Every finding on record at Lake Park of Madison Nursing and Rehabilitation Ce

Based on observations and interviews, the facility failed to maintain a clean and sanitary environment in the shower rooms, soiled utility rooms, and laundry room (photographic evidence obtained). The findings include: A tour of the facility was conducted on 10/31/24 at 11:00 AM with the facility's Administrator and Maintenance Director. During this tour, the following areas of concern were identified: In the East Side Shower Room, 3 of 3 shower stalls were observed to have a large build-up of dark matter on the walls, grout lines, and floors. In the [NAME] Side Shower Room, 2 of 3 shower stalls were observed to have a large build-up of dark matter on the walls, grout lines, and floors. In the East Side Soiled Utility Room, 2 garbage cans were observed without lids. One laundry cart was observed without a cover. Within the laundry cart, the surveyor observed soiled linen present which was not secured in a bag. Also within the laundry cart was a large amount of garbage present under the moveable bottom of the cart. A large build-up of ice in the freezer of the specimen refrigerator located in this soiled utility room was also observed. In the [NAME] Side Soiled Utility Room, 1 laundry cart was observed without a cover. Within the laundry cart, there was soiled linen present which was not secured in a bag. Also within the laundry cart was a large amount of garbage present under the moveable bottom of the cart. The surveyor observed a large build-up of ice in the freezer of the specimen refrigerator located in this soiled utility room as well. In the soiled area of the laundry room, 2 uncovered garbage cans and 2 uncovered laundry bins were observed. The inner liner of 1 of the 2 laundry bins was observed to have numerous rips around the top edge of the bin. Both laundry bins had a large build-up of dirt and debris present in the bottoms. In the dryer room, 2 of 3 dryers had a large build-up of lint and other foreign substances, such as nuts, coins, razor guards, drinking straws, water bottle caps, and plastic lighter parts were present in the lint trap areas. An interview was conducted with Staff A, Laundry Aide, during the laundry room tour. She stated the laundry staff clean the lint traps every 2 hours and the maintenance department cleans the lint traps monthly. The Maintenance Director confirmed that the maintenance department performed monthly maintenance on the dryers.

Based on interviews and record review, the facility failed to complete a comprehensive assessment for 1 of 5 residents sampled for nutrition. (Resident #54) The findings include: A review of Resident #54 electronic medical record revealed the following recorded weights: 2/1/23- 113.8 pounds (lbs.) 3/4/23- 111.6 lbs. 4/5/23- 106.0 lbs. 5/4/23-106.2 lbs. 6/4/23- 102.4 lbs. 7/5/23- 94.6 lbs. These weights indicate that Resident #54 had a weight loss of 16.9% of the resident's total body weight within a six month time frame. A review of the Minimum Data Set (MDS- a comprehensive standardized assessment of each residents' functional capabilities and health needs) dated 5/3/23 revealed that the facility marked No/Unknown for the question asking if the person has experienced a weight loss, loss of 5% or more in the last month or loss of 10% or more in the last 6 months. On 7/20/23 at approximately 12:04 PM, an interview was conducted with the Chief Operating Officer, who confirmed that the MDS quarterly assessment on 5/3/23 did not appropriately capture the significate weight loss for Resident #54. A review of the Policy titled MDS 3.0 Completion provided by the facility which did not have a date reviewed/revised or date implemented stated, Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan.

Based on observations, interviews, and record review, the facility failed to develop a comprehensive care plan for 1 of 5 residents sampled for nutrition. (Resident #38). The findings include: A review of the electronic medical record for Resident #38 revealed that the resident's weight on 2/17/23 was documented as 117.6 pounds. On 7/17/23, the resident's weight was documented as 103.2 pounds, which is a 12.24% weight loss. Review of the Minimum Data Set (MDS) dated [DATE] revealed that the facility did record that the resident experienced significant weight loss, but was not on a physician-prescribed weight loss regimen. Review of the Comprehensive Care Plan for Resident #38 revealed no documentation concerning significant weight loss or nutritional needs. On 7/20/23 at approximately 10:30 AM, an interview was conducted with the MDS coordinator in reference to the care plan for Resident #38. The MDS coordinator confirmed that the resident was coded on the MDS for weight loss but that there was not a care plan for nutritional needs or weight loss for Resident #38. The MDS coordinator agreed that weight loss should have been included and stated, It somehow got missed. On 7/20/23 at approximately 10:35 AM, an interview was conducted with the Director of Nursing (DON), who stated that it was her expectation that residents with weight loss to be care planned for nutrition. Review of the facility policy titled Comprehensive Care Plans date reviewed/revised 1/4/23 revealed: Policy: 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.

Based on observations, interviews, and record review, the facility failed to provide quality of care for the treatment of a skin tear for 1 of 2 residents sampled for skin conditions (non-pressure). (Resident #48) The findings include: Observations of Resident # 48 were made for the following dates and times: On 7/18/23 at approximately 1:30 PM, a skin tear was noted to the top of the left hand which appeared to be scabbed over and redness was noted to the base of the area. At this time, an interview was conducted with Resident #48, who stated that he was being changed by the staff and holding onto the rail. However, when he went to turn over, he hit his hand on the over bed table. On 7/19/23 at approximately 8:45 AM, Resident #48 was observed to be lying in bed watching television with no dressing observed to the top of the resident's left hand. On 7/19/23 at approximately 11:20 AM, Resident #48 was observed lying in bed watching television, still with no dressing to the top of his left hand observed. A review of Resident #48's medical records revealed that there was no order written for the treatment of the top of the left hand. A review of the nurses progress notes revealed no documentation concerning the area to the top of the left hand. On 7/19/23 at approximately 2:10 PM, an interview was conducted with Nurse B, a Licensed Practical Nurse (LPN), concerning the area to the top of Resident #48's left hand. Nurse B stated, I think he got the skin tear to his hand a couple of weeks ago. Nurse B confirmed there was no order for treatment in the resident's medical record. On 7/19/23 at approximately 2:30 PM, an interview was conducted with the Director of Nursing (DON). When informed that there was no documentation concerning the area to the top of Resident #48's left hand, and no treatment orders noted in the resident's records, the DON stated she would look into that. On 7/19/23 at approximately 3:30 PM, a follow up interview was conducted with the DON, who stated that there was an incident report filled out for the skin tear by the night nurse and that the family and physician were notified. The DON went on to state that the night nurse did not write the treatment order for the skin tear in Resident #48's chart, so it was missed. The DON went on to state that the nurse was given a verbal counseling and that they have already started an in-service for the staff concerning skin tears and incident reports. A review of the incident report, dated 7/11/23 at 11:56 PM, revealed, Aid notified this writer that resident had blood to hand. When entered room noted skin tear to left hand. Resident stated he hit his hand on bedside table. Notified provider of skin tear. Clean left hand with NS (normal saline) applied steri-strips (tape that holds the skin together) and three layers of Visco paste and dry dressing. Made several attempts to notify family with no answer and no call back. Notified resident of new treatment order to hand. The policy titled Incidents and Accidents (dated 1/4/23) revealed: Policy: It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Compliance Guidelines: 6. in the event of an incident or accident, immediate assistance will be provided, or securement of the area will be initiated unless it places one at risk of harm. 7. Any injuries will be assessed by the licensed nurse or practitioner and the affected individual will not be moved until safe to do so. First aid will be given for minor injuries such as cuts or abrasions. 9. The nurse will contact the resident's practitioner to inform them of the incident/accident, report any injuries or other findings, and obtain orders, if indicated, which may include transportation to the hospital dependent upon the nature of the injury(ies). 12. The nurse will enter the incident/accident information into the appropriate form/system within 24 hours of occurrence and will documents all pertinent information. 13. Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained or follow-up interventions.

Based on observation, interview, and policy review, the facility failed make ashtrays made of noncombustible materials accessible to all residents in the smoking area for 4 of 4 sampled residents for observation during smoking. (Resident #21) The findings include: On 7/17/23 at approximately 1:15 PM, an observation of residents in the designated smoking area was conducted. Staff Member A, a Restorative Certified Nursing Assistant (CNA), was present to assist and observe the residents during smoking. There were 4 residents (Residents #8, # 20, # 21, and #25) who were smoking around a dust pan. The surveyor observed all 4 of the residents bumping cigarette ashes into the dust pan. The dust pan had multiple extinguished cigarettes in it. The smoking area had 2 other ashtrays located on the other side of the smoking porch. The nearest safety ashtray was more than 15 feet away from the 4 residents during the observation. 2 of the 4 residents who were using the dust pan utilized a wheelchair for mobility. An interview was conducted with Resident #21. He was asked why the residents were using the dust pan. He explained that the other ash trays were difficult to reach. (Photographic evidence was obtained) On 7/17/23 at approximately 1:25 PM, an interview was conducted with Staff Member A, CNA. She was asked if she was responsible for observing the residents during the smoking. The surveyor pointed out to Staff Member A that 4 of the residents were utilizing a dust pan as an ash tray. The surveyor explained that it appeared that the residents might not be able to reach an ashtray. She was asked if they should be utilizing a dust pan instead of a safe ashtray. Staff Member A did not respond but immediately went out to the smoking porch to move an ashtray closer to the 4 residents. On 7/20/23 at approximately 9:15 AM, a second observation was made in the designated smoking area. The same 4 residents were smoking around a dustpan and using it as an ashtray. The dustpan had multiple extinguished cigarettes and ashes in it. Staff Member A was again supervising smoking. The Facility Administrator (FA) was notified. An interview was conducted in the designated smoking area with the FA at approximately 9:20 AM. During the interview, Residents #8, # 20, # 21, and #25 continued to utilize the dust pan as an ashtray. The FA immediately removed the dust pan. She asked Residents #8, # 20, #21, and #25 not to utilize a dustpan for cigarettes or ashes any more. She placed a safety ashtray next to the 4 residents. The administrator was asked for a copy of the facility smoking policy. The FA was asked if the residents should be utilizing a dust pan as an ashtray. She said: Absolutely, no they should not. On 7/20/23 at approximately 10:15 AM the FA provided a copy of the facility's smoking policy along with a purchase order for an additional new flip top floor ashtray that had just been ordered for the smoking area. The FA also provided a copy of a retraining that was just conducted with Staff Member A regarding safety on the smoking porch. The training stated that residents on the smoking porch are not to utilize anything but smoking urns to extinguish cigarettes and ashes. A review of the facility policy titled Resident Smoking was conducted. The policy listed that the facility would provide ashtrays made of non-combustible materials and safe design.

Based on observation, interviews and policy review, the facility failed to assure that services being provided meet professional standards of quality for 1 of 6 residents sampled for Medication Administration review. (Resident #61) The findings include: A record review was conducted for Resident #61 which revealed orders for Metoprolol Tartrate Tablet 25 milligrams (MG), give 1 tablet by mouth one time a day for atrial fibrillation (A-fib, an abnormal heart rhythm) and Digoxin (medication to maintain normal heart rate) 125 micrograms (MCG), give 1 tablet by mouth one time per day, and Midodrine HCl (medication to treat low blood pressure) Tablet 10 MG, give 1 tablet by mouth every 8 hours as needed for Hypotension (low Blood Pressure). On 07/19/23 at approximately 09:30 AM, an medication administration observation was made of Nurse B, a Licensed Practical Nurse (LPN). Nurse B was observed to dispense all routine medication into a medication cup and approached Resident #61 who was sitting upright in bed. A Blood Pressure (BP) was obtained by wrist cuff with residents' right arm lying at her side with a reading of 74/44. The nurse prepared to assist Resident #61 to take her medications as ordered. After observing the BP reading, Nurse B was asked if she thought she should give the Metoprolol, as this medication is usually contraindicated for anyone with a low blood pressure reading. Nurse B responded, this lady has a history of low BP, and she is getting Metoprolol for her A-Fib not her BP. Nurse B was asked if there were BP Parameter orders to hold the drug. Nurse B then reviewed the orders and verified that there were no parameters. On 07/19/23 at approximately 10:50 AM, an interview with the LPN Unit Manager was completed. The Unit Manager reported that Nurse B had informed her of Resident #61's BP of 74/44 and that she had repeated the BP with a standard arm cuff but there was no documentation of the result. The BP obtained with a standard cuff was 90/60. Nurse B was asked if she had called care provider to advise of findings of BP 74/44. She responded she had notified the Assistant Director of Nursing (ADON) of the findings, and he was to notify the APRN (Advanced Practice Registered Nurse) to obtain follow up orders so she could continue with medication administration. On 07/19/23 at approximately 11:00 AM, an interview was conducted with the ADON. He reported that he had notified the APRN of the resident's BP and that the Metoprolol was being held. He stated that the APRN wanted to review residents record before giving any further orders. On 07/19/23 at approximately 11:49 AM, the Director of Nursing (DON) was interviewed regarding her expectations for nursing staff if they assess a BP of 74/44. She responded, I would expect them to lay the patient down, verify BP, if still low, hold the drug, notify the physician. On 07/19/23 at approximately 12:07 PM, a telephone interview was conducted with the APRN, who stated We do not typically write parameter orders for Metoprolol; I would expect a nurse to hold the drug and call me. I would expect them to repeat the BP reading with a manual cuff or Dynamap (an automatic machine used to assess blood pressure electronically). The APRN verified that the Midodrine order should have parameters for administration. She reports that the order had been given by a previous provider. She stated, I am not certain what the outcome would have been had the drug been given because I am not certain that the BP obtained was accurate, but if was it could have sent her to the hospital. A further review of the Electronic Medication Record (EMAR) for Resident #61 revealed a new order per APRN dated 7/19/2023 stating, 11:56 a.m.: Metoprolol Tartrate Tablet 25 MG Give 1 tablet by mouth one time a day for A-fib HOLD IF SYSTOLIC IS LESS THAN 100. On 07/20/23 01:03 PM, the DON provided a document titled Teachable Moment dated 7/19/2023 which revealed a written nursing in-service on what to do for a patient with a BP less than 100/60. (photographic evidence obtained). A review of the Medication Administration Policy (Revised date 1/2/2023) revealed: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 9. Position resident to accommodate administration of medication. 17. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR. 18. Report and document any adverse side effects or refusals. 20. Correct any discrepancies and report to nurse manager . A review of article dated February 19, 2023, in Stat Pearls for the National Institute of Health National Library of Medicine reveals, Hypotension is a decrease in systemic blood pressure below accepted low values. While there is not an accepted standard hypotensive value, pressures less than 90/60 are recognized as hypotensive. Review of Libre Text Nursing Pharmacology (Open RN) 11.04, Chapter 4 revealed: 5.a. Before administering metoprolol, the nurse should always assess the patient's blood pressure and pulse. 5.b. If the systolic blood pressure is less than 100 mm Hg or the apical heart rate is less than 60 beats per minute, the medication should be withheld and the provider notified unless other parameters are provided in the order. Review of Proper use of a wrist cuff instructions presented by the American Medical Association (AMA) revealed: Using a wrist cuff to measure your blood pressure 1. Apply the cuff to your wrist 2. Keep your elbow on table or desk with your forearm bent 3. Place your wrist at the level of your heart 4. Keep your arm relaxed and your hand resting against your body 5. Measure your wrist blood pressure without moving your arm from seated position.

Based on observation, interviews and policy review, the facility failed to maintain its infection prevention and control program for 2 of 6 residents sampled for Medication Administration review. (Residents # 27 and #61) The findings include: On 7/19/2023 at approximately 9:08 AM, an observation was made of Nurse B, a Licensed Practical Nurse (LPN), taking a blood pressure on Resident #27 with a wrist cuff (a piece of medical equipment designed to measure blood pressure on the wrist of a patient). This wrist cuff was taken from the med pass cart prior to providing Resident #27 with her morning medications. Nurse B then placed the wrist cuff on top of medication cart while she prepared medications for Resident #61 in the next room. The nurse then picked up the medication cup and the same wrist cuff and proceeded into Resident #61's room, where she then obtained a blood pressure with wrist cuff for Resident #61. The wrist cuff was not wiped down with disinfectant between the use for these two residents. On 7/19/2023 at approximately 9:40 AM, an interview was conducted with Nurse B concerning infection control policy for multiuse equipment. When asked if there was a policy for cleaning of multiuse equipment between residents, Nurse B stated I'm not sure. When asked if the equipment should be disinfected between residents, Nurse B replied probably. On 7/19/2023 at approximately 10:00 AM, an interview was conducted with the Assistant Director of Nursing (ADON) concerning the policy for disinfection of multiuse equipment. The ADON responded I will check. On 7/19/2023 at approximately 10:10 AM, a follow up interview was conducted with the ADON, who verified that multiuse equipment was to be disinfected between residents with each use per facility policy. A copy of the policy was requested. Review of the Policy titled Cleaning and Disinfection of Resident-Care Equipment (revision date 01/04/23) revealed: Policy: Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection. 1. Staff shall follow established infection control principles for cleaning and disinfecting reusable, noncritical equipment. General guidelines include: a. Verify whether the equipment is single-use or reusable. Discard single-use items after use. b. Each user is responsible for routine cleaning and disinfection of multi-resident items after each use. c. Direct care staff are responsible for cleaning single-resident equipment when visibly soiled, and according to routine schedule (where applicable). d. Multiple-resident use equipment shall be cleaned and disinfected after each use.

Based on record review, staff interview and policy review, the facility failed to develop a comprehensive care plan for 1 of 5 residents sampled for unnecessary medication review (Resident #15) and 1 of 3 residents sampled for respiratory care (Resident #14). The findings include: Resident #14 A review of Resident #14's clinical record was conducted. Review of the admission Minimum Data Set (MDS - a comprehensive, standardized assessment of each resident's functional capabilities and health needs) with an assessment reference date of 12/20/2021 revealed the following under Section I - Active Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section N - Medications revealed the resident received several medications for shortness of breath. Review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's comprehensive care plan dated 12/01/2021 did not indicate the facility was providing respiratory care to the resident. On 03/23/2022 at approximately 11:00 AM, an interview was conducted with the facility's MDS Coordinator. The MDS Coordinator reviewed Resident #14's clinical record and confirmed the resident had respiratory issues that were being addressed by the facility. The MDS Coordinator further confirmed that the comprehensive care plan did not address this area. Resident #15 A review of Resident #15's clinical record revealed the resident received [MEDICATION(S)] 50 mg daily for hypertension since 05/20/2021 and Tylenol with [MEDICATION(S)] #3 three times a day routinely for pain since 12/31/2021. The significant change MDS with an assessment reference date of 01/06/2022 revealed hypertension under Section I - Active Diagnoses. Review of Section J - Health Conditions revealed the resident receives a scheduled pain medication regimen and indicates the resident had pain or hurting in the last 5 days. Review of the resident's current comprehensive care plan revealed no care plan related to hypertension or pain. On 03/23/2022 at 11:07 AM, an interview was conducted with the MDS Coordinator. He stated he missed care planning Resident #15 for hypertension and pain and confirmed this should have been included in the care plan. A review of the Care Plans, Comprehensive, Person-Centered, Culturally Competent and Trauma Informed (revised December 2016) policy and procedure indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Item #8 states the comprehensive, person-centered care plan will: g. incorporate identified problem areas; h. incorporate risk factors associated with identified problems.

Based on observation, staff interview and record review, the facility failed to ensure 1 of 3 vulnerable residents at risk for elopement (Resident #1) was not able to exit the building unsupervised via a window on 2/09/21. Additionally, on 3/29/21, the facility failed to ensure windows and all entry/exit doors were secured to prevent subsequent elopements for 1 of 2 current residents at risk for elopement (Residents #2). The facility's failure to prevent an elopement and eliminate potential hazards placed 2 residents at a likelihood of serious injury and death. Residents are at risk for being injured or killed by passing cars on the highly traveled highway 90 that runs in front of the facility, drowning in lakes/holding ponds that surround the facility, or trapped, injured, or killed in the barbed wired fencing that surrounds the dairy farm located directly behind the facility. Also, residents could be harmed by entering an unlocked, unmanned maintenance shed located behind the facility that houses tools, other maintenance equipment, and chemicals. The situation resulted in a finding of isolated Immediate Jeopardy at a scope and severity of J. The facility Administrator was notified of the Immediate Jeopardy finding on 3/31/21 at 5:10 PM, prior to survey exit on 3/31/21. The Immediate Jeopardy was determined to have begun on 2/09/21, the day Resident #1 exited the building unsupervised via a bedroom window. Immediate Jeopardy was found removed on 3/31/21 when the facility provided evidence of immediate corrective actions. The deficient practice was reduced to a scope and severity level of a D. The findings include: On 3/29/21 at approximately 10:30 to 11:15 AM, a tour was conducted of the facility which revealed 2 resident smoking porches, on the East and West wings, located in the front of the building that exited to the front and side parking lots. The East side door did not alarm when opened, the West side door did alarm, however, on both porches the screen doors exiting the patio/smoking area to the parking lots were unlocked. No staff supervision was observed. During the tour, staff provided a copy of the Elopement Book, a book that contained photographs, a physical description, and the room number of 2 residents that were currently noted to be at high risk of elopement (Residents #2 and #3). Observations of resident #2's room found the window lock to be malfunctioning and the window could be easily opened in either the locked or unlocked position. At this time the resident's roommate indicated the lock has been that way forever. On 3/29/21 between 12:35 PM to 1:05 PM, a tour was conducted outside the building to include the facility parking lots, behind the facility, and the area within 1 mile radius around the facility. During this tour, a female resident was observed to be sitting in a wheelchair on the West wing porch unsupervised by staff. On the East wing porch, a male was also sitting unsupervised. Located at the back of the facility was a maintenance room/office with an unlocked, opened door. Inside were tools and other maintenance supplies. No staff were present, a sign posted read Authorized personnel only. Located behind the facility was a farm which is surrounded by a 4-string barbed-wire fence. There were four buildings and several sheds/barns on the property along with a partially collapsed barn or shed. (photographic evidence obtained) Resident #1 On 3/29/21 a record review was conducted for resident #1 which revealed a nursing note dated 2/09/21 at 1751 (5:51 PM) in which the nurse documented the resident was not in her room at approximately 3:30 PM, and that staff had found her window open with the screen leaned back against the window. The note goes on to say that the sheriff department was notified, and law enforcement found the resident unharmed a short distance from the facility. Review of the facility's investigation of the incident revealed Resident crawled out of the window to her room and replaced the screen to look as if it had not been moved. Resident stated the night before that she was wanting to find her husband. The review also revealed that the resident was wearing a wander alarm (a bracelet type device that alarms if a resident breaches the predetermined perimeter) at the time of her elopement and had previously been on one on one (1:1) staff supervision for exit seeking and threats of suicide but had been taken off 1:1 four days prior to her elopement for not exhibiting exit seeking behaviors (2/5/21). Review of the two witness statements provided by the facility revealed that staff member F, a certified nursing assistant (CNA) had reported she had noticed an elderly white female walking from out of the parking lot at approximately 2:45 PM, on 2/09/21, as she was arriving for her shift. She further stated that she did not realize the woman was a resident of the facility because she had not taken care of her as she worked on the East wing of the facility and the resident was housed on the West wing. Review of the second witness statement by staff member C, the CNA who was caring for the resident at the time she eloped, stated in its entirety Last time that I saw (Resident #1) was at 2:50 during last rounds. Neither statement was dated, and no other statements were obtained by the facility after the event, per the Assistant Director of Nursing (ADON) on 3/29/21 at approximately 12:11 PM. Review of the Madison County Sheriff Office Incident Report dated 2/09/21 indicated the deputy arrived at the facility at 1607 (4:07 PM) after being dispatched for a missing person. He documented that he was advised by dispatch that the resident had altered mental status and has had suicidal thoughts in the past. He further documented that CNA F had reported to him that she had seen the resident walking toward the stop sign at the entrance of the nursing home and was able to give a description of the resident, the clothes she was wearing and the color of a pouch the resident was carrying. The report indicated that the sheriff's deputy was advised at 1617 the resident had been located and was returned to the facility by the police department unharmed. On 3/29/21 at approximately 12:45 PM, the surveyor drove from the facility to the area where the sheriff's report stated an officer had encountered the resident, taking possible routes the resident could have traveled. The facility is located at 259 S Captain Brown Road. Captain Brown Road exits to Highway 90. Highway 90 (also known as U.S. Route 90) is an East-West major United States Highway in the Southern United States. The highway runs from Jacksonville Beach, Florida to Van Horn, Texas. (usends.com reviewed on 3/29/21). The speed limits on this road are 40 to 60 miles per hours within 0.5 miles of the facility, in each direction. Located across the street from the facility, approximately 75 to 100 yards, was a large holding pond with no fence. The resident would have had to cross Highway 90 and walk past the holding pond to reach the area where police encountered her. According to the Sheriff's report, resident #1 was found at College Loop and [NAME] Davis Drive (approximately 0.5 miles from the facility). An observation of the area where resident #1 was located found approximately 50 yards north of the intersection was a body of water without a fence around it which looked to be a small fishing pond or holding pond. Review of resident #1's medical record revealed she had been admitted to the facility on [DATE] with diagnoses of Cerebral infarctions, [CONDITION(S)] with behavioral disturbance, [CONDITION(S)] (a disease that affects the function or structure of the brain), [CONDITION(S)] (A-Fib) (an irregular heartbeat), [CONDITION(S)] (a lung condition that causes shortness of breath), hypertension, suicidal ideations, [CONDITION(S)] (disease of the heart muscle), cognitive social or emotional deficit following CVA (Cerebrovascular accident and stroke) and dysphagia. A review of the discharge paperwork from the hospital revealed she had a history of elopement, confusion, and combative behaviors. The review also revealed the previous hospital had difficulty finding placement for the resident due to her behaviors and that on 1/13/21 the nursing facility had denied the resident stating behavioral management issues and that the facility did not feel they could meet her needs. However, the facility agreed to accept the resident on 1/14/21. Review of the Admission Summary dated 1/15/21 at 1551 (3:51 PM) revealed Resident extremely agitated about being admitted to facility and wants to know when she can go home. Wander guard placed on right wrist for safety. On 1/17/21 at 12:31 PM, a nursing note stated the resident was placed on 1:1 (one on one supervision) for suicidal thoughts/threats resident trying to leave facility. Resident has been reported to be verbally combative toward one on one caretaker and this nurse. The note goes on to quote the resident I am tired of all this and I will commit suicide. The nursing notes document ongoing concerns with the resident's behaviors; 1/20/21 exit seeking and resident agitation; 1/21/21 Passing notes to staff that say she wants to go home 1/24/21 1:1 for self-safety due to prior exit seeking; 1/25/21 reports resident was being verbally abusive to staff, extremely confused and expressing the need to get out of here. At the time of her admission, Resident #1 was receiving [MEDICATION(S)] 5 milligrams (mg) every 12 hours. [MEDICATION(S)] is an antipsychotic used to treat mental disorders. The resident was also receiving [MEDICATION(S)] 500 mg twice a day, an anticonvulsant used to treat psychiatric conditions. Her Brief Interview for Mental Status (BIMS) on her admission Minimum Data Set (MDS) dated [DATE] was noted to be 5 (severely impaired cognition). She was independent with ambulation and activities of daily living with the exception of personal hygiene which required set up assistance. The admission MDS did not identify the resident was wearing any kind of monitoring or alarm device. Review of the resident's base line plan of care dated 1/15/21 indicated the resident was a risk for elopement with a goal will have no episodes of elopement for the next 21 days with interventions to include Apply wander alarm, check placement, working order per facility protocols and to monitor whereabouts frequently. However, review of the Plan of Care dated 1/27/21 made no mention of the resident's elopement risk. Neither Plan of Care identified 1:1 or increased monitoring. A review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for January and February revealed no mention or documentation of the wander alarm, its placement or otherwise. Further review of the record revealed that Resident #1 was transferred to the Coronavirus Disease 2019 (COVID-19) unit on 1/29/21 until she was returned to her original room on 2/5/21. The resident was reported to be on 1:1 during her stay on the COVID-19 unit, with no documented behaviors. However, review of the MAR indicated a new order received on 1/29/21 for [MEDICATION(S)] 0.5 mg give 1 tablet by mouth every 24 hours as needed for anxiety. On 2/5/21 at 9:31 AM, the nurse documented the medication was held and to see nursing notes however there was no corresponding nursing note. On 2/8/21 the resident was seen by the Advanced Registered Nurse Practitioner (ARNP) who documented the resident's chief complaint as I want to go home. At this time the ARNP stopped the resident's [MEDICATION(S)] and started her on Vitamin D. On 2/9/21 at approximately 2:45 PM, the resident eloped out the window in her bedroom and was found 0.5 miles from the facility, across a major highway at a COVID-19 vaccination event being held by the local college. The resident was unattended for 1 hour and 32 minutes, based on witness statements, nursing documentation and review of the Madison County Sheriff's Office incident report. On 3/11/21, 27 days after she was admitted , the resident was transferred to another nursing home with a secured unit. On 3/29/21 at approximately 10:05 AM, an interview was conducted with the facility administrator who stated the facility did not usually admit residents who were elopement risks because the facility did not have a secured unit. She stated that resident #1 was admitted after the facility had initially said no, due to behaviors. She further stated that the resident was admitted with the understanding that if she was not appropriate and did not do well, she would be transferred to another, more secured facility in Jacksonville. She explained that the resident had a history of elopement from another facility. They put the resident on one-on-one (1:1) supervision and put a wander alarm on her following her admission. During the first few weeks the resident did well and did not attempt to leave the facility, therefore they decided to take her off 1:1. The administrator stated the resident eloped through her window on 2/09/21 and that the police had returned her to the facility after hearing a description of her carrying a pink purse. The police officers were approximately 0.5 miles from the facility directing traffic at COVID-19 vaccination site when they encountered the resident. On 3/29/21 at approximately 1:30 PM, an interview was conducted with staff member G, a Licensed Practical Nurse ( LPN), who reported that she was not working the day that resident #1 had eloped but that the resident was always trying to leave and had been passing notes to the staff that she had to get out to see her husband. She also reported that shortly after resident #1 had eloped from the facility, she was sitting at the nursing station one day, she was unable to recall the date, when she heard the zipper to the COVID-19 Unit opening. She stated it was strange to hear that because no one was on the unit and then she saw Resident #1 coming out of the zippered opening. She stated this occurred after the resident had eloped and was on 1:1. She reported another occasion when a Certified Nursing Assistant (CNA) had redirected the resident back to her room after she tried to leave but was unable to recall the date. On 3/29/21 at approximately 2:44 PM, an interview was conducted with staff member C, a CNA, who was working with the resident at the time she eloped. She stated that the facility had started 1:1 because the resident was going to hurt herself but when she returned from the COVID unit she was no longer on 1:1. She reported she last saw the resident at around 2:45 PM, on 2/9/21. CNA C reported resident #1 was pacing, going up to the desk and leaving little notes for staff. She had not stated she wanted to leave but she was not interacting with the CNAs either. She reported the resident would state she wanted to leave a lot. She reported that after resident #1 was returned to the building following her elopement on 2/9/21, the resident attempted to get out the window again, but she was not able to get out. She stated that she was not aware of a section in the chart to document 1:1 supervision. CNA C revealed the wander alarm system will alarm if the resident tries to leave through the front door. CNA C revealed all the doors except the door to the smoking area alarmed when someone tried to exit the doors. On 3/29/21 at approximately 3:06 PM, an interview was conducted with staff member E, an LPN, who reported resident #1 had been placed on 1:1 because she had a history of attempting to leave the facility and because she wanted to harm herself. The resident had graduated off 1:1, but was still on increased monitoring at the time she eloped out her window on 2/9/21. She went on to say that she feels the resident did not walk toward the front of the building after she exited the window as staff would have seen her from the smoking porch and felt that the resident had walked behind the building. The nurse went on to say that documentation of the increased monitoring and the wander alarm would be noted in the resident's record on the plan of care, on the MAR/TAR (Medication Administration Record/ Treatment Administration Record) and on the task sheet; however, when staff member E looked in the resident's record she could not find the documentation stating, It is not here. LPN E stated she could remember that resident #1 was on 1:1. She also reported that the resident had attempted to elope two more times since she was returned to the facility; however, the resident was on 1:1 and staff were able to redirect her. On one of the attempts the resident was able to wander into the COVID-19 isolation area through a zippered secured plastic barrier without staff knowledge (neither of these events were documented in the resident's record). LPN E also reported that the wander alarm system only works on the front door, the other doors in the facility will alarm after 15 seconds except for the smoking doors. She indicated the doors to the porches do not alarm nor do the screen doors on the porches outside the smoking doors. LPN E also confirmed the gates do not lock but they have latches. Interview with staff member K, LPN, on 3/30/21 at 11:30 AM, revealed that following resident #1's elopement the facility implemented the elopement book with photographs of residents at risk for elopement so staff would have a description. LPN K revealed that prior to resident#1's elopement there was not a book that informed staff of which residents was at risk for elopement. She indicated that she never knew who resident #1 was before the elopement because she did not work on the West wing. She stated there was not a book on the East wing, we just knew which residents were elopement risks. LPN K stated that the elopement book was the only intervention implemented since resident #1's elopement. On 3/30/21 at approximately 11:45 AM, during an interview with the ADON, she revealed that documentation of 1:1 supervision could be found in the nursing progress notes. Also, if a resident was on 1:1 supervision, a CNA would be assigned and that documentation could be found on the staff assignments sheets. When asked about the facility's protocol for removing a resident from 1:1, the ADON revealed we don't remove 1:1 until a resident has shown improvement and the behavior is no longer occurring. If someone is 1:1 we step them down to 15 minutes checks before removing coverage completely to make sure the resident is no longer exhibiting whatever behavior caused the 1:1. On 3/30/21 at approximately 12:11 PM, an interview was conducted with the ADON during which she stated that prior to Resident #1, the facility had not admitted residents who were elopement risks and had denied acceptance of this resident but were forced to take her by the higher ups. On 3/30/21 at approximately 2:17 PM, an interview was conducted with the Admission Coordinator who stated that when the hospital called seeking placement for resident #1 they (the facility) had initially refused to accept her due to her history, behavior concerns and the fact that the resident was not taking her medications. The Admission Coordinator revealed the resident's history was a major concern; however, all denials go up to the Regional Director for review. After reviewing the paperwork, the Regional Director stated they could accept the resident because there had not been documented concerns for the month prior to the transfer. She went on to say that the facility's main focus was therapy such as speech, occupational and physical, not behavior concerns because they do not have a locked unit. The Admission Coordinator reported the facility has a wander alarm system, but it only works on the front door. She stated they will accept residents with dementia and/or Alzheimer's disease as long as they were not exit seeking. On 3/31/21 at approximately 10:26 AM, a telephone interview was conducted with the court appointed guardian for resident #1 during which the guardian stated that the resident was hard to place because she does not have the capacity to make her own decisions and had behaviors to include exit seeking that made finding a facility to accept her more difficult. She stated she had concerns that the resident was going to a facility that was not secured, however this facility had stated that if this did not work, they would transfer her to another, more secure, facility. The guardian stated they ended up transferring her because she got out. She reported that during the resident's stay at the nursing facility, she had gotten calls from the facility that the resident was exit seeking, smoking in the bathroom and being verbally abusive to staff. Resident #2 Medical record review documented resident #2 was admitted on [DATE] with the following medical diagnoses: Unspecified Dementia with Behavioral disturbance; need for assistance with personal care; muscle weakness (generalized). She was ambulatory and was documented to be an elopement risk/wanderer according to the resident's care plan and the facility's elopement risk book. On 3/29/21, resident #2's care plan, dated 2/17/21, was reviewed in the facility's electronic health record. The care plan documented resident #2 was an elopement risk/wander as evidenced by impaired safety awareness, Resident wanders aimlessly. The goals indicated the resident's safety will be maintained throughout the review date. The interventions for the resident included Assess her for fall risk. Distract her from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers. Resident is 1:1 for safety due to wandering and exit seeking behavior. 8/15/20. (Create Date:8/26/20). On 3/30/21, the facility provided the surveyor a printed care plan which was indicated as the current care plan, start date not specified on the plan. This care plan documented resident was an elopement risk/wander AEB (as evidenced by) impaired safety awareness, Resident wanders aimlessly. The plan indicated the facility had attempted to have wander guards on resident, she has removed them multiple times and thrown them away. Date initiated: 8/25/2020. Revision on: 3/24/2021. The goals indicated the resident's safety will be maintained throughout the review date. The interventions for the resident included Assess her for fall risk (date initiated 8/25/20 and revision on 11/18/20). Distract her from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers. (date initiated 8/25/20 and revision on 11/18/20). Q (every) 15 minutes checks (dated initiated 3/24/21). Resident is 1:1 for safety due to wandering and exit seeking behavior. (resolved) (date initiated 8/26/20 and revision on 3/24/21). Resident photograph and information in elopement book (dated initiated 3/24/21). A review of the elopement book located on the East hall included resident #2's name and picture. Under the resident's picture it read Gray hair/Ambulatory, East wing 200 Hall. Review of resident #2's MDS revealed the resident to have a BIMS score of 2 which indicates the resident had severe cognitive impairment. An attempt was made to review the documentation of the resident's supervision status, to include nursing progress notes, physician orders, MAR/TAR, and CNA task documentation however there was no documentation in the resident's record that displayed staff documenting either 15 minutes checks or 1:1 supervision for resident #2. Review of the CNA's task kiosk documentation revealed a task for q (every) 15 minute check; however, staff were not documenting consistently and, on some days, not documenting at all. However, the facility did provide their frequent rounding documentation that displayed every resident on the East Unit was on 15 minutes check for inactive call system. Documentation was not specific to resident #2 but it did include her room number being checked every 15 minutes. On 3/29/21, during an initial tour of the facility between 10:25 AM and 11:15 AM, resident #2's window was found to be unlocked and not closed shut. The surveyor attempted to slide the window closed but even with force the window would not close completely shut. (photographic evidence obtained). This surveyor attempted to place the lock in the locked position, but the window could still be slid back and forth. Interview with resident #7, roommate to resident #2, revealed the window does not always catch. Resident #7 revealed staff were aware of the window not catching and that the window had been in that condition for months. She stated she could not remember who she had informed since it had been so long but remembered telling someone. Resident #7 stated they probably just need to clean the dead insects and frogs out of the window track, and it may latch. (Photographic evidence obtained) Interview with staff member K, LPN, on 3/30/21 at 11:30 AM, revealed resident #2 to be an elopement risk. This staff member indicated that staff must keep an eye on the resident when she is up and moving but they try to keep her sitting by the nursing station. She indicated every 15 minutes we try to keep our eyes on her. When asked where documentation of q 15 minutes checks could be located in the resident's medical record, staff member K revealed if it's not the nursing notes, maybe the CNAs do it in the kiosk since they are conducting the checks more often. Staff member K revealed resident #2 did not have a wander guard in place because the resident would continuously remove it, so it was discontinued. On 3/30/21 at approximately 11:45 AM, during an interview with the ADON, she revealed that resident #2 was an elopement risk and identified in the elopement book was currently on q15 minute checks. The ADON confirmed documentation was inconsistent and indicated that staff were at least expected to document at the end of their shift at a minimum. On 3/29/21 at 10:27 AM, an observation was made of a Common Area near the vending machines. The surveyor found an unlocked exit door leading outside to what appeared to be a smoking porch area. On that porch, there was another exit through an unlocked screen door with access outside the building. There is a gate which leads to the front parking lot. The gate has a latch but there is no lock on the gate. The area is surrounded by offices with some blinds up (left side) and residents rooms with all blinds closed. There was no staff supervision in the area at the time of observation. Residents were observed in the common area unsupervised with easy accessibility to the exit. Interview with staff member K, LPN was conducted on 3/30/21 at 11:30 AM. When asked if there was a process for staff (nurses and CNAs) to check doors and windows she stated she was not aware of one. Staff member K stated, we do not check doors or windows, maintenance staff check doors to ensure doors are properly alarming but that's it. Review of the facility policy Wandering, Elopement Risk Resident last updated in August 2014, states that Nurses and staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) using elopement screener and nursing judgement upon admission and as needed. Interventions will be documented in the resident record and evaluated by the DON/Risk Manager for appropriateness at onset, weekly and when resident has a significant change. Discontinue use of interventions when no longer appropriate according to the following outline: Wander Guard - low no incidents or risk behaviors for past 30 days; frequent checks - medium no incident or risk behaviors for past 14 days and 1 on 1 monitoring- high no incidents or risk behaviors for past 7 days. This outline is subject to change based on individual resident need and customized interventions based on Interdisciplinary (ID) team clinical evaluation. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as increase monitoring, wander guard, etc will be included. Frequent monitoring will be documented upon completion of shift by the staff member assigned to monitoring. Interventions immediately following the resident's elopement on 2/09/21 implemented prior to the survey teams entrance included: Resident #1 being placed back on 1:1 supervision(2/09/21), with referral to physiatrist and ultimate transfer to a facility with a secured unit on 3/11/21. Elopement education provided to 33 out of 116 employees (2/17/21), reassessment of the two other residents in the facility who were at risk for elopement (#2 and #3) which they determined were not at risk for going out the window. The elopement occurred the day before the monthly Quality Assurance Performance Improvement committee meeting and therefore was reviewed by the committee within 24 hours of the event. The root cause analysis concluded that The facility management nor the staff would have any reason to believe the resident would elope or open her window having been stabilized and acclimated to her new home for this length of time. The facility also summarized the findings as Resident was unpredictable and we did not anticipate her being physically capable of climbing out the window. The Admission Notification Form was revised to improve communication of risk areas to staff (3/26/21) The Immediate Jeopardy was removed onsite after the receipt of an acceptable IJ removal plan. The survey team verified the facility's immediate corrective actions: On 3/30/21 the facility maintenance staff repaired the broken/ malfunctioning lock in resident #2's room, placed alarms on the windows of the two residents identified as elopement risks and on the doors, exiting the building to the smoking porches. The facility conducted room by room window assessments to ensure all locks were working properly. They conducted elopement education (3/31/21) either in person or on the telephone to all staff who had not been provided elopement education since the resident eloped on 2/9/21 as evidenced by a staff roster with dates education was provided. The facility also conducted a 100% review of residents in the building with risks for elopement and updated their plans of care accordingly (3/31/21), removing one resident (#3) from the list as she had not demonstrated exit seeking for greater than 6 months. Policy review and updated to include a new protocol for assigning and removing 1:1 care for residents, the use of a text blast Pink Alert to alert all employees of an elopement (3/31/21). Elopement drills have been scheduled to include all shifts monthly for the next 6 months and then annually (3/30/21). Window lock inspections have been added to daily room round inspections.

Based on observation, staff interview and record review, the facility Quality Assurance and Performance Improvement (QAPI) process failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to resident elopement that occurred on 2/09/21 (resident #1). The facility's failure to follow the QAPI process may prevent the facility from correcting and improving their systems to ensure resident safety and prevent serious harm for residents at risk for elopement (Resident #2). The facility's failure to prevent an elopement and eliminate potential hazards placed 2 (Residents #1 and #2) residents at a likelihood of serious injury and death. Residents are at risk for being injured or killed by passing cars on the highly traveled highway 90 that runs in front of the facility, drowning in lakes/holding ponds that also surround the facility or residents could be trapped, injured, or killed in the barbed wired fencing that surrounds the cow farm directly behind the facility. Also, residents could be harmed by entering an unlocked, unmanned maintenance shed located behind the facility that houses tools and other maintenance equipment. The situation resulted in a finding of isolated Immediate Jeopardy at a scope and severity of J. The facility Administrator was notified of the Immediate Jeopardy finding on 3/31/21 at 5:10 PM, prior to survey exit on 3/31/21. The Immediate Jeopardy was determined to have begun on 2/09/21, the day Resident #1 exited the building unsupervised. Immediate Jeopardy was found removed on 3/31/21 when the facility provided evidence of immediate corrective actions. The deficient practice was reduced to a scope and severity level of a D. Cross reference F689. The findings include: Resident #1 On 3/29/21, a review of the medical record for resident #1 revealed that on 2/09/21 at approximately 2:45 PM, the resident eloped out the window in her room and was found 0.5 miles from the facility, across a major highway at a COVID-19 (Coronavirus Disease 2019) vaccination event being held by the local college. Per the facility's investigation, the resident was unattended for 1 hour and 32 minutes, having been seen exiting the parking lot at 2:45 PM, and being returned to the facility at 4:17 PM. On 2/11/21, 27 days after she was admitted , the resident was transferred to another facility with a secured unit. A review of the hospital discharge summary dated 1/14/21, prior to resident #1 being admitted , revealed that the facility had originally been denied acceptance due to behavioral management issues. Interviews conducted with the facility administrator, on 3/29/21 at 10:05 AM, the Assistant Director of Nursing, on 3/30/31 at 12:11 PM, and the Admission Coordinator on 3/30/321 at 2:17 PM, all supported that the facility had previously denied the resident for admission because the facility did not admit residents with exit seeking behaviors, but despite this the resident was admitted on [DATE]. She had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Elopement Investigation prepared by the Regional Director indicated that upon arrival to the facility on [DATE] the resident was agitated and stated she wanted to go home. At this time the facility initiated 1 on 1 (1:1) staff supervision and placed a wander guard (a bracelet type device that alarms if a resident breaches the predetermined perimeter) on the resident's wrist. The investigation states that between 1/16/21 until she was removed from 1:1 on 2/6/21 the resident made no attempts to elope, had one episode of agitation on 1/22/21, and voiced only one time she wanted to leave on 1/25/21. The investigation stated Resident interventions remained in place for 21 days. During that time period, she made no attempt to elope, had no exit seeking behaviors and only stated a desire to go home on 3 distinct days the last of which was on 1/25/21. 15 days prior to her elopement. The investigation goes on to state Due to the nature of her disease process unsafe behaviors are often unpredictable. While her past behavior and statements of wanting to go home put her at an increased risk of elopement, her lack of any attempt to do so lead to the appropriate discontinuation of 1 on 1 supervision on 2/6/21. The facility management nor the staff would have any reason to believe the resident would elope or open her window having been stabilized and acclimated to her new home for this length of time the facility had no reasonable control over the resident's unpredictable behavior. However, review of the nursing notes revealed multiple incidents involving resident #1 that were not mentioned in the elopement investigation. These incidents often occurred on the same days the facility investigation had identified no concerns. The Admission Summary dated 1/15/21 at 1551 (3:51 PM) revealed Resident extremely agitated about being admitted to facility and wants to know when she can go home. Wander guard placed on right wrist for safety. On 1/17/21 at 12:31 PM, a nursing note stated the resident was placed on 1:1 for suicidal thoughts/threats resident trying to leave facility. Resident has been reported to be verbally combative toward one on one caretaker and this nurse. The note goes on to quote the resident I am tired of all this and I will commit suicide. The nursing notes document ongoing concerns with the resident's behaviors; 1/20/21 exit seeking and resident agitation; 1/21/21 Passing notes to staff that say she wants to go home 1/24/21 1:1 for self-safety due to prior exit seeking; 1/25/21 reports resident was being verbally abusive to staff, extremely confused and expressing the need to get out of here. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/5/21 at 9:31 AM, the nurse documented the medication was held and to see nursing notes however there was no corresponding nursing note. And on 2/8/21 the resident was seen by the Advanced Registered Nurse Practitioner (ARNP) who documented the resident's chief complaint as I want to go home. During an interview on 3/30/21 at approximately 3:49 PM, the Regional Director was asked about the discrepancies between the elopement investigation and nursing documentation, ARNP assessment and the physician orders, in which she stated she had only reviewed the electronic medical record and not the paper chart which is where the ARNP notes were kept. She further stated that the nursing notes do not support physical efforts by the resident to get out of the building which is why she was removed from 1:1 supervision because she no longer met criteria. When asked what the criteria was for the resident to be deemed an elopement risk or no longer an elopement risk the Regional Director stated, nursing judgement and when asked to explain this she said it is based on criteria. At no point did the regional director offer clarification on the criteria for being taken off elopement risk protocols, the discrepancy in the documentation or a definition of nursing judgement. On 2/10/21, the day after the resident eloped, a Quality Assessment Performance Improvement Meeting was held during which the elopement of resident #1 on 2/09/21 was reported. A Performance Improvement Plan (PIP) was initiated to address concerns and areas of improvement related to the resident's elopement. A review of a PIP dated 2/10/21 titled Elopement Prevention, with a completion date of 21-Apr-2021. The root cause analysis related to resident #1's elopement was Resident was unpredictable, and we did not anticipate her being physically capable of climbing out the window. The report identified the PIP team would meet every two weeks to measure progress toward identified goals. Interventions were listed with start dates and end dates as well as whether the intervention was successful, partially successful, or in progress. The first intervention listed in the facility's PIP was for training. The PIP documented the following: Retrain staff members regarding elopement policies and protocols (start date was noted to be 10-Feb-21 with an end date of 10-Mar-21). Review of the documentation provided by the facility revealed that 33 of 116 staff members had attended the in-service training on elopement conducted on 2/17/21. The facility provided a copy of the real life drill for the day the resident eloped; however, there have been no additional elopement in-services or training offered to staff since the resident eloped. Another intervention identified in the facility's PIP was for the 1 to 1 staff supervision protocol. The PIP documented the following: each elopement eval (evaluation) will include an assessment of residents capability to exit the facility through a window in addition to other exits and make interventions to prevent such as window alarms. The start date for this intervention was noted to be 17-Mar-21 with an end date of 16-Apr-21. The facility indicated there were 2 residents in the facility noted to be elopement risks (resident #2 and #3). Neither resident had been assessed for their ability to elope via their window within their medical records. Resident #2, who was identified as an elopement risk in the elopement book provided by the facility on 3/29/21, had an Elopement Risk assessment from 2/16/21 which revealed no supervision status for resident #2. The Elopement risk assessment for 11/16/20 documented that resident #2's supervision status was eyesight at all times. Nowhere in the medical record was the resident's ability to elope from her window assessed. On 3/29/21, multiple observations of resident #2's room revealed the lock on the window to be malfunctioning. The window could be opened in the locked and unlocked position. Also, the window would not latch. Interview with resident #2's roommate, Resident #7, revealed the window does not always catch. Resident #7 revealed staff were aware of the window not catching and that the window had been in that condition for months. She stated she could not remember who she had informed since it had been so long but remembered telling someone. Resident #7 stated they probably just need to clean the dead insects and frogs out of the window track, and it may latch. (Photographic evidence obtained) Other Interventions included in the facility's PIP included but were not limited to the following: Review Elopement Book System -Conduct Review to determine if book is being kept up-to-date, Admission Assessment, Equipment Review and Policy review. The PIP failed to identify but not limited to the following: unsecured windows and doors; lack of elopement training during new employee orientation; staff not being able to identify elopement risk residents that were not assigned to them; unsafe environments such as the unlocked Maintenance office, where tools, chemicals, and other maintenance equipment; and failed to identify their own role in the resident's elopement by stating there was no way we could have known. The PIP also failed to review the admission protocol based on resident behaviors in the past and a clear process to address future admissions of residents with exit seeking behaviors. Interventions immediately following the resident's elopement implemented prior to the survey team's entrance on 3/29/21 included the following: Resident # 1 was placed back on 1:1 staff supervision and referred to a psychiatrist and was ultimately transferred to another nursing home with a secured unit on 3/11/21, 33 out of 116 employees received elopement education prior to the survey team's entrance, reassessment of the two other residents in the facility who were at risk for elopement (#2 and #3). The facility determined these two residents were not at risk for going out the window. The elopement occurred the day before the monthly Quality Assurance Performance Improvement committee meeting and therefore was reviewed by the committee within 24 hours of the event. The root cause analysis concluded that The facility management nor the staff would have any reason to believe the resident would elope or open her window having been stabilized and acclimated to her new home for this length of time. The facility also summarized the findings as Resident was unpredictable, and we did not anticipate her being physically capable of climbing out the window. Forty-seven (47) days after the facility had developed a PIP, surveyors identified current safety concerns for residents documented as an elopement risk (resident #2 and resident #3). During the initial tour of the facility on 3/29/21 between 10:25 AM and 11:15 AM, the following resident room windows were found to be unlocked and/or with a malfunctioning lock and/or unable to close properly: 204, 208, 102, 107. On 3/29/21 between 12:35 PM and 1:05 PM, a tour was conducted outside the building to include the parking lots, behind the facility, and the area within 1 radius mile around the facility. During this tour, a female resident was observed to be sitting in a wheelchair on the West wing porch unsupervised by staff. On the East wing porch, a male resident was sitting unsupervised. Also observed during the tour, located at the back of the facility, was a maintenance room/office with an unlocked, opened door, inside were tools and other maintenance supplies. No staff were present, and a sign posted read Authorized personnel only. Located behind the facility, is a cow farm which is surrounded by a 4-string [NAME]-wire fence. There were four buildings and several sheds/barns on the property. There was also a partially collapsed barn or shed on property. (photographic evidence obtained) Also, during the tour, an observation was made of a Common Area near the vending machines found an unlocked exit door leading outside to what appeared to be a smoking porch area. On that porch, there was another exit through an unlocked screen door with access outside the building. There was a gate without a lock and only a latch which led to the front parking lot. The area is surrounded by offices with some blinds up (left side) and resident rooms with all blinds closed (right side). There was no staff supervision in the area at the time of observation. Residents were observed in the common area unsupervised with easy accessibility to the exit. A review of medical records at the time of the survey for resident #2 identified the resident's supervision status (1:1, 15 minutes checks, eyesight at all times) to be unclear. Interviews with the Assistant Director of Nursing (ADON) on 3/30/21 at approximately 11:45am and on 3/30/21 at approximately 12:15pm with the Director of Nursing (DON), Regional Director, and Assistant Director of Nursing (ADON), all revealed the resident was on 15- minute checks, though documentation was not consistent. All agreed documentation did not verify 15-minute checks were being completed as required. The Immediate Jeopardy was removed onsite after the receipt of an acceptable IJ removal plan. The survey team verified the facility's immediate corrective actions: On 3/30/21 the facility maintenance staff repaired the broken/ malfunctioning lock in resident #2's room, placed alarms on the windows of the two residents identified as elopement risks and on the doors, exiting the building to the smoking porches. The facility conducted room by room window assessments to ensure all locks were working properly. They conducted elopement education (3/31/21) either in person or on the telephone to all staff who had not been provided elopement education since the resident eloped on 2/9/21 as evidenced by a staff roster with dates education was provided. The facility also conducted a 100% review of residents in the building with risks for elopement and updated their plans of care accordingly (3/31/21), removing one resident (#3) from the list as she had not demonstrated exit seeking for greater than 6 months. Policy reviewed and updated to include a new protocol for assigning and removing 1:1 care for residents, the use of a text blast Pink Alert to alert all employees of an elopement (3/31/21). Elopement drills have been scheduled to include all shifts monthly for the next 6 months and then annually (3/30/21). Window lock inspections have been added to daily room round inspections.

Based on observation, interview, and record review, it was determined the facility failed to ensure a functional resident call system on the entire East Wing of the facility. The findings include: On 2/22/21 beginning at approximately 11:20 AM, a tour of the 100, 200, and 300 hallways was conducted. These hallways were noted to have 53 residents with various levels of dependency. During the tour, residents and staff reported the call bell system for both resident rooms and resident bathrooms was not functional. Staff reported the situation had been ongoing for several months. Residents were observed to have actual bells in their rooms to use instead, however there were no bells or alternate call/alert system for resident bathrooms noted. Several staff indicated that sometimes if the resident's doors are closed staff cannot hear the bells. On 2/25/21 at 11:00 AM, the facility's Consultant Registered Nurse (RN) provided a timeline of the system malfunction. The timeline revealed the initial call system began having limited outages in October 2020. In December 2020 it was determined the system was not repairable and required a full system replacement.

Based on observation, interview and record review, the facility failed to provide Activities of Daily Living (ADLs) assistance related to nail care and grooming for 1 of 20 sampled residents. (residents #51) The findings include: On 2/22/21 at approximately 11:40 AM, resident #51 was observed seated in a wheelchair in the hallway. The resident was observed without any socks or shoes. His toenails were observed to be very long, yellowed, thick, and a small area of discoloration at the base of the right great toenail bed. The resident's left great toe was missing. (photographic evidence obtained) An interview was conducted at this time with the resident's assigned Certified Nursing Assistant (CNA), staff member K. She indicated the resident did not like to wear shoes or socks because his feet hurt. An interview was also conducted at this time with the resident's assigned Registered Nurse (RN), staff member L. She indicated the resident's toenails had been like this for awhile, and he should be seen by the Podiatrist. Both indicated that CNAs and nursing staff do not provide nail care for diabetic residents and a Podiatrist would have to perform that ADL service. A review of the resident's medical record revealed [REDACTED]. The record revealed the resident was last seen by the Podiatrist in January 2020 at which time was noted to have painful onychomycosis, fungus, [MEDICAL CONDITIONS], and [MEDICAL CONDITION] requiring toenail debridement every 2-3 months. A review of the resident's current care plan dated 1/8/21 revealed a goal that the resident would have no complications related to diabetes and the Podiatrist would be consulted. The residents Minimum Data Set ((MDS) dated [DATE] revealed the resident required 1-2 persons assistants with Activities of Daily Living (ADLs) and would be dependent on staff. There is no evidence the resident was provided the ADL service of nail care by a Podiatrist since January 2020.

Based on record review and staff interview, the facility failed to notify a resident ' s representative and State Long Term Care Ombudsman in writing when a transfer to the hospital occurred for 1 of 1 resident sampled for hospitalization . (#102) The findings were: Resident #102 ' s clinical record was reviewed indicating the resident was admitted to the facility on [DATE] and was transferred to the hospital on [DATE]. He was admitted to the hospital with [REDACTED]. He was re-admitted to the facility on [DATE]. On 2/27/18 resident #102 was again transferred to the hospital and readmitted with a primary [DIAGNOSES REDACTED]. His last transfer to the hospital occurred on 3/6/18 and he was admitted to the hospital for pneumonia. Further review of the closed record failed to reveal proper written notification of the resident ' s representative and the Ombudsman in writing for any of the three hospital transfers. An interview was conducted with the corporate nurse liaison on 5/10/2018 at approximately 11:15 am. She stated the facility was not aware they needed to send written notification to the resident representative and the Ombudsman when a resident was transferred to the hospital. She stated they would start ensuring the written notices would be part of the hospital transfer protocol.

Based on observation, staff interview and record review the facility failed to implement a bladder training program as indicated by a bowel and bladder screening program for 1 of 2 sampled residents with urinary incontinence. (#24) The findings include: An observation of resident #24 was conducted on 6/29/16 at approximately 11:40 AM. The resident was sitting in his wheel chair outside on the smoking porch. His pants were visibly wet between his legs. Review of resident #24's record revealed a quarterly minimum (MDS) data set [DATE] indicating the resident was frequently incontinent of urine. A bowel and bladder program screening was conducted and documented on 5/11/16 indicating the resident at least daily but not always voids appropriately without incontinence, transfers to the toilet with assistance of one person, is alert and oriented, and is usually aware of the need to toilet. No documented bladder training was located in the record. An interview was conducted with resident #24 on 7/1/16 at approximately 10:50 AM. He stated he is aware when he has to urinate and could let the staff know. He confirmed he would be willing to participate in a bladder training program. An interview with the 100 hall unit manager was conducted on 7/1/16 at approximately 10:16 AM. He stated the facility did not initiate any bladder training for resident #24 after the screening was conducted on 5/11/16. He was not able to state why the training was not initiated. An interview was conducted with the Director of Nursing on 7/1/16 at approximately 11:02 AM. She stated that the resident should have started a scheduled toileting program after the screening was conducted. She stated the unit manager who completed the assessment should have initiated the bladder training program. The facility policy for bladder management program was reviewed on 7/1/16. The policy stated retraining programs are appropriate for residents who are able to participate and have the cognitive ability to understand and follow directions. #12 of the procedure stated develop toileting schedule with the resident's participation. Toileting schedule should be as close to the resident's customary routine as possible. #16 stated observe and record the resident's voiding pattern and revise toileting schedule to meet resident's needs. This should be done until a routine is established.

Based on interview and record review, the facility failed to ensure adequate monitoring of laboratory tests for prescribed medications for 1 of 5 sampled residents as evidenced by failure to obtain ordered laboratory tests during medication dose adjustments. (Resident # 51) Findings: Record review conducted for Resident #51 revealed resident had [DIAGNOSES REDACTED]. On 3/21/16, based on an elevated laboratory value, the physician ordered the medication to be decreased from 250micrograms (mcg) to 225mcg; and ordered the laboratory value to be repeated in one month. The laboratory test was repeated on 4/28/16; and on 5/4/16, based on an elevated laboratory value, the physician ordered the medication to be decreased by 25mcg; and ordered the laboratory value to be repeated in one month. There was a telephone physician order, dated 5/6/16, to recheck TSH and T4 ([MEDICAL CONDITION] studies) in one month. The medical record failed to include the laboratory values that were ordered to be obtained on 6/6/16. This finding was confirmed by the facility's Director of Nursing (DON) on 6/30/16 at approximately 11:00am. The DON stated the laboratory test omission would have been discovered when the telephone orders were checked for the July Physician order [REDACTED].

Based on observation,interview and record review, the facility failed to follow isolation precautions for 1 of 3 residents rooms on isolation precautions (resident room [ROOM NUMBER]) as evidenced by failure to post signage for staff or guests to alert that the resident was on isolation precautions. The findings include: During the initial facility tour on 06/28/2016 at 10:08 am, an observation was made of an isolation storage cart in the hallway between rooms [ROOM NUMBERS], directly across from room [ROOM NUMBER]. There was no signage observed to be posted on any of the rooms identifying which room held a resident on isolation precautions. An interview was conducted with the unit manager at 10:10am on 06/28/2016 asking about the isolation cart in the hallway. The unit manager stated the cart belonged to room [ROOM NUMBER] and confirmed that there was no signage on or around the door to indicate which resident was on isolation precautions. The unit manager stated that the resident in room [ROOM NUMBER] was on isolation and there should have been signage on the door of the room to indicate the precaution status of the resident. An observation was made of room # 204 upon returning to the hall at 10:17 am, paper signage was observed on the door of room # 204 with instructions to report to nursing before entering the room. An interview was conducted with the CNA (certified nursing assistant) working on hall 200 on 07/01/2016 at 9:10 am, she stated that the resident in room [ROOM NUMBER] had been on isolation precautions since he returned from the hospital on June 14, 2016. On 07/01/2016 beginning at approximately 10:20am an interview was conducted with the facility's Infection Control Nurse (ICN). The ICN stated the facility's process for resident's requiring isolation precautions was to steup Personal Protective Equipment (PPE) containers. She stated that care staff are notified of what type of isolation the resident is on, and a STOP - please see Nurse sign should be placed on the resident's door. Review of facility infection control policy was conducted, and stated Post the appropriate notice on the room entrance door and on the front of the residents chart so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room.

Based on observation and staff interviews, the facility failed to ensure that the dishwasher was maintained in safe operating condition during one of two observations of dishwashing. The findings: On 05/18/2015 at 10:07:01 AM observation of wash cycle for the high temperature dishwasher was conducted in the presence of the Assistant Dietary Manager and the Registered Dietitian. Observation of the wash cycle revealed the temperature gauge did not reach over 135 degrees during the wash cycle. The dishes were washed and then moved through the left side of the dishwasher and another load of dishes was placed into the dishwasher for a washing cycle. Observation of the temperature gauge for the wash cycle revealed the glass to be cracked on the gauge. At this time, interview conducted with the Assistant Dietary Manager revealed no one had advised her that the gauge had not been working on the wash cycle for the dishwasher. She stated the dietary staff had been logging daily temperatures for the wash cycle at 150. The requirement for the wash cycle is between 150 and 160 degrees and for the rinse cycle is between 180 and 190 degrees. She stated that she would be contacting the maintenance repair man to come and replace the temperature gauge for the machine. During observation the facility maintenance personnel verified with a thermometer that the dishwasher temperatures did reach required range. Record review of the instruction manual posted next to the dishwasher on the wall in the kitchen revealed the temperature requirements for the washing cycle is 150-160 degrees and the temperature requirements for the rinse cycle is 180-190 degrees. On 5/18/2015 at 12:00pm a follow up interview was conducted with the Assistant Dietary Manger who stated a new gauge was being installed on that day and the dishwasher would be down until it is repaired and the residents would be served lunch on disposable plate ware. On 05/21/2015 at 10:03:41 AM a follow-up interview was conducted with the Assistant Dietary Manager which revealed the dishwasher is not run until after breakfast and now that the gauge is repaired, it was taking 2 or 3 wash cycles in order to get the temperature up to the required 150 degree minimum temperature. When asked why the dietary staff were not advising her about the broken gauge and temperature issues during my observation on 5/18/15, she advised that they would be conducting inservice training to the dietary staff on making sure they are checking the gauges to ensure it reaches a proper temperature.

Based on observation, interviews and facility policy review, the facility failed to ensure an evaluation conducted by the Interdisciplinary Team (IDT) was completed to determine the safe practice for an individual resident to self-administer medication for 1 of 5 residents observed during medication administration. (Resident #87) The findings include: On 05/20/2015 at approximately 08:15am medication administration for Resident #87 was observed. Staff Member B, after administering the resident's oral medications, handed Resident #87 an aerosol inhaler ([MEDICATION NAME]). The resident proceeded to take one puff from the inhaler, held it in briefly and then exhaled. She waited approximately 15 seconds and repeated the process for a total of 2 puffs. The resident then rinsed her mouth. Staff member B, then handed the resident a nasal spray pump ([MEDICATION NAME]). Resident #87 proceeded to administer 2 squirts of the nasal spray into each nostril, then handed the spray pump back to the nurse. Staff member B did not instruct the resident to wait between puffs from the inhaler. On 05/20/2015 at approximately 9:00am, Staff Member B was asked if she had any resident that self administer medication. She stated she did not. The DON (Director of Nursing), was present and stated that if a nurse is in the room with the patient and supervising the administration of the medication, that this was not considered self administration of medication. A review of the facility's policy and procedure entitled "Self-Administration of Medication By Patients indicates "Each patient who desire to self-administer medication is permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the patient, other patients of the facility, and if the physician provides an order to do so." The assessment criteria document entitled "Assessment for Self-Administration of Medication" includes "18. Can administer inhalant medications with proper procedure?" The document is to be completed by the Interdisciplinary Team, signed by the resident and IDT members. A review of Resident #87's medical record failed to reveal a physician order [REDACTED].

Based on interviews and facility and resident record reviews, the facility failed to ensure the reasonable accommodation of individual needs and preferences, that addressed a resident's dignity related to ADL (Activity of Daily Living) care to meet the needs of the resident dependent on staff for care and assistance (#17 and #70). The findings include: On 05/18/2015 at approximately 11:50am, during Stage One of the survey, Resident #70 was asked if she got to take a bath or shower as often as she liked. Resident #70, stated that she has been at the facility for 2 weeks and had not been offered a shower, this bothered her. She stated she has had one bed bath since being here. She stated she is dependent on staff assistance for getting out of bed. On 05/19/2015 at approximately at 11:00am, Resident #70 mentioned again that she still had not had a shower. The Unit Manager along with the Unit Secretary were then asked about the facility's process for offering and documenting resident showers or baths. The Unit Manager attempted to demonstrate on the Electronic Medical Record (EMR)/ Plan of Care(POC) system a screen which included a "prn (as needed) bathing" section. The 'bathing' section merely identified how much assistance the resident requires and doesn't indicate type of bath/shower, if it occurred or how frequently. Staff were asked to demonstrate, another resident who was included in the Stage One sample, Resident #17 (dependent on staff for bathing/shower assistance), as to when she last had a bath or shower. The Unit Manager stated she had a bed bath the previous day, but there was no documentation to support this, or was there information presented to identify if she had been offered or when she last had a shower. The Unit Manager stated she would try to pull up a report and locate information on resident baths and showers. On 05/19/2015 at approximately 2:00pm, the Unit Manager stated that Resident #17 had a bed bath yesterday (05/18). She was not able to identify when the resident last had a shower. The facility's process revealed a CNA assignment sheet which identified the 'resident, bath/nail schedule, bowel and bladder and dietary intake information.' The CNAs are not prompted by the facility's Point of Care system (kiosk) as to when a resident is scheduled or requests a shower/bath. Bath and/or shower information is documented on the CNA sheet and turned into the Nurse / Unit Manager. The Unit Manager was then asked about Resident #70, as to when she last had a bath or shower. She stated she had been informed by the Resident's CNA that she had been offered a shower, but refused. Resident #70, was then interviewed in the presence of the Unit Manager and asked if she had been offered a shower. The resident stated that she had not been offered a shower in 2 weeks. She stated she had a bed bath, which was a pretty good one, but had not been offered a shower. Per the CNA assignment sheet, Resident #70 is scheduled for showers on the evening shift on Wednesday and Saturdays. The Unit Manager stated that she was surprised that the CNAs assigned to this Resident (on evening shift) had not offered her a shower. (The resident's CNA for evening shift are males). The resident stated that if the CNAs had offered her a shower, she would not be comfortable receiving shower assistance from either of them, as they are males and she would not want a male assisting her with a shower. She stated her preference to the Unit Manager and the Unit Manager took note. The facility was given opportunity to provide additional information regarding how often and when residents received baths, showers or refusals. The CNA schedule sheet which documents ADL care were not maintained as part of the resident's record. There were some CNA sheets located, as far back as 04/21/2015 but failed to reveal supporting documentation in the provision of ADL care for residents #17 and #70, in particular. On 05/20/2015 at approximately 2:45pm an interview was conducted with the CNA currently caring for the resident. She stated she had given the resident a shower today. This was confirmed with Resident #70. The resident's shower request has been modified, per the Unit Manager. The facility failed to provide the care and assistance to meet the need of Resident requiring assisting with bathing, and failed to honor or seek out preference that could impact the resident's dignity. On 05/21/2015 at approximately 10:00am, staff sitting in the nursing station of the West Unit (included both nurses on duty) were asked about where Resident shower preferences were documented. Nurses identified the Master shower log with the CNA information indicating resident #70 shower schedule on W and S during Evening shift. Stated residents were not asked if preference to a male or female - CNA. Nurses stated that if the resident was not comfortable with a male CNA giving them a shower, they could just switch out with someone else. The resident would have to indicate if she was or was not comfortable.. On 05/21/2015 at approximately 10:25am an interview was conducted with the Unit Manager for the West Unit regarding how patient preferences and choices are honored. She stated that the "Admission Coordinator" asks them and then Nursing will ask them other preferences, to include shower schedule preferences. She indicated there is a section in the EMR (Electronic medical record) that asks residents their preferences - this was blank for Resident #70. She stated, Resident #17, her preference choices should be in the paper record. The facility staff were unable to locate any current preference choices for resident #17, admission for resident was 2004. On 05/21/2015 at approximately 10:30am an interview was conducted with the Admission Coordinator. She indicated she coordinates the Admission process for the resident, along with the resident's responsible party. She stated, as part of the admission process, will go over Social Services history but does not ask resident about bathing or showering preferences, that would be something Nursing would do.

Based on interviews and facility and resident record reviews, the facility failed to ensure the provision of ADL (Activity of Daily Living) in accordance with the resident's written plan of care for 1 of 35 Residents included in Stage One sample (Resident #70) The findings include: On 05/18/2015 at approximately 11:50am, during Stage One of the survey, Resident #70 was asked if she got to take a bath or shower as often as she liked. Resident #70, stated that she has been at the facility for 2 weeks and had not been offered a shower, this bothered her. She stated she has had one bed bath since being here. She stated she is dependent on staff assistance for getting out of bed. On 05/19/2015 at approximately at 11:00am, Resident #70 mentioned again that she still had not had a shower. The Unit Manager along with the Unit Secretary were then asked about the facility's process for offering and documenting resident showers or baths. The Unit Manager attempted to demonstrate on the Electronic Medical Record (EMR)/ Plan of Care(POC) system a screen which included a "prn (as needed) bathing" section. The 'bathing' section merely identified how much assistance the resident requires and doesn't indicate the type of bath/shower, if it occurred or how frequently. The facility's process revealed a CNA assignment sheet which identified the 'resident, bath/nail schedule, bowel and bladder and dietary intake information.' The CNAs are not prompted by the facility's Point of Care system (kiosk) as to when a resident is scheduled or requests a shower/bath. Bath and/or shower information is documented on the CNA sheet and turned into the Nurse / Unit Manager. On 05/19/2015 at approximately 2:00pm, the Unit Manager was asked about Resident #70, as to when she last had a bath or shower. She stated she had been informed by the Resident's CNA (Certified Nursing Assistant) that she had been offered a shower, but refused. She then presented a CNA Assignment sheet, dated 05/16, under the heading "Bath/nails" was a checkmark next to the words "evening" W and S (Wednesday and Saturdays). This did not indicate what type of bath / shower the resident had. Resident #70, was then interviewed in the presence of the Unit Manager and asked if she had been offered a shower. The resident stated that she had not been offered a shower in 2 weeks. She stated she had a bed bath, which was a pretty good one, but had not been offered a shower. Per the CNA assignment sheet, Resident #70 is scheduled for showers on the evening shift on Wednesday and Saturdays. The Unit Manager stated that she was surprised that the CNAs assigned to this Resident (on evening shift) had not offered her a shower. (The resident's CNA for evening shift are males). The resident stated that if the CNAs had offered her a shower, she would not be comfortable receiving shower assistance from either of them, as they are males and she would not want a male assisting her with a shower. She then stated her preference to the Unit Manager and the Unit Manager took note. The facility was given opportunity to provide additional documentation regarding residents ADL activity (baths, showers or refusals." The CNA schedule sheet which documents ADL care were not maintained as part of the resident's record. There were some CNA sheets located, as far back as 04/21/2015 but failed to reveal supporting documentation in the provision of ADL care for resident #70, in particular. A review of Resident #70's care plan for ADL's, dated 04/15 indicated that the "resident requires assistance with bed mobility, transfers, locomotion, walking, dressing, toilet use, personal hygiene and bathing." Goals included - Personal hygiene needs (to be) met in accordance with resident preference and need; will be free from odor; will have clean, trimmed nails; will have clean and groomed hair. Honor resident's preferences - bathing, eating and personal hygiene. Care plan interventions included "provide assistance with bathing, encourage resident to take at least 2 showers/tub baths weekly."