she had only had one complaint from a resident about her and that one complaint was from Resident #1. She had complained that I had knocked a drink off of her table, but I did not do that. She did it, but I did cleaned it up and I told the Director of Nursing (DON) that I cleaned it up. During an interview on 2/8/24 at 11:40 AM, with Licensed Practical Nurse (LPN)/Social Services confirmed that she had some complaints on CNA #1 talking ugly to the residents and that Resident #7 filed a formal grievance around the first of January that CNA #1 had refused to get her up that morning and talked ugly to her. She stated that on 1/7/24 Resident #2 came to her office to complain about CNA #1, and she asked him if he could wait to let her get the DON and the Administrator in there so they could hear, and he agreed. She revealed that the DON and the Administrator came to her office and the resident revealed that CNA #1 was passing snacks around 6:30 PM and when he asked her to help him make his bed, she told him she was busy passing snacks. She stated that the resident told them that he asked her if passing snacks that early was as important as helping him make his bed and then as she walked out of the room, she rudely told the resident to make it up himself. She revealed that Resident #1 complained to her on 2/6/24 about CNA #1 and that the resident complained that she had accidentally spilled her drink and CNA #1 told her You going to get that up. She stated that she asked the resident if she wanted to talk with the DON or the Administrator and the resident stated no that she already had, and they were going to take care of it. During an interview on 2/8/24 at 12:30 PM, with Resident #7 confirmed that CNA #1 told her she would Have to wait until she was done talking when she told her she needed to go to the bathroom last night. She stated that CNA #1 was rude but that wasn't the first time, and she is used to it from her. She revealed that she had complained about it to a lot of people, but it does no good; nothing gets done. She revealed she just don't say anything anymore. She stated that she is supposed to go to the bathroom every 2 hours and usually goes at 4:30,and she has told CNA #1 this. CNA #1 told her that she was not coming straight to her as soon as she came on duty to take her to the bathroom, so she knows to not even ask until around the time she ask last night (around 8 PM). She confirmed that she filed a formal grievance back in January of this year, because the night CNAs that included CNA #1 came in her room around 4 AM and told her if she did not get up right then, then she would have to wait until day shift got there to get up. She stated that she was supposed to get up around 5:30 AM and they never came back to get her up. She confirmed that this had been reported to the Social Worker, Administrator, the DON, and some of the other nursing staff but could not remember their names. Record review of Resident #7 Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus without Complications. Record review of Resident #7's MDS with an ARD of 10/30/23 revealed in Section C a BIMS score of 15, which indicates the resident is cognitively intact. Record review of the Grievance/Concern/Comment Report dated 1/2/24 revealed a formal grievance was filed regarding CNAs on the night shift not getting Resident #7 out of bed as requested. During an interview on 2/8/24 at 9:30 AM, with the CNA Supervisor revealed there has been one complaint from a resident back in November 2023 or December about night shift CNA #1 being rude to a resident and that she reported it to the DON and she took care of it. During an interview on 2/8/24 at 10:00 AM, with CNA #4 and CNA #5 revealed that they normally work day shift but sometimes they have to help and work night shift and that some of the residents complain about a CNA on the night shift that is rude to them but would rather not mention any names. She stated that she thinks that everyone knows it and is sure it has been reported to the DON and the Administrator. During an interview on 2/8/24 at 1:40 PM, with the DON confirmed that all staff receive abuse in services on hire and annually unless there is an issue and then we can do one anytime in our computer in-service system. She revealed that as far as she knows there has not been an issue in order to have to do an additional abuse in-service. She admitted that she had received a complaint on CNA #1 on 2/6/24, but that was the first complaint she had on the staff member, and she is not aware of any more complaints on other staff regarding talking disrespectfully. She stated that Resident #1 reported an issue to her on 2/6/24 that CNA #1 talked disrespectfully to her. The DON stated she came in last night and talked to CNA #1 about that issue around 6 PM. During an interview on 2/8/24 at 2:00 PM, with the Administrator, DON, and LPN/Social Services confirmed they had complaints about CNA #1 talking inappropriately to some of the residents. The Administrator stated that the reports he had from Resident # 1 and Resident #2 just did not seem like verbal abuse to him. Both agreed that the reports of how the CNA spoke to Resident #7 last night and how she said it was inappropriate and disrespectful. The DON confirmed at this time that she had known about the report from Resident #1 and Resident #2. When the State Agency (SA) inquired about Resident #6 and her complaint, the DON stated yes, she came into the office and also had a complaint. The DON verified that she had three (3) residents complain about how CNA #1 talked to them. The Administrator stated that CNA #1 had been talked to last night about the complaint that came in on 2/6/24 with Resident #1. The Administrator stated he was not aware that CNA #1 had told Resident #2 to make his own bed as she walked out of his room, but LPN/Social Services confirmed that he did report that to them. The Administrator confirmed that he was aware of the grievance that Resident #7 had filed about them not getting her up when she wanted to but was not aware that either one of them had told her that if she did not get up now, then she would not get up until day shift got there. He admitted that they would have to do an investigation and more than likely let CNA #1 go. During an interview on 2/8/24 at 2:20 PM, with LPN/Social Services confirmed that Resident #1 complained on 2/6/24, Resident #2 complained on 1/7/24 and Resident #7 filed a formal complaint on 1/3/24. Record review of the facility in-services from the last 6 months revealed there was an abuse in-service held in 1/2024 for all staff but was not attended by CNA #1. Record review of CNA#1 employee file revealed that she completed in-services on abuse on 9/25/23 and 12/11/23.

Based on staff interviews, record review, and facility policy review the facility failed to report an allegation of sexual abuse within the required two-hour time frame for one (1) of nine residents sampled for potential abuse. Resident #1 Findings include: Record review of the facility policy titled, Freedom of Abuse, Neglect and Exploitation Standard, dated November 2019, revealed, .Report allegations or suspected abuse, neglect or exploitation immediately to: Administrator, Other officials in accordance with State Law, State Survey and Certification agency through established procedures. VI Reporting/Response A. The facility will have written procedures that include: 1. Reporting all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . Reporting . Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . Record review of the investigation dated 06/12/23 revealed that Resident #5 called Certified Nursing Assistant (CNA) #1 and a Housekeeper into her room around 10:30 AM and stated, (Proper name RN# 1) came in the room and pulled the curtain and started playing with (Resident #1). CNA #1 immediately went and told the Administrator and the Director of Nursing (DON) of the allegation of sexual abuse on 6/12/23 and that Resident #1's roommate (Resident #5) had called them in her room and reported the allegation of sexual abuse at 10:30 AM. Resident #5 was later interviewed by the Administrator that same day on 06/12/23, with no time documented on the written interview and stated, (Proper name RN#1) came into our room around 1:30 AM this morning. He pulled the curtain. He was playing with Resident #1 sexually. Resident #1 was interviewed by the DON, Social Services Director, and the Administrator on 06/12/23 with no time indicated on the written interview and Resident #1 stated that approximately 1:30 AM that RN#1 came into her room and offered her a honey bun and then proceeded to have sex with her. She stated that he did not get undressed or in her bed that they had sex through her diaper. Record review of a physician's order dated 06/12/23 at 1:34 PM revealed a physician's order to send resident to the (Proper name of hospital) for a vaginal exam related to pain. Record review of the hospital Emergency Department (ED) visit stated, This is a [AGE] year-old female patient who presented to the ED on June 12th, 2023, around 2:00 PM brought in by a nursing home worker with patient complaining of vaginal pain. The patient was not cooperative for history of exam according to ED records. The patient finally reported that she was dreaming like she was itching, and a male nurse came in to relieve the itching. She thought she might be pregnant. Patient had a pelvic exam, and no bleeding, injury or discharge was noted. Patient was admitted to observation until recommendations from Adult Protective Services and mental health evaluation can be made. Record review of an interview dated 06/12/23 conducted by the Administrator with the transport driver that took Resident #1 to the local ED stated, I was told to take Resident #1 through the emergency room (ER) by a nurse. So, when we arrive at ER, I gave the paperwork to front desk when they ask why we were there I never said anything. They call us back; the nurse came in and asked what was wrong. I encourage Resident #1 to tell them what she had told them. Resident #1 said she was itching for sex. He was too. The nurse left out and the doctor came in. Resident #1 told them the same story. She wanted sex, he want sex. It was consensual. So, the doctor came back in and said he have to call DHS (Department of Human Services) and the police. I then notified the Administrator. Police officer then came in and she told the police that they had consensual sex. When he asked who, she said RN #1. Interview with the Administrator on 7/20/23 at 1:00 PM, confirmed the facility failed to report the allegation of sexual abuse to the required entities within a two-hour time frame. He stated after the initial allegation the resident changed her statement several times and the immediate investigation, he did within the first two hours revealed the allegation was not credible in his mind. He stated around 1:30 PM, the resident was sent to the hospital and changed her statement several times but that the hospital was unable to note any trauma on her exam. He stated it was after sending resident to the hospital that he notified the State Agency (SA) after the police called him and wanted to get a statement. The Administrator stated that the hospital had notified SA, Adult Protective Services (APS), and the police. The Administrator stated that the police came to the facility to get a statement on the events that occurred after the resident had spoken with the police while in the hospital. The Administrator confirmed that the allegation was not reported to the Attorney General's Office (AGO) by the facility until 7/19/23 and the facility failed to notify the State Agency, Attorney General's Office, and the Local Police Department within a two-hour time frame of when the allegation was made. He confirmed the allegation was made on 6/12/23 at approximately 10:30 AM and the resident was transferred to the hospital on 6/12/23 approximately 1:30 PM, and the facility did not report to the State Agency until after that time. Interview with DON on 7/20/23 at 1:00 PM, she confirmed the facility failed to submit the allegation of abuse to the required entities within the two-hour time frame and stated that she thought since they considered it a false allegation from early on, they did not report timely. Record review of Resident #1's Admission Record revealed the resident was originally admitted to the facility on [DATE]. Diagnoses included Bipolar Disorder, Major Depressive Disorder, Generalized Anxiety Disorder, and Auditory Hallucinations. Record review of Resident#1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Record review of Resident #5's Admission Record revealed that the resident was originally admitted to the facility on [DATE] and had diagnosis which included Diabetes and Heart Disease. Record review of Resident#5's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

Based on observation, staff interview, resident interview, record review, and facility document review, the facility failed to ensure residents received significant medications as ordered as evidenced by Resident #1 did not receive ordered Kayexelate for high potassium levels, Resident #2 did not receive ordered [MEDICATION NAME] for [MEDICAL CONDITION], and Resident #4 did not receive ordered [MEDICATION NAME] for blood pressure for three (3) of five (5) residents reviewed for medication errors out of a total sample of six (6) residents. Findings Include: Review of a facility reported incident dated 1/7/16 revealed the facility reported to their corporate hotline that a nurse was not giving medication according to the Medication Administration Record [REDACTED]. The responsible nurse was suspended, then later terminated due to the result of investigation. Additional information was reported by the facility on 1/15/16. The facility reported it had conducted a medication cart-to-MAR audit with a discrepancy noted regarding Resident #1's medication. This report also included discrepancies with other residents' medications. An interview with the Director of Nursing (DON) on 1/19/16 at 3:25 PM revealed the corporate nurse had come to the facility and assisted in an investigation. The DON indicated they had found concerns regarding three residents. On 1/20/16 at 8:00 AM, the DON stated Licensed Practical Nurse (LPN) #1 had reported concerns regarding Resident #1 to the corporate nurse. Resident #1 In an interview on 1/20/16 at 8:00 AM, the DON indicated LPN #1 reported that LPN #2 had not followed a physician's orders [REDACTED]. The facility received the bottle from pharmacy on 12/16/15. LPN #1 told the DON that RN #1 witnessed her open the full bottle of Kayexelate on 12/19/15. It was also witnessed that this was the first dose administered from the bottle. The DON confirmed she had been shown the bottle on 12/19/15 and could tell that not enough liquid was missing from the bottle for Resident #1 to have previously received the ordered amount. Review of the facility's face sheet revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #1's laboratory (lab) reports revealed a potassium level with a reference range of 3.5-5.5 millimoles per liter (mmol/l). On 12/7/15 the lab reported a result of 6.0 mmol/l which was (high). [MEDICATION NAME] 30 milliliters (ml) or 7.5 grams (g) was ordered for one time only due to the elevated potassium level. On 12/15/15, the resident's potassium level was 6.4 mmol/l (high) and the lab reported to the facility and physician on 12/16/15 (Wednesday). Review of the lab sheet revealed a hand written order for [MEDICATION NAME] 120 ml or 30g to be given daily until Monday (12/21/15). Review of a lab report dated 12/18/15 revealed a potassium level of 6.9 mmol/l (critical) with a reported to the facility date of 12/19/15 (Saturday). An interview with Registered Nurse (RN) #1 on 1/20/16 at 3:20 PM was conducted regarding documentation she had recorded for the facility during their investigation. She stated that her documentation was true and correct. She had recorded that on 12/19/15 LPN #1 asked her why Resident #1 was now receiving 120 milliliters of kayexelate daily. RN #1 stated that she had not received any of this information in report but would look into it. RN #1 then recorded in her report that LPN #1 was observed to open a sealed bottle of kayexelate and administer the medication. She then recorded that the lab phoned shortly after that, and reported a panic potassium level of 6.9 mmol/l (critical) . The RN stated she began looking through lab values and noted an escalation of the potassium level. On 11/24/15, the potassium level was 5.5mmol/l; on 12/7/15 the potassium level was 6.0mmol/l (high) , with an order written [REDACTED]. On 12/18/15, the potassium level was recorded as 6.9mmol/l (critical). A review of orders on Resident #1's record noted that the new order was received on 12/16/15 and that the doses ordered for 12/17/15 and 12/18/15 had not been administered because the bottle received on 12/16/15 had not been opened until she witnessed LPN #1 open it on 12/19/15. During this time, the potassium level had increased from 6.4 to 6.9 mmol (critical) . RN #1 reported this information to the Nurse Practitioner. A new order was received to continue kayexelate as ordered and recheck potassium levels on 12/21/15. RN #1 reported the information to the facility Administrator and the Director of Nursing. RN #1 recorded that on 12/20/15, after LPN #1 administered Resident #1's second dose of Kayexelate, 2 doses had required half the bottle. LPN #1 marked the bottle with a permanent marker at the exact level of the medication. After returning to work on 12/23/15, RN #1 noted that the Kayexelate was at the same level as on 12/20/15. It was obvious that none had been administered. The hospital discharge summary documented Resident #1 was admitted to the hospital on [DATE] with chest pain, shortness of breath and an elevated potassium level. A potassium level on 12/23/15 prior to discharge from the hospital back to the nursing home revealed a potassium level of 4.9 mmol/l. During an interview with Licensed Practical Nurse (LPN) #1 on 1/20/16 at 2:30 PM revealed that she suspected that LPN #2 (the nurse working opposite of her) was not administering medications to some of the residents as ordered. She stated that she had opened the bottle of Kayexelate on 12/19/15, that had been delivered on 12/16/15 and that RN #1 witnessed it. She stated that she reported it to the administrator and showed the bottle to the DON when she came into the facility. Interview with the RN Consultant (Regional Director of Clinical Operations) at 10:00 AM on 1/20/16 revealed that she had been notified on 12/31/15 from the hotline officer. She stated that LPN #1 reported that LPN #2 was not giving medications; that she had reported this to the DON and the Administrator about the Kayexelate and several other residents' medications, and she wanted to be sure that something was done. The RN Consultant stated that she came to the facility on the following Monday and began the investigation on 1/3/16 and 1/4/16. She related that the pharmacist did a cart-to-MAR audit and observed a medication pass with all nurses. LPN #2 could not be reached for interview. Observation of Resident #1 on 1/20/16 at 3:10 PM revealed a frail appearing resident in a low bed, eyes closed, with an IV infusing and a gastric tube feeding by pump. Resident #1's eyes were closed and she did not respond to a loud voice. Resident #2 Review of the QAPI controlled substances record audit on 1/19/16 revealed a reference to Resident #2, indicating that medications ([MEDICATION NAME]) were counted and discrepancy was found. The resident should have had 90 pills and had an actual count of 98 pills. The RN nurse consultant verified Resident #2's discrepancy when interviewed on 1/20/16 at 10:00 AM. The MD was notified and a [MEDICATION NAME] level was obtained. Record review revealed the facility admitted Resident #2 on 12/29/15 with [DIAGNOSES REDACTED]. Review of a lab report dated 1/5/16 revealed a [MEDICATION NAME] level of 67.2 (high) microgram per milliliter (ug/ml). Interview with the DON at 9:10 AM on 1/19/16 revealed that the physician had put a hold on the [MEDICATION NAME], based on lab results. Observation revealed Resident #2 in her room on 1/20/16 at 3:00 PM. She stated she gets her medications, does not remember ever having a problem, then she began a rambling off topic conversation. Resident #4 Review of LPN #1's written statement revealed Resident #4's medications had been pulled and counted. A [MEDICATION NAME] 60 mg box was there and they counted 22 pills left in the box. Eight (8) pills had been administered, six (6) had not been given in accordance with the dosing schedule. LPN #1 indicated that she counted these with the unit manager and asked to pull up the MAR. A review of nurses who had worked revealed that she had worked 7 days and LPN #2 had worked 6 of those days. Record review revealed the facility admitted Resident #4 on 9/17/15 with [DIAGNOSES REDACTED]. Review of Resident #4's medication orders included [MEDICATION NAME] 60 mg daily. Review of blood pressure readings revealed varying levels noted. Interview with RN #1 on 1/20/16 at 3:20 PM referred to her written statement in which she had written concerns for Resident #4's blood pressure levels which were always extremely high outside normal limits every time she and LPN #1 returned to work, and that the blood pressure was usually under control by the end of their 2nd day back. She had written that it had been suspected he had not been receiving medications going back to when he was a skilled resident. Interview with Resident #4 on 1/20/16 at 3:35 PM revealed he gets his blood pressure taken a lot and gets lots of pills. He stated that sometimes he gets a hand full and other times only one or two (pills).

CI MS # 9849 Based on observation, record review, staff interview and policy review, the facility failed to ensure that one (1) of seven (7) residents reviewed (Resident #1) had adequate supervision to prevent neglect. Resident #1 exited the facility on 10/2/11 between 2:45 p.m. and 3:00 p.m., through an unknown facility door. Resident #1 ambulated to an adjoining nursing facility and could not or would not tell the staff at the adjoining nursing facility who she was or where she came from. The local police were summoned on 10/2/11 to the adjoining nursing facility and again Resident #1 could not or would not tell the officers who she was. The staff at Rest Haven Health & Rehab were unaware until 4:45 p.m. on 10/2/11 that Resident #1 was not in the facility. The lack of the implementation of safety measures to ensure that Resident #1, who was assessed as being a high risk for wandering/elopement, did not exit the building without staff supervision or staff knowledge was deemed as an Immediate Jeopardy (IJ) on 11/2/11 at 2:30 p.m. The Administrator and the Director of Nursing were notified at that time. The IJ began on 10/2/11 and was deemed to be removed on *11/3/11. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 11/4/11 at 4:45 p.m. Based on the verification of the facility's corrective action that were validated through observations and interviews, the IJ was removed on 11/3/11 and the scope and severity was lowered on 11/3/11 to a "D" level, which constitutes no actual harm with potential for more than minimal harm. Findings Include: Cross Refer to F-323 for the facility's failure to ensure that Resident #1 had adequate supervision to prevent exiting the facility without staff knowledge on 10/2/11. Review of the facility policy Abuse Prevention, Investigation and Reporting, last revision date 2010, revealed "Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. "Neglect" is clarified by inclusion of the reasonably prudent person standard, which is now used to determine what action is necessary by the caretaker, to maintain the vulnerable adult's mental and physical health. Again, only a single incident is necessary for a determination of neglect. Neglect occurs when facility staff fails to monitor and/or supervise the delivery of resident care and services to assure that care is provided as needed by the residents." "Allegation of Compliance (AoC)" "On Sunday, October 2, 2011, Resident #1 left the facility somewhere between 2:45pm and 03:00pm in search of a cigarette but failed to notify staff about her departure. Resident #1 was last seen standing in common area of B-hall at 2:45pm, on 10/2/11 by Registered Nurse #1 (RN). At 4:45pm, Certified Nursing Assistant's (C.N.A.) were assisting residents to the dining area for the supper meal, when it was noted that Resident #1 was not present at her table by Certified Nursing Assistant #2 (C.N.A). Certified Nursing Assistant #1 went to Resident #1's room at approximately 4:46pm to see if Resident #1 was ready for supper, but did not find Resident #1 in room so C.N.A. #1 began a search at 4:46pm for Resident #1. C.N.A. #1's search extended to all areas of facility and the designated smoking area located to the east side of the facility. RN #1 was notified by C.N.A. #1 at 4:48pm that Resident #1 could not be found. RN #1 announced Code Purple (resident elopement) at 4:48pm on 10/2/11 for Resident #1. RN #1 assigned LPN#2 and LPN#3 to search outside parameters of facility (Rest Haven Health & Rehab). C.N.A. #1 and C.N.A.#3 was assigned to search outside within the parameters of the property. LPN#2 and LPN#3 at approximately 4:52pm got into LPN#2's private vehicle to begin searching outside the parameters of the facility property. A call was made at 4:54pm on 10/2/11 by Licensed Practical Nurse#3 (LPN) to local nursing facility, which is located on adjoining property. LPN#3 was made aware by a staff member answering the telephone of the local nursing facility that the local police department had been called to the facility for a person who matched the description of Resident #1, who was looking for a cigarette. LPN#2 placed a call at 4:55pm on 10/2/11 to the local police department and was told by police dispatch, that a woman matching the description of Resident #1 was in the police station in a holding cell. LPN#2 and LPN#3 went to pick Resident #1 up in LPN#2's private vehicle on 10/2/11 at approximately 5:02pm, at the local police department and returned Resident #1 to facility on 10/2/11 at approximately 5:10pm. A physical assessment was completed by RN#1 on 10/2/11 between 5:15pm and 5:20pm. Resident #1 was found by RN#1 to have no noted injuries and displayed no signs or symptoms of distress. RN#1 applied a wander guard bracelet to left ankle of Resident #1 at approximately 5:35pm. Resident #1 was placed on 15 minute monitoring checks on 10/2/11 at 6:15pm by RN#1. Resident #1 was counseled on 10/2/11 at approximately 5:45pm by RN#1 and LPN #1 on the need and requirement for notification of departure from facility for proper documentation of physical condition or resident prior to leaving. Resident #1 verbalized understanding to both RN#1 and LPN#1 on 10/2/11 at approximately 5:45pm, and stated "I am never leaving the facility again, I was just looking for a cigarette. All these buildings look alike, but they called the police on me." RN#1 asked, if resident was scared and Resident #1 replied "no but I don't want to go back to jail." When asked by LPN#1 about leaving facility, Resident #1 stated, "I left behind the lady when she opened the door." When re-questioned by LPN#1, Resident #1 would not respond to LPN#1's questioning of which door she exited. Resident #1 was her own responsible party at the time of admission on 9/22/11. Notification to attending Physician #1 for Resident #1's elopement was done on 10/2/11 at 8:20pm, by RN#3. An investigation of the elopement incident for Resident #1 was initiated by RN#1 on 10/2/11 at approximately 5:45pm with staff members, residents, and visitors being interviewed over a two day span. This continued over the next few days with the Administrator #1, and the Corporate Quality Improvement Nurse #1 speaking with Resident #1 for validation of understanding for the need and requirement to notify facility staff prior to departure from facility. The State Agency was notified by Administrator #1 on 10/3/11 with time unknown. The care plan of Resident #1 was updated on 10/2/11 by RN#1, to reflect 15 minute monitoring checks and a wander guard bracelet put in place due to Resident #1's recent elopement. A charm bracelet was purchased on 10/6/11 by Social Director #1 on behalf of Resident #1, with Resident #1's name, facility name (Rest Haven Health & Rehab) engraved on bracelet, which was placed on Resident #1's left wrist on 10/6/11 at approximately 9:30am. Forty-six of forty-six medical records were reviewed by RN#1 on 10/4/11 between 8:00am and 4:00pm with seven residents identified to be at high risk for wandering, the remaining thirty-nine residents wandering assessments were reviewed and found to be current and at low risk for wandering. On 10/4/11, the Wandering Identification Book was reviewed by RN#1 and Office Staff#1 for accuracy of maintaining assessed wandering resident(s) face sheet and personal pictures. There were no negative findings at the time of this audit. On 11/2/11, the Wandering/Elopement Policy was changed and approved verbally by the Medical Director#1 to include two hour monitoring checks for residents who are assessed to be at high risk for wandering. On 11/2/11, the facility implemented two hour checks for Resident #1,3,4,5,6, and 7 who are assessed to be at high risk for wandering to be documented by nursing staff (C.N.A/RN/LPN) on a flowsheet labeled Monitoring Check for Residents Who May Be At Potential for Wandering. On 11/3/11 a change was made for the documentation of a resident who may be assessed for high risk for wandering to be added to the Medication Administration Record (MAR) and to be documented by the licensed nurses (LPN/RN). Nursing staff (C.N.A/LPN/RN's) were in-serviced by RN#1 on 11/2/11 for the two hour monitoring flow sheets. On 11/3/11 licensed nurses (LPN/RN's) were in-serviced on the two hour monitoring of residents assessed for high risk wandering, to be documented on the MAR. No licensed nurse will be allowed to return to work until they have been in-serviced on proper monitoring of residents assessed at high risk and documentation on MAR. For all residents who were assessed to be at high risk for wandering, care plans have been reviewed by RN#2 and LPN#1 for accuracy and revised on 11/2/11. Resident #3's care plan was reviewed on 10/4/11 for accuracy, per RN #1, Resident #3 scores at high risk for wandering and has wander guard bracelet in place. Resident #3 does require extensive assistance with mobility and does not exit seek, so therefore no revisions were made. On 11/2/11, care plans were reviewed and revised by RN#2 and LPN#1 to reflect that nurse aide interventions also include checking residents whereabouts every two hours and documenting on flowsheet per nursing staff (C.N.A's) On 11/3/11 a change was made for the documentation of a resident who has been assessed as high risk for wandering to be added to the Medication Administration Record (MAR) and be documented by the licensed nurses (LPN/RN) as outlined in the Wandering/Elopement Policy. A review of Resident #3's behavioral monitoring over the last quarter (August, September, October) by RN #1 and LPN #1 revealed no new wandering behaviors. Resident #4's care plan was reviewed on 10/04/11 per RN #1, due to Resident #4 scoring at high risk for wandering, a wander guard bracelet is in place. Resident #4 does ambulate within the facility but does not exit seek, no revisions were made to care plan.. On 11/2/11, care plans were reviewed and revised by RN#2 and LPN#1 to reflect that nurse aide interventions also include checking residents whereabouts every two hours and documenting on flowsheet per nursing staff (C.N.A's) On 11/3/11, care plans were reviewed and revised by RN #2 and LPN #1 to reflect that nursing interventions also include checking resident whereabouts every two hours and documenting on Medication Administration Record (MAR) by licensed personnel (LPN/RN's) as outlined in the Wandering/Elopement Policy. A review of Resident #4's behavioral monitoring over the last quarter (August, September, October) by RN #1 and LPN #1 revealed no new wandering behaviors. Resident #5's care plan was reviewed on 10/04/11 per RN #1, Resident #5 scores at high risk for wandering but does not have wander guard bracelet due to signed refusal by Resident #5's power of attorney. Resident #5 does ambulate within the facility but does not exit seek so no revisions were implemented at this time. On 11/2/11, care plans were reviewed and revised by RN #2 and LPN #1 to reflect that nurse aide interventions also include checking residents whereabouts every thirty minutes and documenting on flowsheet by nursing staff (C.N.A). On 11/3/11 care plans were reviewed by RN#2 and LPN#1 to reflect nursing interventions also include checking resident whereabouts every two hours and documenting on Medication Administration Record (MAR) by licensed nurses (LPN/RN's) as outlined in the Wandering/Elopement Policy. A review of Resident #5's behavioral monitoring over the last quarter (August, September, October)by RN #1 and LPN #1 revealed no new wandering behaviors. Resident #6's care plan was reviewed on 10/04/11 per RN #1, due to Resident #6 scoring at high risk for wandering, a wander guard is in place. Resident #6 does ambulate within the facility but does not exit seek, no revisions were made. On 11/2/11, care plans were reviewed and revised by RN #2 and LPN #1 to reflect that nurse aide interventions also include checking residents whereabouts every two hours and documenting on flowsheet by nursing staff (C.N.A's). On 11/3/11 care plans were reviewed and revised by RN#2 and LPN#1 to reflect nursing interventions also include checking residents whereabouts every two hours and documenting on Medication Administration Record (MAR) by licensed nurses (LPN/RN's) as outlined in the Wandering/Elopement Policy. A review of Resident #6's behavioral monitoring over the last quarter (August, September, October) by RN #1 and LPN #1 revealed no new wandering behavior. Resident #7's care plan was reviewed on 10/04/11 per RN #1, due to Resident #7 scoring at high risk for wandering, a wander guard bracelet is in place. Resident #7 ambulates within the facility but does not exit seek. On 11/2/11, care plans were reviewed and revised by RN #2 and LPN #1 to reflect that nurse aide interventions also include checking residents whereabouts every two hours and documenting on flowsheet by nursing staff (C.N.A). On 11/3/11 care plans were reviewed and revised by RN#2 and LPN#1 to reflect nursing interventions to include checking residents whereabouts every two hours and documenting on Medication Administration Record (MAR) by licensed nurse (LPN/RN's) as outlined in the Wandering/Elopement Policy. Review of Resident #7's behavioral record by RN #2 and LPN #1 revealed no new wandering behaviors. Resident #1 was evaluated on 10/14/11 by local mental health services and was found to be [MEDICAL CONDITION] with [MEDICAL CONDITION]. Recommendations were by Psychiatric Nurse Practitioner #1 for possible group home placement due to age and ability to interact with peers. Physician #1 was notified on 10/19/11 of recommendations of the local mental health services with an approved order received to refer to group homes for placement. The following local group home agency, was contacted on 10/20/11 by DON#1, who spoke with the local group home director regarding possible placement for Resident #1 into one of the agents group homes. An admission questionnaire was received by DON#1 on 10/23/11, completed and returned by DON#1 to local group home agency on 10/27/11. As of 11/3/11 DON#1 is awaiting response for placement. A Missing Person/Wandering/Elopement in-service was conducted on Sunday, October 2, 2011 by RN#1 and continued through 10/11/11 until all Licensed Practical Nurses, Certified Nursing Assistant, Registered Nurses, Dietary Aides, Housekeeping and Laundry Aides, Maintenance Director, Business Office Staff and Therapy Department were in-serviced. No staff was allowed to work until in-serviced on the facilities policy regarding Missing Persons, Wandering/Elopements and to ensure all parameters in and around facility have been checked for possible missing resident(s) before sounding clear. A-wing door, both doors on B-wing and the front door alarm keypad codes were changed by Plant Operation Manager on 11/3/11, to minimize knowledge of door alarm codes for exiting of facility other than staff members. Mechanical door alarms are checked at least weekly for functionality by the Plant Operation manager, with results being logged on a form labeled Weekly Checklist for Wander Guard Monitor and retained in the Plant Operation Managers office. The wander guard transmitters are checked when initiated and daily thereafter by licensed nurses (RN or LPN) for functionality and recorded on the Medication Administration Record (MAR). Wander guard bracelet is checked for placement by licensed nurses ((RN or LPN) at least 1 time per shift with results being recorded on the medication administration record (MAR). Facility practice is to change door alarm codes at least annually and or as needed. As of 11/3/11 with the door alarm codes being changed, in-servicing began with all staff (C.N.A's, LPN's, RN's, dietary aides, activity director, housekeeping/laundry aides, maintenance director, business office staff and therapy department) and will continue with the change in rotation of staff schedules. No staff member will be allowed to return to work until in-serviced on door alarm code changes. Written correspondence will be mailed to family members for the residents of the facility which were initiated 11/4/11 to inform them that the door alarm codes have been changed and a staff member would assist in them in exiting the building and for the need to be aware of any person exiting behind them that did not come in with family member. All four facility exit doors have a sign posted on the interior side that informs visitors, not to allow anyone to exit behind them that did not enter with them. If this occurs, please notify a staff member immediately. Signs were placed on front door, A-wing door, and both B-wing doors on 11/2/11 by RN#1 and DON#1. The facility Quality Improvement Committee meeting was held on Tuesday, October 11, 2011, with the following individuals attending: Medical Director, RN#2, RN#1, LPN#1, DON#1, Nurse Practitioner #1, Rehab Tech, Activity Coordinator, Social Service Director and Admission/Marketing Director. The events of the Resident #1 leaving the facility without staff's knowledge, a review of all actions taken; On 10/2/11 RN#1 completed a physical assessment of Resident #1 with no injury or signs or symptoms of distress, Resident #1 counseled, wander guard bracelet applied to Resident #1 and placed on 15 minute wandering checks. Summary of findings included that Resident #1 left facility without notifying staff, was observed to be at local nursing facility, police notified by local nursing facility and Resident #1 was taken to local police station, retrieved Resident #1 from local police station and returned to Rest Haven Health & Rehab while being accompanied by LPN#1 and LPN#2., with no injuries sustained and no distress noted by RN#1. Actions to be taken; Monthly monitoring by the facilities Quality Assurance Nurse times one time a week times 4 weeks and then changed to quarterly if no negative findings are found. The monitoring flowsheet will include residents name, risk factor (low/high) wander guard placed if resident at high risk, care plan updated as needed, documentation of functionality, placement, and two hour checks are recorded properly. All findings will be discussed at the monthly Quality Assurance Committee meeting." After verification of the facility's corrective action through observation and interviews with staff on 11/4/11, to ensure that they had been inserviced on resident monitoring and documentation of every two hour checks for resident whereabouts on the MAR, change in door keypad codes and who is allowed to have the door keypad codes. Staff interviewed included Licensed Nurses, Certified Nursing Assistants (CNA), Housekeeping, Maintenance and Dietary. All staff interviewed provided appropriate responses related to the inservices they attended. The IJ was removed and the scope and severity was lowered on 11/3/11 to a "D" level, which constitutes no actual harm with potential for more than minimal harm to ensure the facility's measure could be further reviewed and evaluated by the facility's QA Committee.

CI MS #9849 Based on observation, record review, staff interview and policy review, the facility failed to ensure that one (1) of seven (7) residents reviewed (Resident #1) had a comprehensive care plan initiated and implemented with specific interventions to monitor a resident at risk for wandering/elopement. Resident #1 was assessed as high risk for wandering/elopement and did not have a care plan or specific interventions to address this risk. Resident #1 exited the facility on 10/2/11 between 2:45 p.m. and 3:00 p.m. and ambulated to an adjoining nursing facility. The lack of a comprehensive care plan with specific measures in place to prevent Resident #1 from leaving the facility unsupervised and unassisted was deemed an Immediate Jeopardy (IJ) on 11/2/11 at 2:30 p.m. The Administrator and the Director of Nursing were notified at that time. The IJ began on 10/2/11 and was determined to be removed on 11/3/11. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 11/4/11 at 4:45 p.m. Based on the verification of the facility's corrective action that were validated through observations and interviews, the IJ was removed on 11/3/11 and the scope and severity was lowered on 11/3/11 to a "D" level, which constitutes no actual harm with potential for more than minimal harm. Findings Include: Cross Refer to F-323 for the facility's failure to ensure that Resident #1 had a comprehensive care plan with specific measures to prevent Resident #1 from exiting the facility without staff knowledge on 10/2/11. Review of the facility policy for Care Planning, 2011 revealed "The interim care plan is developed within 8 hours of admission to the facility and is based on resident needs identified in the admission nursing assessments, physician admission orders [REDACTED]." "Allegation of Compliance (AoC)" "On Sunday, October 2, 2011, Resident #1 left the facility somewhere between 2:45pm and 03:00pm in search of a cigarette but failed to notify staff about her departure. Resident #1 was last seen standing in common area of B-hall at 2:45pm, on 10/2/11 by Registered Nurse #1 (RN). At 4:45pm, Certified Nursing Assistant's (C.N.A.) were assisting residents to the dining area for the supper meal, when it was noted that Resident #1 was not present at her table by Certified Nursing Assistant #2 (C.N.A.). Certified Nursing Assistant #1 went to Resident #1's room at approximately 4:46pm to see if Resident #1 was ready for supper, but did not find Resident #1 in room so C.N.A. #1 began a search at 4:46pm for Resident #1. C.N.A. #1's search extended to all areas of facility and the designated smoking area located to the east side of the facility. RN #1 was notified by C.N.A. #1 at 4:48pm that Resident #1 could not be found. RN #1 announced Code Purple (resident elopement) at 4:48pm on 10/2/11 for Resident #1. RN #1 assigned LPN#2 and LPN#3 to search outside parameters of facility (Rest Haven Health & Rehab). C.N.A. #1 and C.N.A.#3 was assigned to search outside within the parameters of the property. LPN#2 and LPN#3 at approximately 4:52pm got into LPN#2's private vehicle to begin searching outside the parameters of the facility property. A call was made at 4:54pm on 10/2/11 by Licensed Practical Nurse#3 (LPN) to local nursing facility, which is located on adjoining property. LPN#3 was made aware by a staff member answering the telephone of the local nursing facility that the local police department had been called to the facility for a person who matched the description of Resident #1, who was looking for a cigarette. LPN#2 placed a call at 4:55pm on 10/2/11 to the local police department and was told by police dispatch, that a woman matching the description of Resident #1 was in the police station in a holding cell. LPN#2 and LPN#3 went to pick Resident #1 up in LPN#2's private vehicle on 10/2/11 at approximately 5:02pm, at the local police department and returned Resident #1 to facility on 10/2/11 at approximately 5:10pm. A physical assessment was completed by RN#1 on 10/2/11 between 5:15pm and 5:20pm. Resident #1 was found by RN#1 to have no noted injuries and displayed no signs or symptoms of distress. RN#1 applied a wander guard bracelet to left ankle of Resident #1 at approximately 5:35pm. Resident #1 was placed on 15 minute monitoring checks on 10/2/11 at 6:15pm by RN#1. Resident #1 was counseled on 10/2/11 at approximately 5:45pm by RN#1 and LPN #1 on the need and requirement for notification of departure from facility for proper documentation of physical condition or resident prior to leaving. Resident #1 verbalized understanding to both RN#1 and LPN#1 on 10/2/11 at approximately 5:45pm, and stated "I am never leaving the facility again, I was just looking for a cigarette. All these buildings look alike, but they called the police on me." RN#1 asked, if resident was scared and Resident #1 replied "no but I don't want to go back to jail." When asked by LPN#1 about leaving facility, Resident #1 stated, "I left behind the lady when she opened the door." When re-questioned by LPN#1, Resident #1 would not respond to LPN#1's questioning of which door she exited. Resident #1 was her own responsible party at the time of admission on 9/22/11. Notification to attending Physician #1 for Resident #1's elopement was done on 10/2/11 at 8:20pm, by RN#3. An investigation of the elopement incident for Resident #1 was initiated by RN#1 on 10/2/11 at approximately 5:45pm with staff members, residents, and visitors being interviewed over a two day span. This continued over the next few days with the Administrator #1, and the Corporate Quality Improvement Nurse #1 speaking with Resident #1 for validation of understanding for the need and requirement to notify facility staff prior to departure from facility. The State Agency was notified by Administrator #1 on 10/3/11 with time unknown. The care plan of Resident #1 was updated on 10/2/11 by RN#1, to reflect 15 minute monitoring checks and a wander guard bracelet put in place due to Resident #1's recent elopement. A charm bracelet was purchased on 10/6/11 by Social Director #1 on behalf of Resident #1, with Resident #1's name, facility name (Rest Haven Health & Rehab) engraved on bracelet, which was placed on Resident #1's left wrist on 10/6/11 at approximately 9:30am. Forty-six of forty-six medical records were reviewed by RN#1 on 10/4/11 between 8:00am and 4:00pm with seven residents identified to be at high risk for wandering, the remaining thirty-nine residents wandering assessments were reviewed and found to be current and at low risk for wandering. On 10/4/11, the Wandering Identification Book was reviewed by RN#1 and Office Staff#1 for accuracy of maintaining assessed wandering resident(s) face sheet and personal pictures. There were no negative findings at the time of this audit. On 11/2/11, the Wandering/Elopement Policy was changed and approved verbally by the Medical Director#1 to include two hour monitoring checks for residents who are assessed to be at high risk for wandering. On 11/2/11, the facility implemented two hour checks for Resident #1,3,4,5,6, and 7 who are assessed to be at high risk for wandering to be documented by nursing staff (C.N.A/RN/LPN) on a flowsheet labeled Monitoring Check for Residents Who May Be At Potential for Wandering. On 11/3/11 a change was made for the documentation of a resident who may be assessed for high risk for wandering to be added to the Medication Administration Record (MAR) and to be documented by the licensed nurses (LPN/RN). Nursing staff (C.N.A/LPN/RN's) were in-serviced by RN#1 on 11/2/11 for the two hour monitoring flow sheets. On 11/3/11 licensed nurses (LPN/RN's) were in-serviced on the two hour monitoring of residents assessed for high risk wandering, to be documented on the MAR. No licensed nurse will be allowed to return to work until they have been in-serviced on proper monitoring of residents assessed at high risk and documentation on MAR. For all residents who were assessed to be at high risk for wandering, care plans have been reviewed by RN#2 and LPN#1 for accuracy and revised on 11/2/11. Resident #3's care plan was reviewed on 10/4/11 for accuracy, per RN #1, Resident #3 scores at high risk for wandering and has wander guard bracelet in place. Resident #1 does require extensive assistance with mobility and does not exit seek, so therefore no revisions were made. On 11/2/11, care plans were reviewed and revised by RN#2 and LPN#1 to reflect that nurse aide interventions also include checking residents whereabouts every two hours and documenting on flowsheet per nursing staff (C.N.A's) On 11/3/11 a change was made for the documentation of a resident who has been assessed as high risk for wandering to be added to the Medication Administration Record (MAR) and be documented by the licensed nurses (LPN/RN) as outlined in the Wandering/Elopement Policy. A review of Resident #3's behavioral monitoring over the last quarter (August, September, October) by RN #1 and LPN #1 revealed no new wandering behaviors. Resident #4's care plan was reviewed on 10/04/11 per RN #1, due to Resident #4 scoring at high risk for wandering, a wander guard bracelet is in place. Resident #4 does ambulate within the facility but does not exit seek, no revisions were made to care plan.. On 11/2/11, care plans were reviewed and revised by RN#2 and LPN#1 to reflect that nurse aide interventions also include checking residents whereabouts every two hours and documenting on flowsheet per nursing staff (C.N.A's) On 11/3/11, care plans were reviewed and revised by RN #2 and LPN #1 to reflect that nursing interventions also include checking resident whereabouts every two hours and documenting on Medication Administration Record (MAR) by licensed personnel (LPN/RN's) as outlined in the Wandering/Elopement Policy. A review of Resident #4's behavioral monitoring over the last quarter (August, September, October) by RN #1 and LPN #1 revealed no new wandering behaviors. Resident #5's care plan was reviewed on 10/04/11 per RN #1, Resident #5 scores at high risk for wandering but does not have wander guard bracelet due to signed refusal by Resident #5's power of attorney. Resident #5 does ambulate within the facility but does not exit seek so no revisions were implemented at this time. On 11/2/11, care plans were reviewed and revised by RN #2 and LPN #1 to reflect that nurse aide interventions also include checking residents whereabouts every thirty minutes and documenting on flowsheet by nursing staff (C.N.A). On 11/3/11 care plans were reviewed by RN#2 and LPN#1 to reflect nursing interventions also include checking resident whereabouts every two hours and documenting on Medication Administration Record (MAR) by licensed nurses (LPN/RN's) as outlined in the Wandering/Elopement Policy. A review of Resident #5's behavioral monitoring over the last quarter (August, September, October)by RN #1 and LPN #1 revealed no new wandering behaviors. Resident #6's care plan was reviewed on 10/04/11 per RN #1, due to Resident #6 scoring at high risk for wandering, a wander guard is in place. Resident #6 does ambulate within the facility but does not exit seek, no revisions were made. On 11/2/11, care plans were reviewed and revised by RN #2 and LPN #1 to reflect that nurse aide interventions also include checking residents whereabouts every two hours and documenting on flowsheet by nursing staff (C.N.A's). On 11/3/11 care plans were reviewed and revised by RN#2 and LPN#1 to reflect nursing interventions also include checking residents whereabouts every two hours and documenting on Medication Administration Record (MAR) by licensed nurses (LPN/RN's) as outlined in the Wandering/Elopement Policy. A review of Resident #6's behavioral monitoring over the last quarter (August, September, October) by RN #1 and LPN #1 revealed no new wandering behavior. Resident #7's care plan was reviewed on 10/04/11 per RN #1, due to Resident #7 scoring at high risk for wandering, a wander guard bracelet is in place. Resident #7 ambulates within the facility but does not exit seek. On 11/2/11, care plans were reviewed and revised by RN #2 and LPN #1 to reflect that nurse aide interventions also include checking residents whereabouts every two hours and documenting on flowsheet by nursing staff (C.N.A). On 11/3/11 care plans were reviewed and revised by RN#2 and LPN#1 to reflect nursing interventions to include checking residents whereabouts every two hours and documenting on Medication Administration Record (MAR) by licensed nurse (LPN/RN's) as outlined in the Wandering/Elopement Policy. Review of Resident #7's behavioral record by RN #2 and LPN #1 revealed no new wandering behaviors. Resident #1 was evaluated on 10/14/11 by local mental health services and was found to be [MEDICAL CONDITION] with [MEDICAL CONDITION]. Recommendations were by Psychiatric Nurse Practitioner #1 for possible group home placement due to age and ability to interact with peers. Physician #1 was notified on 10/19/11 of recommendations of the local mental health services with an approved order received to refer to group homes for placement. The following local group home agency, was contacted on 10/20/11 by DON#1, who spoke with the local group home director regarding possible placement for Resident #1 into one of the agents group homes. An admission questionnaire was received by DON#1 on 10/23/11, completed and returned by DON#1 to local group home agency on 10/27/11. As of 11/3/11 DON#1 is awaiting response for placement. A Missing Person/Wandering/Elopement in-service was conducted on Sunday, October 2, 2011 by RN#1 and continued through 10/11/11 until all Licensed Practical Nurses, Certified Nursing Assistant, Registered Nurses, Dietary Aides, Housekeeping and Laundry Aides, Maintenance Director, Business Office Staff and Therapy Department were in-serviced. No staff was allowed to work until in-serviced on the facilities policy regarding Missing Persons, Wandering/Elopements and to ensure all parameters in and around facility have been checked for possible missing resident(s) before sounding clear. A-wing door, both doors on B-wing and the front door alarm keypad codes were changed by Plant Operation Manager on 11/3/11, to minimize knowledge of door alarm codes for exiting of facility other than staff members. Mechanical door alarms are checked at least weekly for functionality by the Plant Operation manager, with results being logged on a form labeled Weekly Checklist for Wander Guard Monitor and retained in the Plant Operation Managers office. The wander guard transmitters are checked when initiated and daily thereafter by licensed nurses (RN or LPN) for functionality and recorded on the Medication Administration Record (MAR). Wander guard bracelet is checked for placement by licensed nurses ((RN or LPN) at least 1 time per shift with results being recorded on the medication administration record (MAR). Facility practice is to change door alarm codes at least annually and or as needed. As of 11/3/11 with the door alarm codes being changed, in-servicing began with all staff (C.N.A's, LPN's, RN's, dietary aides, activity director, housekeeping/laundry aides, maintenance director, business office staff and therapy department) and will continue with the change in rotation of staff schedules. No staff member will be allowed to return to work until in-serviced on door alarm code changes. Written correspondence will be mailed to family members for the residents of the facility which were initiated 11/4/11 to inform them that the door alarm codes have been changed and a staff member would assist in them in exiting the building and for the need to be aware of any person exiting behind them that did not come in with family member. All four facility exit doors have a sign posted on the interior side that informs visitors, not to allow anyone to exit behind them that did not enter with them. If this occurs, please notify a staff member immediately. Signs were placed on front door, A-wing door, and both B-wing doors on 11/2/11 by RN#1 and DON#1. The facility Quality Improvement Committee meeting was held on Tuesday, October 11, 2011, with the following individuals attending: Medical Director, RN#2, RN#1, LPN#1, DON#1, Nurse Practitioner #1, Rehab Tech, Activity Coordinator, Social Service Director and Admission/Marketing Director. The events of the Resident #1 leaving the facility without staff's knowledge, a review of all actions taken; On 10/2/11 RN#1 completed a physical assessment of Resident #1 with no injury or signs or symptoms of distress, Resident #1 counseled, wander guard bracelet applied to Resident #1 and placed on 15 minute wandering checks. Summary of findings included that Resident #1 left facility without notifying staff, was observed to be at local nursing facility, police notified by local nursing facility and Resident #1 was taken to local police station, retrieved Resident #1 from local police station and returned to Rest Haven Health & Rehab while being accompanied by LPN#1 and LPN#2., with no injuries sustained and no distress noted by RN#1. Actions to be taken; Monthly monitoring by the facilities Quality Assurance Nurse times one time a week times 4 weeks and then changed to quarterly if no negative findings are found. The monitoring flowsheet will include residents name, risk factor (low/high) wander guard placed if resident at high risk, care plan updated as needed, documentation of functionality, placement, and two hour checks are recorded properly. All findings will be discussed at the monthly Quality Assurance Committee meeting." After verification of the facility's corrective action through observation and interviews with staff on 11/4/11, to ensure that they had been inserviced on resident monitoring and documentation of every two hour checks for resident whereabouts on the MAR, change in door keypad codes and who is allowed to have the door keypad codes. Staff interviewed included Licensed Nurses, Certified Nursing Assistants (CNA), Housekeeping, Maintenance and Dietary. All staff interviewed provided appropriate responses related to the inservices they attended. The IJ was removed and the scope and severity was lowered on 11/3/11 to a "D" level, which constitutes no actual harm with potential for more than minimal harm to ensure the facility's measure could be further reviewed and evaluated by the facility's QA Committee.

CI MS #9849 Based on observation, record review, staff interview and policy review, the facility failed to ensure: (1.) that staff documents the residents whereabouts every two (2) hours if a resident has a wandering bracelet in place, (2.) to follow through with the Wandering Resident Assessment with documentation of placement and function of the wander guard bracelet on the Medication Administration Record (MAR), (3.) initiate and implement a comprehensive care plan, (4.) that staff/visitors with the door keypad code do not let residents at risk for wandering exit the facility without adequate supervision, (5.) that the facility maintained signs on the exit doors to alert visitors not to let residents exit the facility as per the facility policy of practice, (6.) that residents had adequate supervision to prevent exiting the facility unsupervised and without staff knowledge. This is for one (1) of seven (7) residents reviewed, Resident #1. Resident #1 exited the facility on [DATE] between 2:45 p.m. and 3:00 p.m., through an unknown facility door. Resident #1 ambulated to an adjoining nursing facility and could not or would not tell the staff who she was or where she came from. The local police were summoned to the adjoining nursing facility and again Resident #1 could not or would not tell the officers who she was. The staff of Rest Haven Health & Rehab were unaware until 4:45 p.m. on [DATE] that Resident #1 was not in the facility. The weather on [DATE] was sunny with a high of 72 degrees. The lack of the implementation of safety measures to ensure that Resident #1, who was assessed as being a high risk for wandering/elopement, did not exit the building without staff supervision or staff knowledge was deemed as an Immediate Jeopardy (IJ) on [DATE] at 2:30 p.m. The Administrator and the Director of Nursing were notified at that time. The IJ began on [DATE] and was deemed to be removed on [DATE]. The facility submitted an acceptable credible Allegation of Compliance (AoC) on [DATE] at 4:45 p.m. Based on the verification of the facility's corrective action that were validated through observations and interviews, the IJ was removed on [DATE] and the scope and severity was lowered on [DATE] to a "D" level, which constitutes no actual harm with potential for more than minimal harm. Findings Include: Resident #1 Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation and interview with Resident #1 on [DATE] at 2:46 p.m. revealed Resident #1 in bed fully dressed in blue jeans, T-shirt and tennis shoes. Attempts to engage Resident #1 in conversation were unsuccessful. Resident #1 had a flat affect, makes no conversation, covers self up with spread and turns away. Review of the initial Minimum Data Set MDS with an Assessment Reference Date (ARD) of [DATE] revealed Resident #1 had short and long term memory impairment with moderately impaired cognitive skills for daily decision-making. Resident #1 was coded on this MDS as having wandering behavior occurring daily. Resident #1's wandering impact was coded 1 (yes) to place the resident at significant risk of getting to a potentially dangerous place (e.g., stairs, outside of the facility). Review of Resident #1's admission Wandering Resident assessment dated [DATE] revealed a score of 10, high risk for elopement. A score of 6 or higher is considered at risk for wandering. Review of History and Physical from a local hospital dated [DATE] which handwritten notations "Pt (patient) is exhibiting paranoid behavior states God is laughing at me." The word "pacing" is written under this notation and "anxiety symptoms" is circled. Review of the Admission History and Physical dated [DATE] revealed that Resident #1 has been a resident in a personal care home that was closing (dates unknown). Resident #1 has been treated for [REDACTED]. Social history: she (Resident #1) is very psychotic and withdrawn. She (Resident #1) does not interact well with others. Interview with the Administrator on [DATE] at 9:15 a.m. revealed that Resident #1 was residing at a personal care home and then admitted to this facility without much medical history. The Administrator stated that Resident #1, being new, was just getting acclimated to the facility when the incident (elopement) occurred. The Administrator stated that Resident #1 was cognitive and was her own responsible party (RP). The Administrator stated that Resident #1 had been doing well since the elopement incident on [DATE]. Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 11:40 a.m. revealed that after Resident #1 was admitted to the facility Resident #1 would pace up and down the halls and go into other resident rooms and take their food or drinks. LPN #1 stated that Resident #1 is not sociable, and a lot of her answers are"yes/no" remarks. LPN #1 stated that Resident #1 would go to the exit door to the smoking area and push on it wanting to go out and smoke and that Resident #1 was easily redirected. Interview on [DATE] with LPN #2 at 12:00 p.m. revealed that she (LPN #2) was called into the facility on [DATE] to assist Registered Nurse (RN) #1. LPN #2 stated that upon arrival to the facility at 5:30 p.m. Resident #1 had been picked up on [DATE] by LPN #3 and LPN #4 at the local police station in LPN #2's private vehicle. LPN #2 stated that Resident #1 stated that she (Resident #1) was looking for a cigarette and followed a lady out the front door. LPN #2 stated that Resident #1 did not have on a wander guard bracelet or other identification bracelet on [DATE]. LPN #2 stated that Resident #1's behavior prior to exiting the facility on [DATE] was that Resident #1 walked up and down the halls, but had no exit seeking behavior. Interview with the Maintenance Director on [DATE] at 12:15 p.m. revealed that the only exit door with the Wander Guard System on [DATE] was the front entrance door, a total of (5)exit doors had the keypads that require a code be entered to exit. The Maintenance Director stated that all the keypad codes were the same for the doors and that the keypad codes have not been changed in the past 12 months. The Maintenance Director stated that the staff have the keypad codes for the doors and they (staff) may give the codes to the family or visitors. Interview with Certified Nursing Assistant (CNA) #1 on [DATE] at 12:22 p.m. revealed that she (CNA #1) last saw Resident #1 in the back dining room on [DATE] wanting to smoke but she (CNA #1) told Resident #1 that the smoke break was not until 3:00 p.m. and Resident #1 turned and walked down the hall toward Resident #1's room. CNA #1 stated that Resident #1 would walk up and down the halls wanting to smoke and Resident #1 was a wanderer. CNA #1 stated that Resident #1 had on a wander guard bracelet on prior to [DATE] and on [DATE] when Resident #1 exited the facility. Observation and interview on [DATE] at 12:55 p.m. revealed that an elderly visitor approached the front door, Unsampled Resident A approached from the front sitting area up to the front door and entered a code allowing this visitor to exit. The visitor left the facility at this time driving a vehicle. Unsampled Resident A stated "you watch and keep it (the code) up here (pointing to his head)." There is no sign at this time on the front door related to not letting residents out. Observation and interview on [DATE] at 1:00 p.m. revealed Unsampled Resident B sitting at a table outside in the smoking area at the east end of B-wing exit door, alone. Unsampled Resident B stated that the facility staff gave him the code to the door "as they know I(Unsampled Resident B) will not go anywhere". There is no sign at this time on the A/B wing exit doors related to not letting residents out. Interview with RN #1 on [DATE] at 1:05 p.m. revealed that RN #1 was filling in as Charge Nurse on [DATE] from 12:00 p.m. until 6:00 p.m. RN #1 stated that she (RN #1) last saw Resident #1 about 2:45 p.m. in the sitting area on B-wing. RN #1 then went to A-wing and saw Resident #1 walking into other resident rooms and being redirected out by another staff person. RN #1 stated that Resident #1 has been observed walking to the smoking exit door and pushing on the door. RN #1 stated that the family and residents have the door keypad codes to exit the facility. RN #1 stated that Resident #1 was noted missing about 4:45 p.m. on [DATE]. RN #1 was told that Resident #1 had walked to the adjoining nursing facility went inside, was wandering in and out of resident rooms. RN #1 stated that the staff of the other facility did not know that Resident #1 was a resident in another nursing home as Resident #1 looked too young to be a resident. RN #1 stated that the other facility called the local police department who took Resident #1 to the police station. RN #1 stated that LPN #3 and LPN #4 picked up Resident #1 from the local police station about 5:30 p.m. on [DATE]. RN #1 stated that if a resident is "borderline" at risk for elopement that sometimes the facility will just observe the resident and if needed will reassess. RN #1 stated that residents at risk for wandering are monitored on routine rounds every two (2) hours. Interview with LPN #3 on [DATE] at 1:30 p.m. revealed that she (LPN #3) was on duty and the assigned nurse for Resident #1 on [DATE] from 6:00 a.m. until 6:00 p.m. LPN #3 stated that Resident #1's normal behavior was to walk the halls and ask if she (Resident #1) could go smoke. LPN #3 stated that Resident #1 is not very verbal. LPN #3 stated that she (LPN #3) last saw Resident #1 between 1:15 p.m. and 1:30 p.m. on [DATE] near room number 200 being redirected by another staff person as Resident #1 had wandered into the resident's room. LPN #3 stated that upon returning from lunch about 3:15 p.m. on [DATE] church visitors were leaving and LPN #3 assisted some of the visitors to exit the front door of the facility. LPN #3 stated that Resident #1 was noted missing at 4:45 p.m., a search was begun by facility staff and facility staff could not locate Resident #1 within the building. LPN #2 called the adjoining nursing facility who reported their facility did not know that Resident #1 was a nursing home resident and called the local police department. LPN #3 stated that the police department was called and Resident #1 was at the police station. LPN #2 and LPN #3 picked Resident #1 up at the local police station between 5:15 p.m. and 5:30 p.m. on [DATE]. LPN #3 stated that Resident #1 would not talk only saying "I don't know". LPN #3 stated that the CNA's check resident's every two (2) hours and nurse check resident's every four (4) hours. LPN #3 then stated that residents at risk for wandering are monitored visually at least every hour. LPN #3 stated that alert resident's of the facility, visitors and families have the exit door keypad codes. Interview with CNA #2 and CNA #3 on [DATE] at 2:05 p.m. revealed that Resident #1 would walk the halls and go to the smoke exit door. Both CNA #2 and CNA #3 did not know if Resident #1 had a wander guard bracelet on prior to exiting on [DATE]. CNA #2 and CNA #3 stated that alert residents, families and staff knew the keypad code to exit the doors. On [DATE] at 2:30 p.m. with RN #2 all resident wander guard bracelets a total of (4) were checked and found to be functioning properly. The front door was also checked at this time for the wander guard system function and noted to be functioning properly. On [DATE] at 2:55 p.m. the drive distance from this facility to the adjoining nursing facility where Resident #1 was found and picked up by the local police department is 0.1 mile. The area is residential as well as business, all roads are paved and there were no major hazards noted (e.g., ditches, brush, trees, hills). The area was low traffic with about ,[DATE] cars observed in a ,[DATE] minute period on [DATE] between 2:55 p.m. and 3:15 p.m. Interview with the Administrator of the adjoining nursing facility (located on the same street) on [DATE] at 9:30 a.m. revealed Resident #1 entered their facility with some church visitors between 3:00 p.m. and 3:15 p.m. and was noted going in and out of resident rooms. Staff of the adjoining nursing facility reported that Resident #1 was asking for a lighter, but the staff did not know who Resident #1 was with. The Administrator stated that Resident #1 would not give her name, but stated "it don't matter" to everything asked of Resident #1. The Administrator stated Resident #1 "did not appear to be a resident as she was too young" and that Resident #1 was dressed in tennis shoes, blue jeans and a T-shirt. The Administrator stated that Resident #1 was taken outside to the front porch while staff inside called the local police department. The Administrator stated that Resident #1 began going through parked cars in their parking lot. The Administrator stated that Resident #1 was brought back to the front porch and given something to drink while waiting on the police. The Administrator stated that when the police officer arrived Resident #1 gave the police officer a name that she (Administrator) could not hear; Resident #1 got into the police car and left. The Administrator stated that she (Administrator) got a call from one her staff members about 5:30 p.m. reporting that Resident #1 was a resident of the adjoining nursing facility. Interview with CNA #5 on [DATE] at 10:32 a.m. revealed that Resident #1 had been seen on [DATE] wandering into other resident rooms and taking their drinks. CNA #5 stated that Resident #1 always wanted to go smoke and had been seen trying to punch in numbers on the keypad and pushing on the door to get out (date unknown). CNA #5 stated that Resident #1 never says much "I don't know" is about all that Resident #1 says. Interview with the Medical Director (Resident #1's attending Physician) on [DATE] at 11:10 a.m. revealed that Resident #1 was hurriedly accepted by this facility from a local personal care home that was closing and that Resident #1 was not the best candidate for this facility. The Medical Director stated "the elopement was an unfortunate incident". The Medical Director stated that if a resident was identified to be at risk for wandering/elopement that he expected a wander guard bracelet to be placed on the resident. Interview with the Director of Nursing (DON) on [DATE] at 11:45 a.m. revealed that the facility uses their discretion as to whether or not to apply a wander guard bracelet to resident's at high risk for wandering/elopement. The DON stated that Resident #1 was a high risk for wandering/elopement and ambulated about the facility. The DON stated that with Resident #1's cognitive status the facility did not think Resident #1 would exit seek or leave the facility. Observation [DATE] revealed: 10:00 a.m. observation of the front exit door revealed that upon entering now has a sign posted for visitors about not letting residents out;10:15 a.m. the door keypad codes were being changed on [DATE] by the Maintenance Director: 11:10 a.m. observed the same sign posted on the front door posted on A-wing exit and the two (2) B-wing exit doors. Interview with RN #3 on [DATE] at 11:15 a.m. revealed that she (RN #3) assessed Resident #1 on admission [DATE] and Resident #1 was a high risk for wandering/elopement at that time. RN #3 stated that Resident #1's high risk score was reported to the RN Team Leader (RN #4) on that day ([DATE]). RN #3 stated that if the team (Administrator, DON and RN Team Leader) are present in the building than the team (Administrator, DON and RN Team Leader) decide about placing a wander guard bracelet on Resident #1. RN #3 stated that Resident #1 when first admitted would pace the short hall by the smoke exit door until it was time to go out and smoke. RN #3 stated that some of the residents at risk for wandering were checked every hour and some every two (2) hours but this was not documented anywhere. RN #3 stated that some residents, visitors and families had the keypad code and was able to enter and exit the facility without staff assistance. RN #3 stated that Resident #1 does not look like a resident and that going out was easy for Resident #1 to go outside with a visitor because visitors would believe that she (Resident #1) was a visitor. Interview with the Administrator on [DATE] at 2:20 p.m. revealed that the sign alerting visitors not to let residents exit the facility had just fallen off (date unknown). Interview with RN #4 on [DATE] at 11:30 a.m. revealed that she (RN #4) was on duty the day Resident #1 was admitted ([DATE]). RN #4 stated that RN #3 did the wandering/elopement assessment for Resident #1 and that Resident #1 scored a high risk for wandering/elopement. RN #4 stated that RN #3 reported on [DATE] this score to her and she (RN #4) reported to the DON and obtained a wander guard bracelet on [DATE] from the DON for Resident #1. RN #4 stated that she (RN #4) applied the wander guard bracelet to Resident #1's left ankle on [DATE]. RN #4 stated that she decided to place the wander guard bracelet on Resident #1 because Resident #1 was a new admission, in a new environment, there was not a lot of information sent with Resident #1 and that Resident #1 did not look like a nursing home resident. RN #4 stated that she (RN #4) placed the wander guard bracelet on Resident #1 as a trial to see how Resident #1 was going to do. RN #4 stated that she (RN #4) was not aware of any prior wandering behaviors. RN #4 stated that Resident #1 wanted to smoke a lot and would follow staff and other residents out of the facility to the smoke area. RN #4 stated that resident's at risk for wandering were monitored every two hours but monitoring was not documented anywhere. RN #4 stated that she (RN #4) did not place the wander guard on Resident #1's Medication Administration Record (MAR) to check for placement and function and did not initiate a care plan for Resident #1 related to potential risk for wandering. Interview with the Maintenance Director on [DATE] at 12:00 p.m. revealed that the door keypad codes (total of 5) had been changed today ([DATE]) and that all doors had the same keypad code. The Maintenance Director stated that the keypad code had been given to the Administrator. Interview with Police Officer #1 on [DATE] at 1:05 p.m. revealed a call came in to the police department from the adjoining nursing facility for an "unknown person" on [DATE]. Police Officer #1 responded to the adjoining facility at 3:00 p.m. on [DATE]. Police Officer #1 stated that Resident #1 would not give her name or where she was from. Police Officer #1 stated that the department was just lost with what to do with Resident #1 and thought if Resident #1 was missing surely someone would contact the police department. Police Officer #1 stated that to his knowledge Resident #1 had no identification or other type of bracelet on her (Resident #1) person. Interview with CNA #6 and CNA #7 on [DATE] at 1:15 p.m. revealed that they (CNA #6 and CNA #7) last saw Resident #1 between 2:30 p.m. and 2:45 p.m. while passing out snacks. CNA #6 and CNA #7 both stated that they had no idea which door Resident #1 left out of. CNA #6 and CNA #7 both stated that Resident #1 had a wander guard bracelet on, because when she was brought back through the front door it alarmed. CNA #6 and CNA #7 stated that the other exit doors do not have an alarm on them and a lot of families park in the back and come in and out of the A-wing and B-wing exit doors. Interview with LPN #3 on [DATE] at 1:30 p.m. stated that when Resident #1 was brought back through the front door an alarm did sound. LPN #3 stated that she (LPN #3) did not know that Resident #1 had a wander guard bracelet on as the wander guard was not documented on the MAR to check for placement or function. Interview with CNA #8 on [DATE] at 1:45 p.m. revealed that Resident #1 was last seen when going to lunch about 2:15 p.m.. Resident #1 was in another residents room trying to take a drink. CNA #8 stated on return from lunch at 3:15 p.m. she (CNA #8) did not see Resident #1. CNA #8 stated Resident #1 paced B-wing by the smoke door and had not seen Resident #1 near the front door. CNA #8 stated that Resident #1 had a wander guard bracelet on. Interview with the DON and RN #1 on [DATE] at 2:00 p.m. stated that Resident #1 did not have a wander guard bracelet on prior to [DATE]. RN #1 stated that on return to the facility [DATE] she (RN #1) assessed Resident #1 and did not have on a wander guard, but that she (RN #1) did apply a wander guard on [DATE]. RN #1 stated that no alarm sounded when Resident #1 came back through the front door. Interview with CNA #9 on [DATE] at 2:25 p.m. revealed that she (CNA #9), assigned to Resident #1, had just finished giving Resident #1 a bath between 2:30 p.m. and 3:00 p.m. and Resident #1 was walking toward B-wing to smoke. Interview with LPN #4 on [DATE] at 2:35 p.m. revealed that Resident #1 would walk halls near B-wing always wanting to smoke. LPN #4 stated she (LPN #4) last saw Resident #1 between 2:45 p.m. and 3:00 p.m. walking in hall toward B-wing asking to smoke. LPN #4 stated between 5:15 p.m. and 5:30 p.m. she (LPN #4) and LPN #3 went to the police station and picked up Resident #1. LPN #4 stated that on return from the local police station, coming in the front door the wander guard alarm sounded and that Resident #1 did have a wander guard bracelet on her ankle. Interview with the Administrator on [DATE] at 3:15 p.m. stated that she (Administrator) did not understand why RN #4 and other staff would say that Resident #1 had on a wander guard bracelet on [DATE] and never care plan this for Resident #1 for being at high risk for wandering/elopement or document monitor on the MAR or tell anyone about the wander guard bracelet. Interview with RN #1 and RN #2 on [DATE] at 9:30 a.m. revealed that the facility did not have a policy and procedure for wandering/elopement assessments. Both RN #1 and RN #2 stated that the facility reviews the Wandering Resident Assessment quarterly, with significant change in mental status and mobility. Review of Resident #1's nurses notes revealed the following: [DATE]"uncooperative, withdrawn, disinterested with staff, with other residents, resident is in her room most of the time, paces up and down the hall wanting to go smoke then back to her room; repeats questions showing signs of being lost or bored daily. "can I go smoke now." Had repetitive physical movements daily. pacing appears withdrawn is aggressive, is demanding, difficulty following directions at times, uncooperative irritable makes decisions which are poor; requires cues and supervision when making decisions"; [DATE] "Pacing up and down hallways redirection talk with resident no change noted in intervention, will continue to monitor, flat affect, limited insight, staff assist needed to reorient, confused at times, difficulty following directions at times, pacing repetitive questions restlessness in and out of her bed can't sit still exit seeking stealing from other residents and staff taking (stealing) cigarettes from other residents. withdrawn behavior wandering nervousness";[DATE] "Resident has been pacing the halls going into other's room and drinking whatever they have. Getting into refrigerator in snack room and takes the top off of the pitcher and drinks from it and replaces it back into refrigerator; while you are trying to give her a glass. She is constantly asking to go smoke"; [DATE] "has difficulty making decisions in new situations, can I smoke Repeats questions showing signs of being lost or bored daily". Review of a nurses note dated [DATE] at 6:06 p.m. (late entry for [DATE]) revealed "exited building without notifying staff [DATE] between 2:45 pm and 3:00 pm day shift. Resident was noticed not to be in facility at about 4:45 pm when staff was announcing it was time for supper. Upon facility search, in and out of facility, with no success of identifying residents whereabout, a call was made to (name of facility), located next door to this facility. It was discovered that the police were called out to their facility due to a visitor, with suspicious behavior, inside of facility. A call was place to (name) police department and it was discovered that they indeed had resident in custody and facility staff could pick her up immediately. Resident was retrieved and returned to our facility with her making a statement that the reason she left was that she was looking for a cigarette." Review of Resident #1's Activity of Daily Living (ADL) Flow Record for [DATE] revealed that on [DATE], [DATE] through [DATE] Resident #1 was code for wandering behaviors. Resident #1 exhibited no behaviors on [DATE] or [DATE]. Review of a mental health pre-evaluation screening form for Resident #1 dated [DATE] revealed the following documentation: "psychotic-like behaviors withdrawn, does not make sense, loose association, wanders off, disorganized speech or behavior, suspiciousness, flat or inappropriate affect, poor judgement." Review of Resident #1's initial care plan and CNA care card dated [DATE] revealed no documented evidence that Resident #1 was care planned for high risk for wandering and there were no interventions for monitoring/supervising of Resident #1's high risk for wandering. Review of a police report dated [DATE], time 3:00 p.m. revealed incident-unknown person. Narrative: "Suspect later known as (name) (Resident #1), was picked up at (name) (adjoining nursing facility) she was unable to tell officers who or where she came from. She is transported to (name) jail." RN #1 submitted a printed document on [DATE] at 12:06 p.m.. RN #1 stated that this is the guide the facility uses for assessing residents at risk for wandering. Review of the guide titled "Wandering Resident Assessment" revealed "High Risk for Wandering/implement a plan of care to safeguard resident including but not limited to increased supervision, wanderguard/other code alert bracelet, frequency checks, structured activities through the day, redirection techniques, etc. Reassess wandering with a change in cognitive and or mobility status." Review of the facility policy Wandering/Elopement, last revision date 2010, revealed "It is the policy of this facility to identify those residents at risk for wandering/elopement and to take appropriate steps to minimize the risk of an elopement. All residents are assessed for the potential to wander prior to or upon admission using the Wandering Resident Assessment. The facility will identify the behavior and interventions to be implemented on the resident care plan. Staff monitors risk factors and documents the resident's whereabouts every two hours if resident has wandering bracelet in place and every thirty minutes if a refusal has been obtained for the wandering bracelet to ensure that the resident's safety and well-being are maintained. Unsafe Wandering or Elopement-Wandering is random or repetitive locomotion. This movement may be goal- directed (e.g., the person appears to be searching for something such as an exit) or may be non goal-directed or aimless. Non-goal directed wandering requires a response in a manner that addresses both safety issues and an evaluation to identify root causes to the degree possible. Moving about the facility aimlessly may indicate that the resident is frustrated, anxious, bored, hungry, or depressed. Unsafe wandering and elopement can be associated with falls and related injuries. A resident entering into another resident's room may lead to an altercation between residents or result in the resident's lost items and clothing. Alarms can help to monitor a resident's activities. Staff responds to the alarms sounding in a timely manner. Alarms do not replace the staff's supervision of resident's. Code Alert Bracelet is used to discreetly identify residents at risk for wandering and/or eloping." Review of the facility policy Monitoring of Wander Guard System, dated [DATE], revealed "Purpose It is the policy of Rest Haven Health and Rehab to monitor the wander guard system to ensure safety of the residents and to ensure proper functioning of the system. Policy 1. Nursing will test wander guard transmitting device daily for adequate alarm functioning of the transmitter and document on MAR and initial. 2. Nursing will record daily on checking of device functioning. Doors will be checked weekly for adequate functioning. 3. Any malfunctioning will be report to maintenance. 4. Wander guard bracelets will be changed every year and as needed or when expired. 5. Nursing will check to see if device is in place every shift and indicate location of device (on R wrist, R ankle, etc) on their MAR and initial." Review of the facility policy Abuse Prevention, Investigation and Reporting, last revision date 2010, revealed "Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. "Neglect" is clarified by inclusion of the reasonably prudent person standard, which is now used to determine what action is necessary by the caretaker, to maintain the vulnerable adult's mental and physical health. Again, only a single incident is necessary for a determination of neglect. Neglect occurs when facility staff fails to monitor and/or supervise the delivery of resident care and services to assure that care is provided as needed by the residents." Review of the facility policy for Care Planning, 2011 revealed "The interim care plan is developed within 8 hours of admission to the facility and is based on resident needs identified in the admission nursing assessments, physician admission orders [REDACTED]." "Allegation of Compliance (AoC)" "On Sunday, [DATE], Resident #1 left the facility somewhere between 2:45pm and 03:00pm in search of a cigarette but failed to notify staff about her departure. Resident #1 was last seen standing in common area of B-hall at 2:45pm, on [DATE] by Registered Nurse #1 (RN). At 4:45pm, Certified Nursing Assistant's (C.N.A.) were assisting residents to the dining area for the supper meal, when it was noted that Resident #1 was not present at her table by Certified Nursing Assistant #2 (C.N.A.). Certified Nursing Assistant #1 went to Resident #1's room at approximately 4:46pm to see if Resident #1 was ready for supper, but did not find Resident #1 in room so C.N.A. #1 began a search at 4:46pm for Resident #1. C.N.A. #1's search extended to all areas of facility and the designated smoking area located to the east side of the facility. RN #1 was notified by C.N.A. #1 at 4:48pm that Resident #1 could not be found. RN #1 announced Code Purple (resident elopement) at 4:48pm on [DATE] for Resident #1. RN #1 assigned LPN#2 and LPN#3 to search outside parameters of facility (Rest Haven Health & Rehab). C.N.A. #1 and C.N.A.#3 was assigned to search outside within the parameters of the property. LPN#2 and LPN#3 at approximately 4:52pm got into LPN#2's private vehicle to begin searching outside the parameters of the facility property. A call was made at 4:54pm on [DATE] by Licensed Practical Nurse#3 (LPN) to local nursing facility, which is located on adjoining property. LPN#3 was made aware by a staff member answering the telephone of the local nursing facility that the local police department had been called to the facility for a person who matched the description of Resident #1, who was looking for a cigarette. LPN#2 placed a call at 4:55pm on [DATE] to the local police department and was told by police dispatch, that a woman matching the description of Resident #1 was in the police station in a holding cell. LPN#2 and LPN#3 went to pick Resident #1 up in LPN#2's private vehicle on [DATE] at approximately 5:02pm, at the local police department and returned Resident #1 to facility on [DATE] at approximately 5:10pm. A physical assessment was completed by RN#1 on [DATE] between 5:15pm and 5:20pm. Resident #1 was found by RN#1 to have no noted injuries and displayed no signs or symptoms of distress. RN#1 applied a wander guard bracelet to left ankle of Resident #1 at approximately 5:35pm. Resident #1 was placed on 15 minute monitoring checks on [DATE] at 6:15pm by RN#1. Resident #1 was counseled on