Every finding on record at Green River Trails

Based on observation, interview, record review, and review of facility's policies, it was determined the facility failed to provide a safe, clean, comfortable and homelike environment for its residents. Observation revealed the facility failed to provide a safe, clean comfortable and homelike environment for it's residents, as evidenced by insufficient upkeep of the physical environment. The findings include: Review of the facility's policy titled, Cleaning and Disinfecting Resident's Rooms, dated August 2013, revealed the facility would ensure environmental surfaces were disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces were visibly soiled. Further review revealed curtains in resident areas were to be cleaned when the surfaces were visibly contaminated or soiled. Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated September 2022, revealed the facility was to ensure non-critical items such as bed rails, bedside tables, etc. (e.g., curtains) that might meet intact (resident) skin, but not mucous membranes were to be cleaned and disinfected according to current Centers for Disease Control (CDC) recommendations. Review of the facility's April 2024 Monthly Meeting Report regarding cleaning schedule for the facility including: the floors, kick plates, linens, hallways, and quality control. The report revealed Kick plates had been scrubbed to the best of our ability. However, even with the strongest products we have, they remain stained. Further review of the Monthly Meeting Report revealed repairs to the kick plates recommended to administrator that they be painted or replaced. Review of the Maintenance (personnel's) job description dated December 2009, revealed the Maintenance Department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Continued review revealed the Maintenance Department was to be under the direct supervision of the facility's Assistant Administrator. Further review revealed the Maintenance Department was responsible for maintaining the building in good repair and free from hazards. Review of the facility's Quality Control Inspection Housekeeping log dated April 2024, revealed the vents were to be cleaned. Housekeeping logs was filled in with the rooms cleaned and the vents and air conditioning units were listed on the cleaning list. Items completed were initialed. Observation on 05/21/2024 at 1:00 PM. revealed yellow-brown stains on four floor tiles and cracked ceiling tiles around the circular vent, in front of resident room [ROOM NUMBER]. Continued observation revealed heavy dust particles on two output vents near resident room [ROOM NUMBER] and a sticky substance on the door frame of that room. Observation on 05/21/2024 at 1:30 PM, revealed flies in the hallway during lunch time. Continued observation revealed loose brown dirt in corners of the entrance door at resident room [ROOM NUMBER]. Observation on 05/21/2024 at 1:33 PM, revealed a marred, blackish gray dirty kick-plate on the resident bath shower entrance door, next to resident room [ROOM NUMBER]. Observation on 05/21/24 at 4:38 PM, revealed resident room [ROOM NUMBER]-B's sheets with brown stains and food particles covering the bolster mattress on the bed. Observation on 05/21/24 at 4:40 PM, revealed brown/yellowish stain coloring on floors at edges between rooms one and two on the facility's north hall and some loose baseboards in the nearby hallway. Observation on 05/21/2024 5:10 PM, of resident room [ROOM NUMBER] of Resident (R) 58's bed, revealed a heavily soiled privacy/divider curtain with multiple large brown stains on it. Observation on 05/21/2024 at 1:35 PM, revealed inside resident room [ROOM NUMBER]-2, an empty Mountain Dew soda can lying on the floor, in the walkway path. Continued observation revealed a gap, on the corner of a vent cover between the vent cover and the painted drywall, located just inside the entrance door to room [ROOM NUMBER], on the left. Further observation revealed a loose plug-in cover on wall, which created about a, 1/8-inch gap, along the top of the plug-in cover. Additionally, observation revealed marring approximately 4 inch long, dark grayish, black markings resembling scrape/scuff marks on the door and marring blackish linear scrape markings on wall. Observation on 05/21/2024 at 1:00 PM, residents' room [ROOM NUMBER] and room [ROOM NUMBER] revealed brown tan colored lint hanging from vents in the bathroom. Observation of resident room [ROOM NUMBER] on 05/21/2024 at 1:04 PM, revealed the privacy curtain separating the beds had a brown substance on the bottom of the curtain, and the curtain was stained in multiple spots with dark brownish unknown substance. Further observation revealed the residents' bathroom had a strong urine scent detectable. Observation on 05/22/2024 at 9:00 AM, revealed resident room [ROOM NUMBER] had a small brown stain on the privacy curtain. Observation on 05/22/2024 at 4:19 PM, revealed the same two dust filled ceiling outlet vents on each side of resident room [ROOM NUMBER]. Observation of resident room [ROOM NUMBER]-2 on 05/24/2024 at 12:00 PM, revealed the room curtains had two soiled areas; one almost inch long area noted approximately shoulder high on the curtain, with a small round soiled area about 2 inches from the larger area. Further observation revealed brownish soiled areas approximately 4 feet up on the divider curtains. Observation of resident room [ROOM NUMBER] on 05/24/2024 at 12:05 PM, revealed a divider curtain soiled about three feet up and approximately 12 inches inward from the divider curtain edge. Further observation revealed the soiled areas appeared to be a dripping, linear dark brown/black substance. Review of R21's Admission Record revealed the facility admitted the resident on 04/07/2023, with diagnoses of unspecified atrial fibrillation, chronic obstructive pulmonary disease, type 2 diabetes mellitus, bipolar disorder, major depressive disorder, and generalized anxiety disorder. Review of R21's Annual Minimum Data Set (MDS) Assessment, dated 04/11/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R21 was cognitively intact. During an interview on 05/21/2024 at 4:15 PM, R21 in room [ROOM NUMBER]-1 stated he could not remember the last time the privacy curtain in his room had been taken down and washed and cleaned. R21 stated the privacy curtain had those same stains ever since he had been living in the room, and the brown substance had been on there for at least a month. Review of R21's Admission Record revealed the facility admitted the resident on 04/07/2023, with diagnoses of unspecified atrial fibrillation, chronic obstructive pulmonary disease, type 2 diabetes mellitus, bipolar disorder, major depressive disorder, and generalized anxiety disorder. Review of R21's Annual Minimum Data Set (MDS) Assessment, dated 04/11/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R21 was cognitively intact. During an interview with R13 on 05/21/2024 at 4:30 PM, room [ROOM NUMBER]-2 he stated housekeeping cleaned the residents' bathroom daily, but the urine scent was always still there. R13 stated the brown substance had been on the privacy curtain for a few weeks and he was not sure what the substance was. The resident stated the privacy curtain had the stained spots on it for as long as he had been living in the facility. During an interview with Housekeeping/Sanitation (H/S) 1 revealed she had a routine when cleaning the residents' rooms. H/S 1 stated her routine is to dust the rooms first, then sweep and mop last. She stated a pre-mixed cleaner was used for the floors, another cleaner used for the bathroom and a different one used for odors. H/S 1 stated a duster was used for high areas such as the top of the TV. She added, one cleaning rag is was used per room to avoid any contamination of other areas, and garbage containers were emptied daily, sprayed, and lined with new liners. Spoke with H/S 1 concerning dusty tan colored lint hanging form vents and she stated they were not routinely cleaned by housekeeping. Housekeeping does keep a log of the rooms cleaned and cleaning the vents and air conditioning is listed on the worksheet log. She further stated it is was important to clean the dust off the vents to prevent residents from getting sick. She did not state she was trained by the facility, because she is contracted by Health Services. She did not state whether or not she was trained by Health Services. During an interview with Maintenance Director 1 on 05/23/2024 at 4:35 PM, he stated he had worked at the facility for two years and only had one assistant. He stated he would change the filters in outlet vents monthly. Moving forward he plans to create a log for each resident room and areas of the facility to ensure filters are changed and vents cleaned. He plans to incorporate the new forms as part of his quality assurance. Maintenance Director #1 stated he did a monthly check of resident rooms to address any areas needing repair, and his process was to do a walk through with a checklist and check for frayed cords, areas that needed painting, walls that might need to be calked. He further stated he would keep a notebook of things he had addressed, but there were not any facility forms or check off sheets that were to be initialed. Maintenance stated he changed filters in each outlet vents monthly. He toured the facility monthly to check for needed repairs. He did not state whether he had received any training upon hire. During an interview with Environmental Services Director (ESD) 1 revealed he was aware some of the resident room divider curtains had stains, paint, and fingernail polish on them, and he would put in a request for new curtains periodically. The ESD stated he had received three or four divider curtains a few months ago, and had hung the curtains. Furthermore, he stated three more had been ordered, but they had been back ordered. He provided an order for the recent purchase order dated May 2024. He did not have a regular process for replacement. He stated he would give the request to [NAME], who ordered them. ESD felt it important to change the diver curtains out routinely. He stated he would try to take about three rooms at a time down and replace with clean curtains and that all diver curtains were replaced monthly with a clean diver curtain. And the ones taken down were then cleaned and used again. Interview on 05/22/2024 at 10:55 AM, with the Administrator revealed he expected resident safety to be an optimum priority and he also wanted to provide for the safety of staff as well. In further interview he stated he expected staff to provide a safe environment for the residents. The Administrator stated he was committed to training staff to work as a team to maintain a safe environment for the residents and for the staff.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure its dietary staff provided proper hand hygiene in accordance with professional standards for food service safety. Observation revealed a Dietary Aide (DA) washed his hands; however, failed to dry his hands before putting away clean dishes. The findings include: Review of the facility's policy titled, Handwashing/Hand Hygiene, dated August 2019, revealed all personnel should be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. Further policy review revealed all personnel should follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Observation during the initial tour of the kitchen on 05/21/2024 at 11:00 AM, revealed DA 1 placed dirty dishes on the dish racks to run through the dishwasher. Continued observation revealed DA 1 washed and rinsed his hands in the sink, shook the water off his hands; however, failed to dry his hands. Further observation revealed DA 1 then began to process and put away the clean dishes on the clean side of the dishwasher rack with his wet hands. During an interview with DA 1 on 05/21/2024 at 11:30 AM, he stated at one time there had been a paper towel dispenser on the wall for staff to use; however, the dispenser was removed to repair the wall and was never replaced. The DA stated he could not remember how long it had been gone. He stated he had been in-serviced by the Dietary Manager on proper handwashing and further stated he should have dried his hands thoroughly prior to handling the clean dishes. During an interview with the Dietary Manager on 05/21/2024 at 12:00 PM, she stated the facility had repaired the wall in the kitchen and removed the paper towel dispenser about a year ago, but failed to put the dispenser back up for staff use. She further stated the importance of washing and drying hands between handling clean/dry dishes was to prevent cross-contamination and spread of infections to other personnel, staff, and residents.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure residents received care and treatment in accordance with professional standards of practice for one (1) of thirty five (35) sampled residents.) (Resident #149). The facility admitted Resident (R)149 from the hospital post-treatment of a femur fracture. The Physician ordered thrombo-embolic deterrent (TED) hose to R149's right lower extremity every morning and off every evening. The order for the TED hose was changed on 05/21/2024, for the hose to be applied to the resident's bilateral legs. However, the facility failed to implement the Physician's orders and clearly document the TED hose treatment ordered. The findings include: Review of the facility policy titled, Baseline Care Plan dated 05/16/2024, revealed a Baseline Care Plan was to be completed and implemented within 48 hours of a resident's admission to promote continuity of care and communication among nursing home staff. Additionally, review revealed the Baseline Care Plan was also to be completed and implemented to increase resident safety and safeguard against adverse events that were most likely to occur right after admission. The State Survey Agency (SSA) Surveyor requested a facility policy related to TED hose application; however, the facility did not supply a specific policy related to TED hose application. Review of the Admission Record for R149 revealed the facility admitted the resident on 05/16/2024, with diagnoses that included: Parkinson's Disease, Fracture of Right Femur, and Entercolitis (inflammation in a person's digestive tract), due to Clostridium Difficile (a bacteria that causes diarrhea and inflammation of the colon). Review of the admission assessment information dated 05/21/2024, revealed the facility assessed R149 with a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated the resident was moderately cognitively impaired when admitted to the facility. Review of R#149's Physician Orders revealed an order dated 05/16/2024 for TED hose to the right lower extremity every morning and off every evening, which was discontinued that same date. Continued review of the Physician Orders revealed on 05/18/2024, an order for a STAT (urgent) Venous Doppler for edema, and discoloration times two days. Further review of the Physician Orders revealed another order for TED hose dated 05/21/2024 at 8:00 PM, for the hose to be applied to R149's legs in the AM and taken off at bedtime to prevent swelling of the legs. In addition, review revealed the 05/21/2024 Physician order was discontinued at 8:41 PM on that same date. Further review of Physician revealed the order for TED hose to bilateral legs, on in AM , and off every HS was added on 05/23/2024 (Although the NP stated she had given the verbal order on 05/21/2024 for TED hose to bilateral legs, and did not know why it had been discontinued.) Review of the Baseline Care Plan for R149 revealed the facility had developed an Activities of Daily Living (ADL) focus initiated on 05/16/2024, for the resident which included an intervention to apply TED hose, on in the morning (AM) and off in the afternoon/evening (PM). Per review of the Baseline Care Plan, on 05/17/2024, an intervention was added for TED hose to be applied to R149's right leg, on in AM, and off every HS (bedtime) which had a resolved date for that same date. Further review revealed an additional intervention was noted on the Baseline Care Plan on 05/24/2024, for TED hose to be applied to R149's bilateral legs, on in the AM and off every HS. Review of the STAT Venous Doppler of the left lower extremity report dated 05/20/2024 revealed a negative exam, with no thrombus noted. During an interview on 05/21/2024 at 5:00 PM, with R149's daughter she stated her mother had requested over the weekend for R149 to have TED hose put on. She stated her mother was told they needed a Physician Order. Review of R149's Treatment Administration Record (TAR) for May 2024, revealed a TED hose was placed on only the resident's right leg in the AM and removed in the PM on 5/17/2024, 05/18/2024, 05/19/2024, 05/21/2024, and 5/23/2024. Continued review of the TAR revealed documentation noting R149 refused the TED hose on 05/22/2024. Further review revealed on 05/23/3034, it was documented R149 had his TED hose were applied to his bilateral legs in the AM as ordered on that date. Review of the Nurse Practitioner's Note dated 05/21/2024, revealed R149's left lower extremity had 2+ pitting edema. (order was already in place for RLE TED hose). Per review, the NP's plan was to apply TED hose to R149's bilateral lower extremities on in the morning and off at bedtime. Further review of the NP Note revealed the NP's plan was also to increase R149's Bumex (diuretic) from 0.5 milligram (mg) to 1 mg. daily. Observation of R149 on 05/21/2024 at 4:48 PM, revealed however, the resident sitting up in a wheelchair, in the dining/lounge area, without his TED hose on either extremity. Further observation revealed R149's legs were hanging down in a dependent position with swelling and mild redness of bilateral legs observed in both legs, more swelling on the left than the right. Observation on 05/22/2023 at 9:35 AM, revealed R149 again sitting up in a wheelchair, legs down in a dependent position with no TED hose on as ordered. Further observation revealed R149 had increased edema and redness since the previous observation on 05/21/2024, to his bilateral lower extremities. Observation also revealed R149 was complaining of his legs hurting. Observation on 05/23/2024 at 9:30 AM, revealed R149 was sitting up in a wheelchair with black TED hose on his bilateral legs. Observation on 05/24/2024 at 9:15 AM revealed Resident up in wheelchair with white TED hose in place, as well as non-skid socks. In interview on 05/24/2024 at 10:58 AM, Certified Nursing Assistant (CNA) 8 stated the CNA's could put TED hose on for residents in the morning and remove them at night. CNA 8 stated if a resident refused to allow staff to put the TED hose on the CNA's reported that information to the nurse, and then the nurse would try to encourage the resident to allow the TED hose to be put on. The CNA further stated that R149 refused at times to wear his TED hose. In addition, she stated the risk for residents not wearing their TED hose which would allow more swelling and/or cause a blood clot to form. Telephonic (Phone) attempts were made on 05/23/2024 to contact Registered Nurse (RN) 2 who documented R149 refused his TED hose on 05/22/2024; however the attempts were unsuccessful. Phone attempts were made on 05/22/2024 at 4:22 PM, 05/23/2024 at 2:07 PM, and 05/24/2024 at 12:02 PM, to contact LPN #1, the nurse who NP #1 gave the verbal order to for R149's TED hose on 05/21/2024; however, all attempts were unsuccessful. During an interview on 05/23/2024 at 2:35 PM, with Nurse Practitioner (NP) 1 she stated R149's TED hose were initially ordered for the right leg only on admission on 05/16/2024, as the resident had edema related to the femur repair surgery. She stated she ordered the bilateral TED hose on 05/21/2024 around 3:00 PM or so, because R149 had edema in both legs. NP 1 further stated she had ordered a Venous Doppler study for R149, and that was negative for thrombus. The NP also stated the family brought in some TED hose a few nights ago. In interview with RN 1 on 05/24/2024 at 10:32 AM, she stated she had worked at the facility for the past [AGE] years. RN 1 stated Resident 149 refused to wear his TED hose at times, and she had documented the refusals in the computer. She stated nurses or aides could apply TED hose, but the nurse was the one who had to ensure the TED hose was on because that information had to be documented on the TAR. RN 1 stated she could not recall when the order came through for R149's TED hose. She further stated the risk of a resident not wearing their TED hose as ordered could be increased swelling or possible blood clots. In an interview on 05/24/2024 at 11:05 AM, with Unit Manager #1(UM) she stated LPN #1 had put in the order for TED hose to R149's bilateral legs, on 05/21/2024. The UM stated she was not sure why the order had been discontinued that same day. In an interview on 05/24/2024 at 12:04 PM, with R149's spouse she stated she informed staff that R149 was supposed to be wearing TED hose; however, was unable to recall who that staff person was. She stated she was informed that staff would contact the Physician or NP and get an order for TED hose R149. The spouse further stated her grandson had gone out and bought a pair of TED hose for R149 and took those to the facility on [DATE]. In an interview on 05/24/2024 at 12:17 PM, with R149's grandson he stated he bought TED hose for R149 and took them to the facility and placed them on R149 himself on 05/22/2024. The grandson further stated he was not sure of what time of day it had been, but thought it was late evening. In an additional interview on 05/24/2024 at 1:10 PM, NP 1 stated she had given a verbal order on 05/21/2024 to an LPN (LPN 1) for R149's TED hose to be applied to the resident's bilateral legs. She stated however, she was not sure why the order placed in the resident's Electronic Medical Record (EMR) had been discontinued on that same day. She stated she knew LPN 1 applied the TED hose to R149's legs prior to her (NP) leaving the facility late on the evening of 05/21/2024. In interview with the Director of Nursing (DON) on 05/24/2024 at 1:10 PM, she stated she had been the DON at the facility for over a year. The DON stated any nurse, Kentucky Medication Aide (KMA), or Certified Nursing Assistant (CNA) could apply residents' TED hose. She stated it was the nurses who had the order for TED hose and they received those orders from either the Physician or the NP. The DON stated it was her expectation, if a resident had an order for TED hose, for the resident to have the TED hose applied as ordered. She stated if the NP gave an order, whether it was a written order or a verbal order, it was her expectation for those orders to be followed. The DON stated nurses were the ones who documented on the TAR whether residents were wearing their TED hose. She said the nurses placed that information into the facility's computer system when the TED hose were applied in the morning and to taken off at bedtime. The DON stated nurses were ultimately responsible for doing rounds to ensure residents had their TED hose either on or off for the day. She stated if a resident refused to wear their TED hose, then the nurse was to document the refusal and notify the doctor and the family so they were aware of the refusal. The DON further stated all Physician orders were discussed in clinical meetings and the residents' care plans were updated at that time. She further stated she expected residents' TED hose orders to be on a care plan. In interview on 05/24/2024 at 1:45 PM, Physical Therapist (PT) 1 stated when she performed R149's evaluation on 05/17/2024, the resident did not have TED hose on. She stated she recalled that information because she had to find R149 some clothes as he only had pajamas to wear until his family brought more clothes in for him. PT 1 further stated she had provided therapy for R149 on 05/22/2024 around 11:00 AM, and recalled the resident did not have on TED hose at that time either.

Based on interview, record review, and facility policy review, it was determined the facility failed to develop and implement a Baseline Care Plan for one (1) of thirty five (35) sampled residents (Resident #149). Resident (R) 149 was admitted to the facility from the hospital, where the resident had been treated for a femur fracture. However, the facility failed to implement a Baseline Care Plan for the application of Thromboembolic Deterrent hose (anti-embolism stockings) for R149. The findings include: Review of the facility's, Baseline Care Plan policy revealed the completion and implementation of the Baseline Care Plan within 48 hours was intended to promote continuity of care and communication among nursing home staff; increase resident safety; and safeguard against adverse events that were most likely to occur right after a resident's admission. Further review revealed the facility was also to ensure the resident representative(s) were informed of the initial plan for delivery of care and services by receiving a written summary of the Baseline Care Plan. Review of R149's Admission Record revealed the facility admitted the resident on 05/16/2024, with diagnoses of Fracture of Right Femur, Entercolitis (inflammation in a person's digestive tract), due to Clostridium Difficile (a bacteria that causes diarrhea and inflammation of the colon), and Parkinson's Disease. Review of R149's Baseline Care Plan dated 05/16/2024, revealed the facility had developed a focus for Activities of Daily Living (ADLs) for the resident. Continued review of the ADL focus revealed an intervention for application of TED hose (anti-embolism stockings) on in AM (morning) and off in the PM (evening), initiated on 5/16/2024. Further review revealed on 05/17/2024 an intervention was added for TED hose to be applied to R149's right leg on in AM, and off every HS (bedtime) with a resolved date of 05/17/2024. In addition, review of the Baseline Care Plan revealed on 05/24/2024, an intervention was added for TED hose to be applied to R149's bilateral legs, on in the AM and off every HS. Review of R149's Physician Orders revealed an order dated 05/16/2024, for TED hose to be applied to the resident's right lower extremity every morning and off every evening, which was discontinued on 05/16/2024. Continued review of the Physician Orders revealed on 05/18/2024, an order for a STAT (urgent) Venous Doppler (ultrasound) for edema and discoloration times two days. Further review of R149's Physician Orders revealed a new order dated 05/21/2024, for TED hose to be applied to the residents' legs, put on in the AM and take off at bedtime to prevent swelling of the legs. Review of R149's Treatment Administration Record (TAR) revealed documentation of TED hose placed on 05/21/2024 in AM and off in PM. Continued review of the TAR revealed on 05/22/2024, it was noted R149 refused the TED hose, and on 05/23/3034, it was documented the resident's TED hose were applied in the AM; and removed in the PM. Observation of R#149 on 05/21/2024 at 4:48 PM revealed no TED hose on Resident #149, legs were in dependent position. Further observation noted swelling of bilateral legs more swollen on the left. The Resident was up in the wheelchair in the dining area in front of the nursing station. Observation on 05/22/2023 at revealed Resident #149 up in wheelchair, legs dependent position, and no TED hose on. More edema and redness than yesterday noted to bilateral lower extremities. Resident with complaints of legs hurting. Observation on 05/23/2024 at revealed Resident up in wheelchair, legs dependent position with black TED hose on bilateral legs Observation on 05/24/2024 at revealed Resident up in wheelchair with white TED hose in place. During an interview on 05/23/2024 at 2:35 PM, with Nurse Practitioner (NP) 1 she stated the order for R149's TED hose was initially placed for the right leg only on his admission on 05/16/2024, because the resident had edema due to his femur repair surgery. NP 1 stated she ordered bilateral TED hose for R149 on 05/21/2024 around 3:00 PM or so, because the resident had edema in both his legs. She stated she had ordered a Venous Doppler study for R149, which had been was negative for thrombus. The NP further stated R149's family brought in some TED hose for the resident a few nights ago. In interview with the Director of Nursing (DON) on 05/24/2024 at 1:10 PM, she stated she had been the facility's DON for over a year. She stated any nurse, Kentucky Medication Aide (KMA), or Certified Nursing Assistant (CNA) could apply residents' TED hose. The DON further stated all the Physician orders were discussed in clinical meetings and the residents' care plans updated at that time. She stated her expectations were for residents' TED hose orders to be placed on their care plan. In an interview on 05/24/2024 at 1:25 PM the Administrator stated his expectation was for the clinical team to handle all clinical matters.

Based on observation, interview, and facility policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for three of 10 sampled residents (Residents [R] 4, 15, and 38). The findings include: Review of the facility's policy titled, Policies and Practices--Infection Control, revised October 2018, revealed the facility's infection control policies and practices were intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Review of the facility's policy titled, Enhanced Barrier Precautions, revised August 2022, revealed standard precautions applied to the care of all residents regardless of suspected or confirmed infection or colonization status. 1. Review of R4's Face Sheet revealed the facility admitted the resident on 01/06/2016, with admitting diagnoses to include: spina bifida, major depressive disorder, generalized anxiety disorder, and other seizures. Review of R4's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated intact cognition. Review of R4's Comprehensive Care Plan (CCP) dated 01/06/2016, revealed the facility care planned the resident as at risk for an alteration in respiratory status related to shortness of breath with a goal for oxygen saturation to remain above 90%. Continued review of the CCP revealed the interventions included: administration of oxygen as ordered by the physician; monitor oxygen saturations on room air and/or oxygen; and apply bilevel positive airway pressure (BiPap, a machine used to help with breathing) at bedtime and remove in the mornings. Review of R4's Physician Orders dated April 2023, revealed R4 had been on oxygen at two liters per minute (2 LPM) per nasal cannula (NC) during the night with BiPap therapy. Continued review of the Physician Orders revealed R4 had BiPap orders with settings of minimum 18, maximum 22 centimeters (cm) with oxygen liter flow of 2 LPM every night and the BiPap was to be removed every morning. Observation of R4's room on 05/21/2024 at 1:31 PM, revealed undated oxygen tubing lying on the bed with no barrier covering it. Continued observation revealed undated BiPap tubing was lying next to the uncovered BiPap machine and not in the bag, which was lying on the opposite side of the machine from the tubing. Further observation revealed the oxygen concentrator filter was noted to have dust on it. Observation of R4's room on 05/22/2024 at 11:44 AM, revealed undated oxygen tubing lying uncovered on top of the oxygen concentrator uncovered. Continued observation revealed the BiPap tubing was lying uncovered on the shelf next to the BiPap machine, and the oxygen concentrator filter continued to have dust on it. In interview with R4 on 05/21/2024 at 5:15 PM, she stated she wore her BiPap during the night for sleep apnea and oxygen at 2 LPM per NC ran through the machine at that time. R4 stated it had been about three weeks since her BiPap tubing had been changed and she was not sure when the last time her oxygen tubing had been changed. The Resident stated when staff removed her BiPap mask in the morning, they would just throw it up on the shelf and she never saw them put the mask in a bag. R4 stated staff would put her oxygen tubing either on top of the machine or on the bed once she got up for the day. She stated staff rarely covered or placed her oxygen tubing in a bag. R4 further stated staff did not clean the filter on her oxygen concentrator when they did change out the oxygen tubing and she was not sure when the last time the filter had been cleaned. 2. Review of the R 15's Face Sheet revealed the facility admitted the resident on 11/20/2021, with admitting diagnoses to include: emphysema, mild cognitive impairment of unknown etiology, unspecified depression, and unspecified persistent mood affective disorder. Review of R 15's Annual MDS assessment dated [DATE], revealed the resident had a BIMS score of 15 out of 15, which indicated intact cognition. Continued review of the MDS revealed R 15's was on oxygen therapy during the night. Review of R 15's CCP dated 12/03/2021, revealed the facility had care planned the resident for altered respiratory status related to emphysema with a goal for oxygen saturations to remain above 90% through the next review date. Continued review of the CCP revealed R 15's had interventions for: oxygen at 3 LPM via a NC every night with monitoring of oxygen saturation every shift; staff to cleanse the BiPap mask and tubing with warm soapy water and rinse weekly and air dry; and to keep the resident's head of bed elevated to prevent shortness of breath. Observation of R 15's room on 05/21/2024 at 1:10 PM, revealed a continuous positive airway pressure (C-PAP) machine sitting on the shelf above the bed with the tubing hanging from the machine with the open end of the C-PAP flex tubing lying on the floor. 3. Review of R 38's Face Sheet revealed the facility admitted the resident on 12/09/2020, with admitting diagnoses to include unspecified dementia, generalized anxiety disorder, other specified depressive episodes, and unspecified dyspnea. Review of R 38's Quarterly MDS assessment dated [DATE], revealed the facility care planned the resident to have a BIMS score of three out of 15, which indicated severe cognitive impairment. Review of R 38's CCP dated 02/24/2024, revealed the facility care planned the resident for altered respiratory status/difficulty breathing related to low oxygen saturation; experiencing shortness of breath with exertion and if attempted to lie flat, with a goal for pulse oximetry to remain above 90% through the next review date. Continued review of the CCP revealed the interventions included: to administer medications as ordered by the physician; monitor for signs and symptoms of respiratory distress and report to the physician as needed; and for the resident to wear oxygen at 2 LPM via a NC as needed. Review of R 38's physician's orders dated February 2024, revealed an order for oxygen at 2 LPM via a NC as needed to keep oxygen saturation above 90%. Observation of R 38's room on 05/21/2024 at 2:55 PM, revealed undated oxygen tubing lying on the floor next to the resident's bed. Further observation revealed the oxygen concentrator filter appeared dusty. Observation of R 38's room on 05/22/2024 at 9:30 AM, revealed undated oxygen tubing lying on top of the oxygen concentrator uncovered and the oxygen concentrator filter continued to appear dusty. In interview with Kentucky Medication Aide (KMA) 1 on 05/21/2024 at 5:05 PM, she stated any oxygen tubing or BiPap tubing should have been stored in a bag and the tubing was to be changed weekly. KMA #1 stated she was not sure when the oxygen concentrator filters were to be cleaned. She stated the tubing's were to be placed in a bag when not in use to prevent the spread of infections. In interview, the KMA stated she had seen tubing not stored appropriately in bags in the past, but she always disposed of it and got new tubing for those residents, which she date. KMA #1 stated the risk to the residents, wearing the tubing after it was left uncovered and/or lying on the floor, was for an infection which could get into the lungs from the unprotected tubing and possibly cause pneumonia in the residents. In interview with Licensed Practical Nurse (LPN) 1 on 05/21/2024 at 5:20 PM, she stated the oxygen, BiPap and C-PAP tubing, once removed from off the residents, were to be placed in a bag to protect the residents from the spread of infection. LPN 1 stated the tubing was to be thrown away after it had been found lying unprotected and new tubing was to be obtained for the resident, and dated and placed in a bag for future usage. LPN 1 stated she made random rounds during the week to follow up with residents and would spot check to ensure respiratory tubing was dated and stored appropriately. She stated if she saw tubing not stored properly, she threw it away and obtained new tubing which she dated. LPN 1 further stated the risk to residents using dirty tubing was an increased risk for infections such as pneumonia. In interview with the facility's contract supplier Manager for respiratory items on 05/23/2024 at 10:15 AM, he stated his company was contracted to provide equipment and to do routine maintenance on the oxygen equipment as needed. The contract supplier Manager stated their personnel were required to do a walk through in the facility once a month to identify any issues, but they usually came in routinely on a weekly basis and addressed any issues. He stated the facility contracted with a specialty medical services (SMS) provided for a Respiratory Therapist (RT) to provide cleaning of the BiPap and C-PAP machines. The contract supplier Manager stated the RT also was responsible for keeping the tubing clean. He stated it was the facility staff who were responsible for cleaning the oxygen tubing and filters and the contract RT staff kept the BiPap and C-PAP tubing cleaned during their visits to the facility. The contract supplier Manager stated it ultimately fell on the facility's nursing staff to change any oxygen tubing, BiPap or C-PAP tubing for issues like tubing lying on the floor or lying unprotected in the resident's rooms. In interview with the Admissions Coordinator (AC) on 05/24/2024 at 10:05 AM, she stated she had worked as a Registered Nurse (RN) in the building for the past five years, but for the last year, she had worked as the AC for the facility. She stated any respiratory tubing was to be kept in a bag and labeled with a date for when the tubing had been changed, which was to occur weekly. The AC stated any respiratory tubing lying in a resident's room uncovered was to be thrown away and newly dated tubing provided which was to be placed in a bag. She further stated the risk for residents wearing tubing not stored properly would be the residents breathing in contaminates, which would lead to infections. In interview with Unit Manager (UM) #1 on 05/24/2024 at 10:18 AM, she stated any oxygen tubing, BiPap or C-PAP tubing not in use was to be placed in a bag to prevent the spread of infection. UM #1 stated any unprotected tubing used placed residents at risk for increased infections such as pneumonia or staph infections. She stated those infections could lead to hospitalization s for the residents and require antibiotic therapies. UM 1 stated the facility contracted a respiratory company to come in weekly to change out respiratory tubing. She stated nurses made rounds daily to ensure residents were wearing their oxygen per the Physician orders and to ensure any tubing not in use was stored properly in a bag. UM 1 further stated it was the nurses responsibility to ensure tubing was stored appropriately in a bag when not in use and to dispose of tubing not in bags, and obtain new tubing and date it. In interview with RN 1 on 05/24/2024 at 10:32 AM, she stated she expected to find any resident's respiratory tubing properly stored in a bag or on the resident. RN 1 stated if the tubing was found anywhere else, she would change out the tubing, date the new tubing, and place it in a bag. She stated all tubing was to be dated to ensure other nurses were aware of the changing of the tubing and know when it was to be changed again. RN 1 stated the risk to residents wearing tubing which had been lying on the floor or lying uncovered on a shelf was the residents could breathe in bacteria, which could lead to the spread of infections such as pneumonia's. In interview with Certified Nursing Assistant (CNA) 7 on 05/24/2024 at 10:46 AM, she stated any oxygen tubing,C-PAP, or BiPap tubing was to be stored in a bag when not in use to prevent the spread of infection. CNA 7 stated she told the nurse whenever she saw uncovered (respiratory) tubing, so the nurse could dispose of that tubing. She stated the risk for the residents wearing tubing which had been uncovered was the risk of spreading infections and the growing of bacteria, which could get into the lungs of the residents. In interview with the Assistant Director of Nursing (ADON) on 05/24/2024 at 12:56 PM, she stated she expected to find all respiratory tubing, whether it was oxygen tubing, C-PAP, or BiPap tubing, to be stored in a bag or the resident wearing it. The ADON stated the tubing, when not in use, was to be stored in a bag to protect it from bacteria. She stated her expectation was if a resident's tubing was found lying on the floor, lying on the bed, or lying on a shelf uncovered, for her nursing staff to throw that tubing away and obtain new tubing which was to be labeled and placed in a bag. The ADON stated the risks for residents wearing tubing that was unprotected (not stored in a bag) was the risk for increased infections such as pneumonia's, which could lead to hospitalization s and ultimately death if the resident was severely compromised. In interview with the Director of Nursing (DON) on 05/24/2024 at 1:10 PM, she stated her expectation was for residents to be wearing respiratory tubing which had been stored appropriately. The DON stated she also expected any respiratory tubing which had been compromised, to be disposed of by nursing staff, with new tubing obtained and dated and stored in a bag to prevent the spread of infections. She stated the risks for residents wearing the unprotected, contaminated tubing, whether it was oxygen tubing or BiPap tubing, was the spread of bacteria which could lead to respiratory infections such as pneumonia, re-hospitalization s for residents, or the need for antibiotic therapies for compromised residents. She stated her expectation was for her nurses to be observant when making rounds to ensure the residents' respiratory tubing was properly placed in a bag. She also stated she expected the nurses to either change residents' tubing and/or clean the filters at any time if needed regardless of the due dates for tubing changes. The DON stated it was ultimately the responsibility of her nurses to ensure the residents had clean respiratory equipment. She further stated if the nurses did not perform their job duties as required, then she would re-educate them and give disciplinary action for continued failure to perform their job duties. In interview with the Administrator on 05/24/2024 at 1:25 PM, he stated he expected the nursing staff to be making rounds to ensure residents' respiratory equipment was properly stored when not in use to prevent the spread of bacteria. The Administrator stated regardless of who was supposed to clean the equipment or change the tubing, it was ultimately up to nursing staff to ensure the residents' tubing was clean and stored in a bag when not in use. He further stated if a resident was wearing tubing which had been uncovered and/or lying on the floor, it could lead to the spread of infection, and put the resident at risk for increased lung infections.

Based on observation, interview, review of facility policy, and review of the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) guidance, it was determined that the facility failed to prevent the possible spread of COVID-19. On 09/10/2020, four (4) residents were observed in the common area of the facility with no face mask in use and two (2) were observed not socially distanced for approximately forty-five (45) minutes. Further observations on 09/10/2020 conducted in the Red Zone of the facility (where COVID-19 positive residents resided) revealed one (1) nurse had her mask positioned below her nose and mouth and another nurse was observed assisting a resident while wearing a mask but was not utilizing a face shield or gown as required. Observations on 09/10/2020 revealed two (2) staff members exited the Yellow Zone (an isolation area where residents under investigation for signs/symptoms of COVID-19 resided) and had not doffed Personal Protective Equipment (PPE) appropriately as required. Interviews with one (1) agency nurse revealed no training had been conducted related to the required use of PPE before providing resident care in the facility. The findings include: A review of COVID-19 Long-Term Care Facility Guidance from CMS dated 04/02/2020 and review of the facility's policy, Coronavirus Disease (COVID-19) Prevention and Control, dated March 2020, revealed the current Centers for Disease Control and Prevention (CDC) guidelines had been implemented in the facility and had been included in the facility's policy that all staff and residents (when in a common area of the facility) should wear a face mask and maintain social distancing of six (6) feet from others while they are in the facility. According to CDC guidance for Using PPE, updated on 06/09/2020, when applying a face mask, the nose piece (if the mask has one), should be fitted to the nose with both hands and should be extended under (the) chin. The guidance stated both the mouth and nose should be protected. The guidance also stated that face masks should not be pulled below the chin. Review of the facility policy titled Sequence for Personal Protective Equipment, not dated, revealed staff were instructed to remove all personal protective equipment (PPE) before exiting the patient room. The PPE staff guidance also stated staff were to remove the face shields first and indicated the outside of the shields were contaminated. The policy also stated staff should remove their masks (respirators) after leaving the resident's room and closing the door. Interview with the Director of Nursing (DON) on 09/11/2020 at 1:50 PM revealed the facility had no policy on ensuring that agency staff, utilized for resident care in the facility, was trained on the required use of PPE in the facility. She stated she relied on the person screening staff for that day to train agency staff on the facility requirements; however, she had no follow-up process to ensure that was completed as required. The DON also stated staff that provided care for residents in the Red Zone of the facility were required to utilize full PPE at all times, which included a K-N95 face mask, a face shield, and gowns. She also stated gloves should be utilized as appropriate when providing resident care. 1. Observation on 09/10/2020 at approximately 11:35 AM, revealed Licensed Practical Nurse (LPN) #1 and Advanced Practice Registered Nurse #1 (APRN) #1 exited the Yellow Zone and both staff were still in full PPE (face shields, masks, gown, and gloves). LPN #1 was observed to remove her PPE, and place the PPE in a trashcan with no can liner observed. APRN #1 was observed to remove her PPE, and disposed of it in a trashcan with no can liner. APRN #1 was also observed to maintain use of her face shield and mask. The APRN then entered a resident's room, with one (1) resident observed in the room (not in isolation), and wash her hands in the resident's room. Interview with LPN #1 on 09/10/2020 at 11:45 AM, revealed she had been trained on how to properly remove PPE in the facility. She stated she should have removed the PPE outside of the resident's room, inside the isolation area. She also stated she should have removed her shield and sanitized it appropriately outside the resident room as required. The LPN also stated PPE should be disposed of in a red bag, and should not have been placed in a can with no liner outside the isolation area of the facility. An attempt to contact the APRN on 09/11/2020 was unsuccessful. Interview with the DON on 09/10/2020 at 11:40 AM revealed staff should remove PPE upon exit from the resident's room, and PPE should be disposed of properly in a biohazard red bag container. She also stated staff should remove their face shields, after exiting a resident's room, and disinfect them because the outside of the face shields were considered contaminated. The DON also stated the APRN should not have entered a resident's room to perform hand hygiene, with a shield on that had not been sanitized properly. 2. Observations conducted on 09/10/2020 from approximately 11:45 AM to 12:30 PM, of the common area in the facility revealed Resident #1 and Resident #2 were observed to not have a face covering on. Continued observations revealed Residents #3 and #4 were seated at a table together with neither resident utilizing a face covering and sitting approximately three (3) feet from each other. Continued observations revealed staff were passing by the residents in the common area and nurses were seated at the nurses' station; however, no staff were observed to attempt to ensure residents were utilizing face coverings, or maintaining a safe social distance as required. Interview with LPN #2 on 09/10/2020 at 1:20 PM revealed residents were required to maintain a six (6) foot distance from one another and face coverings should be utilized when residents were in a common area of the facility. However, the LPN stated that even though she had been seated in view of residents not following the guidelines, she had not identified that the guidelines were not being followed. 3. Observations conducted on 09/10/2020 at 2:55 PM revealed Registered Nurse (RN) #1 was observed in the Red Zone (where COVID-19 positive residents resided) assisting a resident in a wheelchair while wearing a mask. The RN had not utilized a face shield or gown as required when resident care was provided. Further observations of the Red Zone revealed LPN #3 was at the nurses' station with her mask pulled below her nose and mouth, and no face shield was in use. Interview with RN #1 on 09/11/2020 at 2:30 PM revealed she had been trained to utilize face masks, a face shield, gown, and gloves when care was provided to residents in the Red Zone. The RN also stated she knew the appropriate measures to take with PPE in the Red Zone and she just wasn't thinking. Interview with LPN #3 on 09/11/2020 at 12:50 PM revealed she was agency staff and this was her first week providing care at the facility and had not received any training related to the required use of PPE in the Red Zone of the facility. She acknowledged she had placed her mask below her nose and mouth and was not utilizing a face shield because she was getting ready to leave for the day. LPN #3 stated she had not been informed that she was required to wear a K-N95 mask and a face shield when she was in the Red Zone of the facility. An interview with the Director of Nursing (DON) on 09/11/2020 at 1:50 PM, revealed all staff were required to wear a K-N95 face mask, face shields, and gowns to cover their clothing when in the Red Zone of the facility. She also stated residents were required to wear a face covering and maintain a six (6) foot social distance from each other when out of their rooms, to help prevent the spread of the Coronavirus. She stated some residents were reluctant at times to follow the guidelines; however, staff should have encouraged their compliance with the required measures that had been implemented in the facility. The DON also stated all staff had been trained on the required CDC guidelines in the facility. According to the DON, she made rounds to monitor to ensure staff were following the policy and she was providing on-the-spot education if needed. The DON stated she had not identified any concerns with the facility's implementation of the required guidelines to help prevent the spread of the Coronavirus in the facility. She also stated she was not aware that agency staff had not been trained on the PPE requirements in the facility; however, she stated she would implement a better process to ensure all staff that provided care in the facility was aware of the PPE requirements before providing care to facility residents.

Based on interview, record review, review of the facility's investigation, and review of the facility's policy, it was determined that the facility failed to ensure a care plan for one (1) of twenty-six (26) sampled residents (Resident #14) was developed that described the services that were required to attain or maintain the highest practicable physical and psychosocial well-being. The facility assessed Resident #14 to require two staff members for bed mobility; however, the facility failed to develop a care plan to address the assistance the resident required. On 03/19/19, one staff person assisted the resident with bed mobility, the resident slid out of bed and landed on his/her knees, and sustained a leg abrasion. The findings include: Review of the facility's Care Plan Policy Care Plans, Comprehensive Person-Centered, revised (MONTH) (YEAR), revealed The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #14's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderately impaired cognition. Further review of the MDS revealed the resident was assessed to require extensive assistance of two (2) staff members for bed mobility. Review of Resident #14's Daily Care Plan dated 05/20/19 revealed the facility identified that the resident required staff assistance with Activities of Daily Living (ADLs) related to dementia, weakness, and a history of falls. Further review revealed the facility developed interventions to prevent falls that included assisting the resident to turn and reposition and to use a pillow or wedge to maintain good body alignment. There was no documented evidence that the facility developed an intervention to address the assistance the resident required with bed mobility. In addition, review of Resident #14's State Registered Nurse Assistant (SRNA) Kardex revealed no documented evidence that the facility addressed the number of staff members needed to assist the resident with turning and repositioning. Observation and interview with Resident #14 on 05/21/19 at 1:32 PM revealed the resident was in bed. A fall mat was observed at the bedside and an air mattress on the bed. The resident stated he/she did not remember falling, but stated he/she slid out of bed onto his/her knees once. Further observation revealed there was signage above the resident's bed indicating the number of staff required for assistance with ADLs. Interview on 05/23/19 at 1:54 PM with SRNA #2 revealed all residents had figures above their bed indicating the number of staff needed to assist the resident. SRNA #2 further stated that staff reviewed a resident's Kardex, care plan, or Kiosk to determine the amount of assistance a resident required. According to SRNA #2, she was aware that Resident #14 required the assistance of two (2) staff members for ADLs including bed mobility. A review of a facility incident report for Resident #14 dated 03/19/19 revealed the resident's upper body was on the bed; however, the resident's knees were on the fall mat on the floor. The report stated a nursing assistant was assisting the resident with turning and incontinence care when the resident slid off the side of the bed, onto the floor. According to the report, the resident sustained [REDACTED]. The report stated a new intervention was implemented to check the weight setting on the resident's air mattress, verify placement of the resident in the bed prior to repositioning the resident, and encourage the two (2) staff members to assist with turning and repositioning, and incontinence care. An interview was attempted on 05/23/19 at 1:00 PM and 1:30 PM with SRNA #1, the SRNA that was assisting the resident when the fall occurred, via phone; however, the attempts were unsuccessful. Interview on 05/23/19 at 2:21 PM with the Director of Nursing (DON) revealed the Interdisciplinary Team discussed falls every morning in a stand up meeting. The DON stated she was unaware that neither Resident #14's Kardex nor Care Plan stated that the resident required the assistance of two staff members.

Based on record review and interview, it was determined that the facility failed to ensure the accuracy of the Minimum Data Set (MDS) for one (1) of twenty-two (22) sampled residents (Resident #27). Resident #27 was admitted to Hospice services on 08/21/18; however, the facility failed to ensure that MDS assessments completed for the resident on 08/30/18, 11/19/18, and 02/28/19 reflected that the resident was receiving Hospice services. The findings include: Review of Resident #27's medical record revealed the facility admitted the resident on 04/24/18 and the resident had [DIAGNOSES REDACTED]. Review of Resident #27's physician orders [REDACTED]. Review of the Hospice Interdisciplinary Team conference dated 05/09/19 revealed that Resident #27 was admitted to Hospice services on 08/21/18 with [DIAGNOSES REDACTED]. Review of the care plan for Resident #27 revealed the facility identified that Hospice services were initiated on 08/17/18 and developed a care plan. Review of Resident #27's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a significant change in status; however, there was no documented evidence that the facility identified that the resident received Hospice services. Review of quarterly MDS assessments dated 11/29/18 and 02/28/19 also revealed no documented evidence that the resident was receiving Hospice care in the facility. Interview with the MDS Coordinator on 05/23/19 at 10:38 AM revealed that the MDS Significant change in status dated 8/30/18 was completed due to Resident #27's admission to Hospice services on 08/17/18. Further interview with the MDS Coordinator revealed that Resident #27 had received Hospice services since 08/17/18. According to interview, the MDS assessments dated 08/30/18, 11/29/18, and 02/28/19 were completed incorrectly and should have reflected that Resident #27 was receiving Hospice services in the facility.

Based on observation, interview, record review, review of the facility's investigation, and review of the facility's policy it was determined that the facility failed to ensure that one (1) of twenty-six (26) sampled residents (Resident #14) received adequate supervision to prevent accidents. Resident #14 was assessed by the facility to require the assistance of two (2) staff members for bed mobility; however, on 03/19/19 at 7:10 AM, one (1) staff member assisted the resident with turning and repositioning and the resident slid out of bed and sustained an abrasion to the left knee. The findings include: Review of the facility policy titled Accidents and Incidents - Investigating and Reporting, revised (MONTH) (YEAR), revealed, The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. Incident/Accident reports will be reviewed by the Safety Committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #14's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eleven (11), indicating the resident had moderately impaired cognition. Further review of the MDS revealed the resident was assessed to require extensive assistance of two (2) staff members for bed mobility. However, review of Resident #14's Daily Care Plan dated 05/20/19 and State Registered Nurse Assistant (SRNA) Kardex dated 05/20/19 revealed no documented evidence that the facility developed a care plan with interventions to address the assistance the resident required with bed mobility. Observation and interview with Resident #14 on 05/21/19 at 1:32 PM revealed the resident was in bed. A fall mat was observed at the bedside and an air mattress on the bed. The resident stated he/she did not remember falling, but stated he/she slid out of bed onto his/her knees once. Further observation revealed signage above the resident's bed indicating the resident required two staff members to assist the resident with ADLs. Interview on 05/23/19 at 1:54 PM with SRNA #2 revealed all residents had figurines above their bed that indicated the number of staff needed to assist the resident. According to SRNA #2, she was aware that Resident #14 required the assistance of two (2) staff members for ADLs including bed mobility. A review of a facility incident report for Resident #14 dated 03/19/19 revealed the resident's upper body was on the bed; however, the resident's knees were on the fall mat on the floor. The report stated a nursing assistant was assisting the resident with turning and incontinence care when the resident's knees slid off the side of the bed, onto the floor. According to the report, the resident sustained [REDACTED]. Further review of the report revealed the facility identified that the cause of the resident's fall was related to the air mattress. The report stated a new intervention was implemented to check the weight setting on the resident's air mattress, verify placement of the resident in the bed prior to repositioning the resident, and encourage two (2) staff members to assist with turning and repositioning, and incontinence care. An interview was attempted on 05/23/19 at 1:00 PM and 1:30 PM with SRNA #1, the SRNA that was assisting the resident when the fall occurred, via phone; however, the attempts were unsuccessful. Interview on 05/23/19 at 2:16 PM with Licensed Practical Nurse (LPN) #2 revealed she monitored to ensure staff were turning and repositioning residents in accordance with care plans and had identified no concerns with staff following care plans. Interview on 05/23/19 at 2:21 PM with the Director of Nursing (DON) revealed the Interdisciplinary Team discussed falls every morning in a stand up meeting. The DON further stated that staff notified the DON, Assistant DON, or the Staff Development Coordinator when a resident fell . She stated they looked at the root cause analysis to see what actually caused the fall. According to the DON, the facility determined the root cause of Resident #14's fall was due to the air mattress that was being used on the resident's bed and that the resident required the assistance of two staff members for repositioning. The DON stated she was not aware that neither Resident #14's Kardex nor Care Plan was developed with an intervention that required two staff members to assist the resident with ADLs.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure drugs and/or biologicals were labeled, stored, and dated appropriately. Observation revealed opened and unlabeled topical creams and medicated treatment supplies were stored in two (2) of three (3) treatment carts, and opened undated eye drops were stored in one (1) of four (4) medication carts. In addition, medical supplies available in two (2) of two (2) medical crash carts were past the expiration date. The findings include: 1. Review of the facility's policy, Labeling of Medication Containers, revised (MONTH) 2007, revealed all medications maintained in the facility were to be properly labeled in accordance with current state and federal regulations. Individual drug containers were to be labeled with the resident's name and expiration date. Labels for floor stock medication and over-the-counter drugs would include the expiration date when applicable. Observation of North Unit Medication Cart One, on [DATE] at 3:13 PM, revealed a container of Liquid Tears available for administration. The container was past the discard date, and labeled with an opened date of [DATE]. Observation of South Unit Treatment Cart One, on [DATE] at 9:15 AM, revealed one (1) box containing two (2) tubes of [MEDICATION NAME] Cream, both opened and unlabeled with the date opened. The labels contained the dates dispensed to the facility as [DATE] and [DATE]. Further observation revealed a jar of [MEDICATION NAME] packing strips available for use with an opened date of [DATE], and no resident name on the jar. There was a container of H-Chlor 6 solution, opened with no date opened on the bottle. Observation of South Unit Treatment Cart Two, on [DATE] at 9:25 AM, revealed an opened, partially empty jar of Icy Hot, without the date opened on the label. Interview with Registered Nurse (RN) #1, on [DATE] 3:13 PM, revealed the bottle of Liquid Tears in North Unit Medication Cart One, with an opened date of [DATE], was outdated as it should have been discarded thirty (30) days after it was opened. Interview with Licensed Practical Nurse (LPN) #5, on [DATE] at 9:15 AM, revealed the two (2) tubes of [MEDICATION NAME] Cream in South Unit Treatment Cart One, should have been labeled with the date opened, and the tube labeled dispensed [DATE], was expired and staff should have discarded. LPN #5 stated staff should have labeled the jar of [MEDICATION NAME] packing strips with the resident's name because the risk existed for staff to use on other residents, leading to cross contamination. In addition, she stated the jar was expired and should have been discarded. LPN #5 revealed staff should have labeled the H-Chlor 6 solution with the date opened, then discarded it after thirty (30) days because of the risk of decrease effectiveness. According to LPN #5, the Icy Hot in South Unit Treatment Cart Two should have been labeled with the date opened. Interview with LPN #6, on [DATE] at 10:16 AM, revealed the facility process for use of medications, treatments, and supplies, included labeling the container with the date opened. She stated the [MEDICATION NAME] packing material was stocked in-house and should have been labeled with the resident's name to prevent use on another resident and avoid multiple open containers. In addition, she stated the risk of not labeling containers with the resident's name was cross contamination and possible spread of infection. LPN #6 stated the purpose of labeling containers with the date opened was to assure items were disposed of on the appropriate day to assure effectiveness. LPN #6 further stated the risk of not discarding medications, treatments, and supplies when they were outdated was they could have been used beyond the discard date and posed a risk of spread of infection and decreased effectiveness. She stated the facility had in-services at least quarterly, and the last time medications were discussed was last month. She stated staff assigned to the cart was to ensure containers were labeled appropriately. In addition, she stated pharmacy also checked the medication carts monthly, as recent as [DATE]. Interview with LPN #2, on [DATE] at 10:52 AM, revealed staff was to label containers when opened with the date because treatments were good for a limited time and should not be kept past the date when they should be discarded. She stated the risk of not labeling containers included the treatment could have been used on the wrong resident and problems such as allergic reactions could result. She stated staff was instructed daily to ensure labels included staff initials and date opened. She further stated training on labeling medications was included in medication competencies performed annually. In addition, she stated staff assigned to the medication cart was to check for unlabeled and expired items, and treatments cart were to be checked at least weekly. She stated there was no written schedule for checking the carts and the Charge Nurse and Pharmacy also checked the medication and treatment carts. Interview, on [DATE] 12:53 PM, with the Pharmacist revealed when the facility accepted medications or creams from the pharmacy; the facility had custody and their policies took precedence. He stated standard practice for opening a treatment or medication was for staff to label the container with the date opened and ensure the container included a patient identifier. 2. The facility did not provide a policy related to auditing the medical crash carts. Observation of the North Unit Medical Crash Cart, on [DATE] at 10:15 AM, revealed the cart contained one (1) pre-loaded endotracheal tube and stylet with an expiration date of (MONTH) (YEAR), one (1) suction catheter kit with saline with an expiration date of (MONTH) 2006, and one (1) opened irrigation tray with sixty (60) milliliter (ml) bulb syringe with an expiration date of (MONTH) (YEAR). Review of the Crash Cart Checklist for the North Unit for (MONTH) (YEAR), revealed audits were documented twenty-six (26) of twenty-eight (28) days. Review of the Checklist for (MONTH) (YEAR), revealed audits were documented six (6) of seven (7) days. Observation of the South Unit Medical Crash Cart, on [DATE] at 11:06 AM, revealed the cart contained one (1) Bard Clean-cath olive Coude Tip urethral catheter with an expiration date of (MONTH) (YEAR) and twelve (12) Microshield clear mouth barriers with an expiration date of (MONTH) (YEAR) marked on the outer bag. Review of the Crash Cart Checklist for the South Unit for (MONTH) (YEAR), revealed audits were documented sixteen (16) of twenty-eight (28) days. Review of the Checklist for (MONTH) (YEAR), revealed audits were documented four (4) of seven (7) days. Interview with LPN #2, on [DATE] at 10:53 AM, revealed she believed the medical emergency carts were checked on the overnight shift, and staff audited the carts to ensure the specified supplies were present. LPN #2 stated she believed the audit included checking for expired items. She stated an expired item, if used, may not be effective, and should be removed from the cart during the audit of the cart. The LPN stated she did not think there was training on checking crash carts. Interview with LPN #4, on [DATE] at 11:25 AM, revealed the crash carts should be checked daily to assure the contents were current so staff was prepared for an emergency. She stated she did not know why there would be expired supplies on the crash cart. She stated the facility Infection Control Nurse was responsible for monitoring. LPN #4 revealed the facility did not train her on checking the crash cart. She stated if items were expired, they could dry rot and could potentially injure the resident, but she was not aware of any expired items in the crash cart. Interview with the Unit Manger (UM), on [DATE] at 10:58 AM, revealed medical emergency carts were audited daily on the 11:00 PM to 7:00 AM shift to ensure the correct supplies were present and unexpired. The UM stated she could not specify the potential effects of using expired supplies, but added that expired items should be removed from the cart during the daily audits of the cart. She stated she could not explain why the expired supplies were present on the cart. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 11:52 AM, revealed staff audited the medical emergency crash carts nightly but added she was aware it was not always accomplished nightly. The ADON stated it was the nursing department's responsibility to audit the medical emergency cart. She stated using expired medical supplies might affect the efficacy and quality of the item. Interview with the Executive Director (ED), on [DATE] at 12:39 PM, revealed he was not aware of any issues with unlabeled, undated, or expired supplies in the facility. He added he expected staff to label and date products when opened, remove, and replace expired supplies. The ED stated labeled, dated, and unexpired supplies ensured the correct items were used on the correct resident.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to revise the plan of care to reflect pain control for one (1) of twenty-five (25) sampled residents, Resident #78. The findings include: Review of the facility's Pain Assessment and Management Procedure, revised (MONTH) (YEAR), revealed Pain Management was a multidisciplinary care process that included assessing the potential for pain, effectively recognizing the presence of pain, identifying the characteristics of pain, addressing the underlying causes of pain, developing and implementing approaches to pain management, identifying and using specific strategies for different levels and sources of pain, monitoring for the effectiveness of interventions, and modifying approaches as necessary. The facility would conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there was a significant change in condition, and when there was onset of new pain or worsening of existing pain. Review of the facility's Change in a Resident's Condition or Status Procedure, revised (MONTH) (YEAR), revealed if a significant change in the resident's physical or mental condition occurred, a comprehensive assessment of the resident's condition would be conducted as outlined in the Minimum Data Set (MDS) Resident Assessment Instruction (RAI) Manual. The facility was to use the assessment to revise and prepare the comprehensive nursing care plan. Review of the RAI 3.0 User's Manual, dated (MONTH) (YEAR), Chapter 4, revealed the comprehensive care plan was an interdisciplinary communication tool and should be revised on an ongoing basis to reflect changes in the resident and the care the resident received. Review of Resident #78's clinical record revealed the facility admitted the resident on 02/17/15, with [DIAGNOSES REDACTED]. On 01/23/18, the facility referred the resident to Hospice to evaluate and treat following the resident's increasing confusion, dementia, and weight loss. Review of Resident #78's Significant Change MDS, dated [DATE], revealed the facility assessed the resident with a score of ninety-nine (99) on the Brief Interview for Mental Status (BIMS) and determined the resident was not able to complete the interview and was severely impaired regarding Cognitive Skills for Daily Decision Making. The facility assessed the resident received scheduled pain medication and had no pain in the last five (5) days. Review of Resident #78's Comprehensive Care Plan, dated 02/17/15, revealed the resident had Impaired Communication due to confusion and hard of hearing with interventions that included staff to anticipate his/her needs, listen carefully, and validate verbal and non-verbal expressions. Continued review revealed the resident had Pain, dated 02/20/15, due to [MEDICAL CONDITION] with interventions to include administer pain medication as ordered and evaluate need to provide medication prior to treatment or therapy. Further review of the Care Plan revealed the resident had Behaviors, dated 01/02/18, which included hitting, and screaming and yelling out during care. Interventions included to give medications as ordered and make sure he/she was not in pain or uncomfortable. Review of Resident #78's Medications Orders, for (MONTH) (YEAR), revealed [MEDICATION NAME] (for pain) 400 milligrams (mg) twice a day related to Bilateral Primary [MEDICAL CONDITION] of the Hip, start date 05/04/16, and [MEDICATION NAME] (for pain) 50 mg one (1) tablet three (3) times a day related to [DIAGNOSES REDACTED], start date 06/19/17. Review of the Medication Administration Records for (MONTH) (YEAR) and (MONTH) (YEAR) revealed the medications were administered as ordered. Observation of Resident #78's wound care, on 03/07/18 at 2:05 PM, revealed Licensed Practical Nurse (LPN) #1 and LPN #2 began the treatment and touched Resident #78's left foot and the resident began to moan with facial grimacing that continued throughout the treatment. At the end of the treatment, the resident began to moan with less intensity and decreased facial grimacing. LPN #1 and LPN #2 did not stop during the treatment to assess the resident's pain and continued with the treatment procedure. Interview with LPN #1, the Wound Care Nurse, on 03/08/18 at 9:45 AM, revealed if she were aware of a resident experiencing pain during a procedure, she would ask the resident's nurse to give him/her pain medication prior to the treatment. LPN #1 revealed Resident #78 had behaviors and always moaned and groaned whenever the treatment was performed and did not feel it was necessary to stop and assess his/her pain level. Interview with the Hospice Nurse, on 03/08/18 at 10:00 AM, revealed she assessed Resident #78 on a weekly basis. During her visits, she had not observed the resident to be in pain and in conversation with the staff, they contributed his/her moans, groans, and facial grimacing when touched to be more behavioral than actually pain; a cognitive impairment rather than pain. She stated the resident's pain control regimen was not revised when he/she was transferred to Hospice. The resident currently remained on [MEDICATION NAME] and [MEDICATION NAME] with no as needed medication for pain. Interview with the MDS Nurse, on 03/08/18 at 12:10 PM, revealed resident care plans were revised on a quarterly, significant change, and annual basis. The care plans were also updated daily during the morning clinical meeting when new physician orders [REDACTED]. She stated Resident #78's care plan was revised on 02/08/18, when a Significant Change MDS was completed due to continued decline in the resident and he/she was transferred to the care of Hospice. The MDS Nurse stated her observation of the resident revealed he/she was non-verbal and did not appear to be in pain at the time of her observation. Interview with LPN #4, the Unit Manager, on 03/08/18 at 9:30 AM, revealed Resident #78 received his/her scheduled pain medication between 11:00 AM and 12:00 PM the day of the dressing change, 03/07/18. She stated the nurses had not reported increased observations of pain with the resident and pain assessments were performed daily with medication administration and every Thursday. She stated if a resident were experiencing pain, which was not controlled by the current medication regimen, the nurse would contact the physician or nurse practitioner for new medication orders. Interview with the Nurse Practitioner, on 03/07/18 at 11:30 AM, revealed she began caring for Resident #78 when he/she was transferred to Hospice the end of (MONTH) (YEAR). At the time of the resident's admission to Hospice, there was no need to revise his/her pain medication regimen. She stated the nurses had not notified her of any pain associated with the resident's wound care treatments. Interview with the Executive Director, on 03/08/18 at 12:39 PM, revealed he had not identified issues or trends related to resident pain issues not being addressed in the care plans. He stated staff should update resident care plans as appropriate to reflect the care needed to provide the best quality care.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to report an allegation of abuse timely. On 12/26/17, State Registered Nurse Aide (SRNA) #3 witnessed Registered Nurse (RN) #2 verbally abuse Resident #1. The SRNA failed to report the allegation to administrative staff until 12/27/17 at 2:45 PM. The facility failed to report the allegation to the state agency until 7:00 PM on 12/27/17, approximately four hours after the allegation was reported to the facility, and more than twenty-four hours after the allegation occurred. The findings include: Review of the facility's policy titled Reporting Abuse to Facility Management, revised December 2013, revealed any individual who observed an incident of resident abuse or suspected resident abuse must immediately report such incident to the Administrator, Director of Nursing Services, or Charge Nurse. Review of the facility's policy titled Reporting Abuse to State Agencies and Other Entities/Individuals, revised December 2009, revealed verbal/written notices to agencies were required to be made within two (2) hours of the occurrence of abuse (physical or verbal). Review of Resident #1's medical record revealed the facility admitted the resident on 06/26/12, and the resident had [DIAGNOSES REDACTED]. Review of Resident #1's comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status score (BIMS) of fifteen (15), indicating Resident #1 was cognitively intact. Observation and interview with Resident #1 on 01/10/18 at 9:40 AM revealed a nurse (did not remember the nurse's name) putting on and saying something mean because the resident asked for his/her medication. Review of a facility investigation dated 12/31/17 revealed on 12/26/17, SRNA #3 overheard RN #2 ask Resident #1 why the resident had to be such a jerk? The resident replied that he/she was just trying to live. RN #2 responded, Why would you even want to live being such a jerk everyday. Just give up on life because there's no reason to live everyday being a jerk. According to the facility's investigation, SRNA #3 did not report the allegation until the next day, 12/27/17, at 2:45 PM. Review of the report the facility made to the state agency revealed the facility did not notify the state agency of the abuse allegation until 7:00 PM on 12/27/17. Interview with SRNA # 3 on 01/10/18 at 2:17 PM revealed she witnessed RN #2 verbally abuse Resident #1 on 12/26/17, but did not report the incident until 12/27/17 because she was intimidated by RN #2 and was afraid of the RN. Interview with the Director of Clinical Services on 01/10/18 at 3:47 PM revealed that on 12/27/17, SRNA #3 reported that RN #2 talked to Resident #1 inappropriately on 12/26/17. She stated she immediately reported the allegation to the Assistant Director of Nursing and Administrator. Interview with the Assistant Director of Nursing (ADON) on 01/10/18 at 4:00 PM revealed on 12/27/17, the Director of Clinical Services reported the allegation involving Resident #1 that occurred on 12/26/17. The ADON stated all staff were required to immediately report suspected or witnessed abuse immediately. Interview with the Administrator on 01/10/18 at 4:25 PM revealed an investigation was immediately initiated when the allegation of verbal abuse regarding Resident #1 was reported. He stated the staff was educated to report suspected or witnessed abuse immediately to a supervisor and was aware that the facility was required to report allegations of abuse to the state agency within two hours. The Administrator stated he got tied up with the investigation and time got away from him and the two-hour reporting requirement was not met.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure allegations of abuse were reported immediately to the Administrator for one (1) of three (3) sampled residents (Resident #1) to ensure residents were protected. Review of a facility investigation revealed on 06/22/17, State Registered Nurse Aide (SRNA) #2 witnessed SRNA #1 hold Resident #1's arms down with force during care. SRNA #2 also heard SRNA #1 call Resident #1 a dirty old f***er and an old ba***rd. SRNA #2 failed to immediately report the allegation of abuse in accordance with the facility's policy. The findings include: Review of the facility's policy entitled Abuse and Neglect, not dated, revealed the facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the facility. .You must report any occurrences of potential mistreatment you observe, hear about, or suspect by employees, family member, other residents, or strangers .No matter what the situation .You should not wait until the end of your shift or wait for the charge nurse or Director of Nursing (DON) to come in . Review of Resident #1's medical record revealed the facility admitted the resident on 05/12/15 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6), indicating severe cognitive impairment. Observations of Resident #1 on 07/19/17 at 9:45 AM and 10:45 AM revealed the resident was sitting in the dining room in a high backed wheelchair. No bruising or suspicious injuries were observed. Observations of staff interactions with the resident were pleasant and the resident did not appear fearful of staff. Review of the facility's final investigation dated 06/30/17 revealed on 06/22/17, SRNA #1 and SRNA #2 were providing care to Resident #1. SRNA #2 stated she observed SRNA #1 hold Resident #1's arms down with force while providing care and SRNA #1 told Resident #1 that he/she was a dirty old f***er and an old ba***rd. SRNA #2 did not report the allegation of abuse until 06/25/17, three days later. At that time, SRNA #1 was suspended pending the facility investigation and was terminated on 06/26/17. Interview with SRNA #1 on 07/19/17 at 2:34 PM revealed she helped SRNA #2 provide incontinence care for Resident #1 on 06/22/17. She stated the resident started hitting at her and she held his/her hands while SRNA #2 finished providing care. She stated she did not hold the resident's arms down with force. Further interview revealed she held the resident's hands and told the resident not to hit her because she was pregnant. She stated she did not call the resident names or speak to the resident inappropriately. An interview with SRNA #2 was attempted on 07/19/17 at 12:32 PM, 1:30 PM, and 2:45 PM; however, she did not have a working phone number. Interview with Licensed Practical Nurse (LPN) #1 on 07/19/17 at 12:54 PM revealed she was the nurse caring for Resident #1 on 06/22/17. She stated SRNA #2 did not report an allegation of abuse to her related to Resident #1 and SRNA #1. She stated if abuse was reported to her she would have reported to the DON immediately. Interview with the DON on 07/19/17 at 2:01 PM revealed the allegation involving Resident #1 was reported to her on 06/25/17 and an investigation was initiated. She stated that it was reported to her that SRNA #2 witnessed SRNA #1 hold Resident #1's arms down with force during care. SRNA #2 also heard SRNA #1 call Resident #1 a dirty old f***er and an old ba***rd. Further interview with the DON revealed SRNA #1 was suspended pending the investigation and terminated on 06/26/17. According to the DON, she expected staff to report any allegation of abuse immediately. Interview with the Administrator on 07/19/17 at 2:33 PM revealed any allegation of abuse was taken seriously. He stated when the allegation of abuse was reported to him related to Resident #1 and SRNA #1, he suspended SRNA #1 and started a formal investigation. He stated there had not been any other allegations of abuse reported to him related to SRNA #1 and he had not identified any concerns with staff not reporting abuse immediately.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure the resident's environment remains as free of accidents and hazards as is possible for three (3) sampled residents (Residents #3, #7, and #9), in the selected sample of twenty-one (21) residents, and for one (1) Unsampled resident (Resident A), related to bed and chair alarms not being on or functioning. Additionally, observations during the survey revealed aerosol spray cans in the rooms of two (2) sampled residents (Residents #5 and #6), in the selected sample of twenty-one residents, and for five (5) Unsampled residents (Residents B, C, D, E and F). The findings include: Review of the facility's procedure for alarms provided by the Director of Nursing (DON) on 12/07/16 revealed alarms are utilized for the purpose of fall intervention and prevention. Once an alarm is determined to be needed by the Interdisciplinary Team or nurse an order will be obtained and added to the Nursing Assistant Care Guide and the Care Plan. Further review revealed the alarms are checked every shift for functioning and placement. Review of the facility alarm Owner's Manual for the Pressure Alarm, no date, revealed always test the system, battery level and pad life (if applicable) status before every use. A warning is provided to always verify the system is working properly before leaving the resident unattended. Further review revealed to plug the pad into the bottom of the monitor and place the pad under the resident and test the system by applying pressure to the pad to activate the sensor device. After the device is activated the In Use light will blink to indicate that pressure has been applied to the pad. Review of the maintenance care of the alarm revealed always test the system before every use. Review of the facility alarm supplier brochure for the Economy Attendant pad alarm, no date, revealed there is an on/off switch that can disable all functionality. The in-use light notifies the caregiver at a glance that the unit is properly operating and the low battery alert light alerts caregivers when the battery is near expiration. Review of the facility alarm supplier brochure for the Deluxe Attendant pad alarm, no date, revealed there was no on/off switch and the alarm shuts off when pressure is reapplied to the pad. The in-use light notifies the caregiver at a glance that the unit is properly operating. 1. Record review revealed the facility admitted Unsampled Resident A on 03/23/08 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was severely cognitively impaired. Review of Resident A's Care Plan, initiated on 01/27/16 and revised on 12/05/16, revealed he/she was care planned to be at risk for falls. Review of an intervention included a chair alarm was to be on when the resident was out of bed. Observation, on 12/06/16 at 9:15 AM, revealed Resident A was up in his/her wheelchair (w/c) with an alarm on the back of the w/c. Further observation revealed the light on the alarm was not illuminated, which indicated the alarm was not on or functioning. Licensed Practical Nurse (LPN) #6 and LPN #7 took Resident A into the nursing station where LPN #5 and LPN #6 attempted to get the alarm box to work. After taking the alarm box apart and changing the batteries, they were still unable to get the alarm box to work. Interview with LPN #6, on 12/06/16 at 10:00 AM, revealed the alarm should have been working. Interview with LPN #2, on 12/08/16 at 3:20 PM, revealed alarms should be in working order when on a bed or wheelchair. LPN #2 further stated it was not acceptable to have alarm boxes that did not function. 2. Record review revealed the facility admitted Resident #5 on 03/29/16 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed a BIMS score of eight (8). Review of the Care Plan for Resident #5, initiated on 04/18/16, revealed the resident was care planned for confusion, not always knowing where he/she is with an intervention to include helping the resident to make safe choices. Observation during tour, on 12/06/16 at 8:19 AM, revealed two (2) cans of aerosol hairspray in Resident #5's room. 3. Record review revealed the facility admitted Resident #6 on 06/25/15 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed a BIMS score of six (6). Review of the Care Plan for Resident #6, initiated on 02/02/15, revealed he/she was casre planned for short term memory loss with an intervention of helping the resident to make safe choices, and helping with reminders and cues. Observation, on 12/06/16 at 9:20 AM, revealed a can of hair spray on the shelf above the bed in Resident #6's room. Observation, on 12/08/16 at 10:30 AM, revealed one (1) eleven (11) ounce can of Pantene aerosol hair spray on the bedside stand. 4. Record review revealed the facility admitted Unsampled Resident E on 11/27/16 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed a BIMS score of thirteen (13). Review of the Care Plan for Resident E, initiated on 09/06/16, revealed at risk for alteration in Respiratory Status due to COPD with an intervention of administering oxygen as needed. Additionally, review of a Care Plan for forgetting safety issues and making poor choices with interventions of helping with reminders and cues, helping the resident to make safe choices and redirect the resident as needed if it will assist in resident safety or safety of others. Observation, on 12/06/16 at 8:22 AM and at 10:32 AM, revealed a can of hair spray on the sink and on the bedside table of Resident E. Review of the label on the can revealed hair spray was flammable and harmful if sprayed toward the eyes or if swallowed. 5. Record review revealed the facility admitted Unsampled Resident F on 09/26/16 with [DIAGNOSES REDACTED]. Review of a Significant Change MDS, dated [DATE], revealed a BIMS score of seven (7). Review of the Care Plan for Resident F, initiated on 06/06/16, revealed the resident was care planned for periods of confusion and short term memory loss with interventions of reminders and cues to make safe choices. Observation, on 12/08/16 at 10:35 AM, revealed two (2) cans (five (5) ounces each) of deodorant and aerosol spray on the sink in the resident's room. Interview with the Director of Nursing (DON), on 12/08/16 at 2:20 PM, revealed the facility had no policy related to aerosol spray cans. 6. Record review revealed the facility admitted Resident #9 on 08/11/16 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the BIMS score of three (3), indicating the resident was not interviewable. Review of the physician's orders [REDACTED]. Review of the Comprehensive Care Plan, dated 11/19/16, revealed the resident was at risk for falls related to a left above the knee amputation (AKA), medications, and weakness. Further review revealed, on 11/19/16, the resident rolled out of bed. Review of the goal revealed the resident would have no fall related injuries. Interventions included a bed alarm to the bed at all times to alert staff of the resident attempting to get out of bed or getting too close to the edge. During observation of incontinent care for Resident #9, on 12/06/16 at 5:25 PM, with Certified Nurse Aide (CNA) #6 and CNA #7, they revealed Resident #9 tried to climb out of the bed when they first went into the resident's room. After incontinent care was completed, they discovered the alarm for the bed was not functioning and was turned off. Further interview with CNA #6 and CNA #7 revealed the alarms should have been turned on and should have sounded when the resident tried to climb out of bed. Both CNAs revealed it was their responsibility to check the alarms and ensure the alarms were on and functioning. Interview with the DON, on 12/08/16 at 10:55 AM, revealed she expected all alarms to be turned on. She revealed Resident #9's spouse routinely turned the alarms off when visiting; however, she expected the CNAs and nursing staff to check them on a regular basis to ensure the alarms were working. 7. Record review revealed the facility admitted Unsampled Resident C on 11/17/16 with [DIAGNOSES REDACTED]. Review of the Comprehensive MDS, dated [DATE], revealed a BIMS score of fifteen (15) indicating he/she was interviewable. Observation, on 12/06/16 at 8:00 AM, revealed an eleven (11) ounce can of Suave Max Hairspray on a shelf above the resident's bed, within reach of anyone who could ambulate in the room. Review of the Material Safety Data Sheet (MSDS) for Suave Aerosol Hairspray revealed it was flammable and could explode when exposed to excessive heat. Additionally, if it came in contact with someone's eyes, it should be flushed with copious amounts of water immediately. 8. Record review revealed the facility admitted Unsampled Resident D on 08/18/16 with [DIAGNOSES REDACTED]. Review of the Annual MDS, dated [DATE], revealed a BIMS score of five (5), indicating the resident was not interviewable. Observation, on 12/06/16 at 9:32 AM, revealed a can of Tresumme hairspray eleven (11) ounces, on a closet shelf inside the resident's door, with the door completely open and could be seen from the hall. Review of warnings on the can were as follows: avoid contact with eyes, can cause eye irritation, in case of contact with eyes, flush thoroughly with water. Flammable, do not use product near fire, flame or sparks. Do not smoke until hair is thoroughly dry. Contents under pressure. Do not puncture, incinerate or crush. Do not expose to heat or store at temperatures above 120 degrees Farenheit (F) as the can may burst. Concentrating and inhaling the contents can be harmful or fatal. Review of a list of wanderers by each hall revealed a total of twelve (12) residents (six (6) residents each on North and South halls). Seven (7) of twelve (12) residents had a BIMS score of less than eight (8) and were non interviewable. Interview with the DON, on 12/08/16 at 10:55 AM, revealed there were no policies or procedures related to potentially hazzardous materials such as aerosol hair sprays. 9. Record review revealed the facility admitted Resident #3 on 03/13/14 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed he/she was unable to complete the BIMS and received a score of ninety-nine (99), indicating the resident was not interviewable. Further review of the MDS revealed the resident was extensive assistance of two (2) people for bed mobility, transfers, and toileting. Review of the physician's orders [REDACTED]. Review of the Certified Nurse Aide (CNA) Care record, no date, revealed only a chair alarm to check placement. Review of the Nursing Fall Care Plan, dated 05/24/13, revealed an alarm to the wheelchair to alert staff if the resident attempted to get up without assistance. Further review of the care plan revealed a bed alarm, dated 05/22/15, as well as to monitor the alarm function and placement, dated 02/06/15. Observation of Resident #3, on 12/06/16 at 8:25 AM, revealed he/she was laying in his/her bed and the bed alarm box was not blinking nor connected to a pad. Interview with CNA #4, on 12/06/16 at 8:37 AM, revealed she was unsure if the resident was to have a bed alarm and would have to ask the nurse. She also verified the alarm was not plugged into a pad and would not activate. She stated if something happened to the alarm, the staff member should get another one and replace it. Interview with Licensed Practical Nurse (LPN) #7, on 12/06/16 at 8:40 PM, revealed the green light on the box should be green if the alarm was turned on, and there were papers above the bed which let the staff know if the resident has an alarm, whether to the bed, chair, or both. Interview with CNA #5, on 12/06/16 at 8:39 AM, revealed she would have to look at the care plan to determine if the resident had an alarm to the bed. She also verified the alarm was not attached. Further interview with the CNA, on 12/06/16 at 8:48 AM, revealed the resident was to have an alarm on the bed and was trying to locate the pad to connect to the box. Interview with CNA #3, on 12/08/16 at 8:12 AM, revealed the paper above the bed told which type of alarm the resident was suppose to have placed on them. She stated Resident #3 did not have a B above the bed indicating a bed alarm, only a C for a chair. She revealed she would have to look at the Care Guide to find out if the resident had an alarm on the bed, and if not on the Care Guide, then go to the nurse. Interview with LPN #2, on 12/08/16 at 8:15 AM, revealed the codes, B for bed and C for chair, were above the bed to remind the staff of the type of alarm. She further revealed Resident #3 only had a C above the bed. 10. Record review revealed the faciity admitted Resident #7 on 08/12/15 with [DIAGNOSES REDACTED]. Review of the Annual MDS, dated [DATE], revealed he/she was interviewable with a BIMS score of fourteen (14). Further review revealed the resident required extensive assistance of two (2) people for bed mobility, toileting, and transfer. Review of the physician's orders [REDACTED]. Review of the Fall Care Plan, dated 01/19/16, revealed a bed and chair alarm as ordered. Review of the CNA Care Guide, no date, revealed a bed and chair alarm on 01/18/16 check placement working. Observation, on 12/06/16 at 8:25 AM and 8:45 AM, revealed Resident #7 was sitting in the breezeway with an alarm to the back of the wheelchair, but the alarm was not blinking. Interview with CNA #5, on 12/06/16 at 8:48 AM, revealed the alarm on the wheelchair was not turned on, and stated the alarm should have been turned on. Observation, on 12/07/16 at 2:12 PM, revealed the bed alarm was not turned on while the resident was laying in the bed. CNA #8 verified the alarm was not turned on. Interview with CNA #8, on 12/07/16 at 2:12 PM, revealed the alarm should have been turned on when the resident was assisted to bed. Interview with LPN #2, on 12/07/16 at 2:12 PM, revealed Resident #7's alarm should have been turned on and she expected the CNAs to look at the Care Guide to see if an alarm was ordered. She further stated the nurses were responsible to check the alarms every shift and mark on the Treatment Sheet that the alarms are on and functioning. Interview with CNA #3, on 12/08/16 at 8:12 AM, revealed everyone who provided care for the residents was responsible to ensure alarms were on and working. She revealed the staff knew when the alarms worked because they beeped with pressure and some had a turn on switch. She further stated it was a good idea to take the cord out of the box and reinsert as an added check and protection. Interview with the DON, on 12/08/16 at 10:45 AM, revealed alarms should be checks by the CNAs at a minimum of every shift and with transfers. She stated the alarms will beep when the batteries are dead, but unfortunately cannot prevent mechanical errors with the alarms. She stated the alarms were on the Care Guides for the CNAs to know if a resident had an alarm, and if not on the care sheet, then passed on shift to shift. She further stated she expected the bed alarm to be placed on Resident #3's Care Guide when the order was written. 11. Record review revealed the facility admitted Unsampled Resident B on 02/04/15 with [DIAGNOSES REDACTED]. Review of a cognitive assessment completed by the facility on 11/11/16 revealed he/she was cognitively intact and interviewable. Observation, on 12/06/16 at 8:50 AM and at 12:06 PM, on 12/07/16 at 8:56 AM, and on 12/08/16 at 11:15 AM, revealed an eleven (11) ounce can of Aqua Net hairspray on the sink in the room, which read on the label to Keep out of Reach of Children and Avoid Spraying in Eyes. Interview with the DON, on 12/08/16 at 10:45 AM, revealed anything aerosol should be kept in the closet behind closed doors. She further stated she expected staff to place items like this in the closet behind closed doors with the residents' name on the item.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the services provided or arranged by the facility as outlined by the Comprehensive Care Plan must be provided by qualified persons in accordance with each resident's plan of care for three (3) sampled residents (Residents #3, #7, and #9), in the selected sample of twenty-one (21) residents, and for one (1) Unsampled resident (Resident A), related to bed and chair alarms not being on and functioning. The findings include: Review of the facility's Care Plan Policy, Resident Assessment Instrument (RAI), Chapter Four (4), dated 08/2010, revealed facilities were responsible for assessing and addressing: all care issues that are relevant to individual residents, a well-developed and executed assessment and care plan to re-evaluate the resident's status at prescribed intervals (quarterly, annually, or if a significant change occurred) using the RAI and then modified the individualized care plan as appropriate and necessary. Review of the facility's procedure for alarms provided by the Director of Nursing (DON) on 12/07/16 revealed alarms are utilized for the purpose of fall intervention and prevention. Once an alarm is determined to be needed by the Interdisciplinary Team or nurse an order will be obtained and added to the Nursing Assistant Care Guide and the Care Plan. Further review revealed the alarms are checked every shift for functioning and placement. 1. Record review revealed the facility admitted Unsampled Resident A on 03/23/08 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was severely cognitively impaired. Review of Resident A's Care Plan, initiated on 01/27/16 and revised on 12/05/16, revealed he/she was care planned to be at risk for falls. Intervention included a chair alarm. Observation, on 12/06/16 at 9:15 AM, revealed Unsampled Resident A was up in his/her wheelchair (w/c) with an alarm on the back of the w/c. Further observation revealed the light on the alarm was not illuminated, which indicated the alarm was not on or functioning. Licensed Practical Nurse (LPN) #6 and LPN #7 took Unsampled Resident A into the nursing station where LPN #5 and LPN #6 attempted to get the alarm box to work. After taking the alarm box apart and changing the batteries, they were still unable to get the alarm box to work. Interview with LPN #6, on 12/06/16 at 10:00 AM, revealed the alarm should have been working. Interview with LPN #2, on 12/08/16 at 3:20 PM, revealed alarms should be in working order when on a bed or wheelchair. LPN #2 further stated it was not acceptable to have alarm boxes that did not function. 2. Record review revealed the facility admitted Resident #9 on 08/11/16 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the Brief Interview for Mental Status (BIMS) score was three (3), indicating the resident was not interviewable. Review of the Comprehensive Care Plan, dated 11/19/16, revealed the resident was at risk for falls related to a left above the knee amputation (AKA), medications, and weakness. Further review revealed, on 11/19/16, the resident rolled out of bed. Review of the goal revealed the resident would have no fall related injuries. Interventions included a bed alarm to the bed at all times to alert staff of the resident attempting to get out of bed or getting too close to the edge. Review of a physician's orders [REDACTED]. During observation of incontinent care for Resident #9, on 12/06/16 at 5:25 PM, with Certified Nurse Aide (CNA) #6 and CNA #7, they revealed Resident #9 tried to climb out of the bed when they first went into the resident's room. After incontinent care was completed, they discovered the alarm for the bed was not functioning and was turned off. Further interview with CNA #6 and CNA #7 revealed the alarms should have been turned on and should have sounded when the resident tried to climb out of bed. Both CNAs revealed it was their responsibility to check the alarms and ensure the alarms were on and functioning. Interview with the Director of Nursing (DON), on 12/08/16 at 10:55 AM, revealed she expected all alarms to be turned on. She revealed Resident #9's spouse routinely turned the alarms off when visiting; however, she expected the CNAs and nursing staff to check them on a regular basis to ensure the alarms were working. 3. Record review revealed the facility admitted Resident #3 on 03/13/14 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed he/she was unable to complete the BIMS and received a score of ninety-nine (99), indicating the resident was not interviewable. Review of the physician's orders [REDACTED]. Review of the Certified Nurse Aide (CNA) Care record, no date, revealed only a chair alarm to check placement. Review of the Nursing Fall Care Plan, dated 05/24/13, revealed an alarm to the wheelchair to alert staff if the resident attempted to get up without assistance. Further review of the care plan revealed a bed alarm, dated 05/22/15, as well as to monitor the alarm function and placement, dated 02/06/15. Observation of Resident #3, on 12/06/16 at 8:25 AM, revealed he/she was laying in his/her bed and the bed alarm box was not blinking nor connected to a pad. Interview with CNA #4, on 12/06/16 at 8:37 AM, revealed she was unsure if the resident was to have a bed alarm and would have to ask the nurse. She also verified the alarm was not plugged into a pad and would not activate. She stated if something happened to the alarm, the staff member should get another one and replace it. Interview with CNA #5, on 12/06/16 at 8:39 AM, revealed she would have to look at the care plan to determine if the resident had an alarm to the bed. She also verified the alarm was not attached. Further interview with the CNA, on 12/06/16 at 8:48 AM, revealed the resident was to have an alarm on the bed and was trying to locate the pad to connect to the box. Interview with CNA #3, on 12/08/16 at 8:12 AM, revealed she would have to look at the Care Guide to find out if the resident had an alarm on the bed, and if not on the Care Guide, then go to the nurse. Interview with Licensed Practical Nurse (LPN) #7, on 12/06/16 at 8:40 PM, revealed the green light on the box should be green if the alarm was turned on. 4. Record review revealed the faciity admitted Resident #7 on 08/12/15 with [DIAGNOSES REDACTED]. Review of the Annual MDS, dated [DATE], revealed he/she was interviewable with a BIMS score of fourteen (14). Further review revealed the resident required extensive assistance of two (2) people for bed mobility, toileting, and transfer. Review of the physician's orders [REDACTED]. Observation, on 12/06/16 at 8:25 AM and 8:45 AM, revealed Resident #7 was sitting in the breezeway with an alarm to the back of the wheelchair, but the alarm was not blinking. Interview with CNA #5, on 12/06/16 at 8:48 AM, revealed the alarm on the wheelchair was not turned on, and stated the alarm should have been turned on. Observation, on 12/07/16 at 2:12 PM, revealed the bed alarm was not turned on while the resident was laying in the bed. CNA #8 verified the alarm was not turned on. Interview with CNA #8, on 12/07/16 at 2:12 PM, revealed the alarm should have been turned on when the resident was assisted to bed. Interview with LPN #2, on 12/07/16 at 2:12 PM, revealed Resident #7's alarm should have been turned on and she expected the CNAs to look at the Care Guide to see if an alarm was ordered. She further stated the nurses were responsible to check the alarms every shift and mark on the Treatment Sheet that the alarms are on and functioning. Interview with CNA #3, on 12/08/16 at 8:12 AM, revealed everyone who provided care for the residents was responsible to ensure alarms were on and working. Interview with the DON, on 12/08/16 at 10:45 AM, revealed alarms should be checks by the CNAs at a minimum of every shift and with transfers. She stated the alarms will beep when the batteries are dead, but unfortunately cannot prevent mechanical errors with the alarms. She stated the alarms were on the Care Guides for the CNAs to know if a resident had an alarm, and if not on the care sheet, then passed on shift to shift. She further stated she expected the bed alarm to be placed on Resident #3's Care Guide when the order was written.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure the resident has the right to be free from any chemical restraint imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for one (1) sampled resident (Resident #7), in the selected sample of twenty-one (21) residents, and for two (2) Unsampled residents (Residents K and L), related to the administration of [MEDICATION NAME] Intramuscular (IM) injections. The findings include: Review of the facility's policy Antipsychotic Medication Review, dated 03/17/16, revealed any resident who received antipsychotic medication should contain documentation supporting the appropriateness and necessity for the use of the drug. Further review revealed the care plan should contain the following information to include the antipsychotic medication, reason (purpose) for the medication, side effects, behaviors, and suggested interventions. Ensure a consent form or documentation noting the risks and benefits for the use of an antipsychotic medication have been discussed with the Resident/Responsible Party. Review of the facility form Assessment of [MEDICAL CONDITION] Medications, not dated, revealed the assessment was to be completed within seven (7) days of a new drug start or admission on drug. 1. Record review revealed the facility admitted Resident #7 on 08/12/15 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed the resident was interviewable with a Brief Interview for Mental Status (BIMS) score of fourteen (14). Review of a physician's orders [REDACTED]. There was no documented evidence an Assessment of [MEDICAL CONDITION] Medication form was completed for the new order, as well as no documentation discussing the Risks and Benefits with the resident or responsible party. Review of the Nurses' Progress Notes and Medication Administration Record, [REDACTED]. Further review of the Nurses' Progress Notes, dated 08/16/16 at 7:30 AM, revealed [MEDICATION NAME] 10 mg IM was administered for increased agitation, and again on 08/21/16 for increased anxiety. Review of the Nurses' Progress Notes, dated 09/12/16 at 4:30 PM, revealed he/she was agitated and trying to climb out of the bed, and [MEDICATION NAME] IM was administered. Further review revealed no documentation of an assessment conducted to determine the need for the administration of the medication. In addition, there was no documented evidence the physician was notified or a least restrictive measure was attempted. Interview with Licensed Practical Nurse (LPN) #4, on 12/08/16 at 2:56 PM, revealed Resident #7 was hard to deal with, restless, and would call out. If trying to distract and talk to the resident did not work, then [MEDICATION NAME] IM was administered. Interview with LPN #5, on 12/08/16 at 3:00 PM, revealed Resident #7 received [MEDICATION NAME] IM for behaviors. She stated she would speak to the resident first and redirect him/her, but if that did not work, then she would administer a shot. 2. Record review revealed the facility admitted Unsampled Resident K on 03/12/15 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the resident was interviewable with the ability to understand, and understand others, with a BIMS score of eleven (11). Review of a physician's orders [REDACTED]. There was no documented evidence an Assessment of [MEDICAL CONDITION] Medication form was completed, as well as no documentation discussing the Risks and Benefits with the resident or responsible party. Review of the Anti-psychotic Medication Care Plan, dated 06/09/15, revealed no list of medications, side effects, behaviors, or interventions to be used prior to administration. Review of the MAR, dated 09/21/16 and 09/24/16, revealed Unsampled Resident K received [MEDICATION NAME] ten (10) mg IM for anxiety. Further review revealed no evidence of an assessment conducted to determine the need for the administration of the medication. In addition, there was no documented evidence the physician was notified or a least restrictive measure was attempted. Interview with LPN #1, on 12/08/16 at 3:30 PM, revealed when she administered the medication on both days, the resident was calling the nurse into his/her room about the heater and the lights, wanting them turned off then back on. She further stated the resident seemed to be in fear of being alone and wanted her to stay with him/her. She stated the resident did not curse, cry, or act out. She revealed she felt the resident would have been miserable if the [MEDICATION NAME] was not administered. She stated the resident does have behaviors when he/she had a Urinary Tract Infection [MEDICAL CONDITION], such as circling letters on a book or magazine. Interview with the resident's family member, on 12/08/16 at 2:26 PM, revealed he/she was placed on [MEDICATION NAME] when she/he was in the hospital. The family member stated the resident took the medication because he/she was unable to sleep. 3. Record review revealed the facility admitted Unsampled Resident L on 08/12/14 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the resident was coded as 00, indicating the resident was not interviewable. Review of the physician's orders [REDACTED]. There was no documented evidence an Assessment of [MEDICAL CONDITION] Medication form was completed, as well as no documentation discussing the Risks and Benefits with the resident or responsible party. Review of the Anti-psychotic Medication Care Plan, dated 08/25/14, revealed no list of medications, side effects, behaviors, or interventions to be used prior to administration. Review of the Nurses' Progress Notes and MAR indicated [REDACTED]. In addition, there was no documented evidence the physician was notified after the initial order was obtained on 10/22/16, or a least restrictive measure was attempted. Interview with LPN #3, on 12/08/16 at 2:05 PM, revealed she had administered [MEDICATION NAME] IM to Resident L because he/she would get figity, and tried to climb out of the bed. She further revealed the resident would usually exhibit behaviors and got all tore up before a bath. She stated the Nurses' Notes should be more descriptive as to what occurred in order to determine if the medication was warranted. She stated the Nurse Aides would ask if Resident L could be given something, so she would administer [MEDICATION NAME] IM. Interview with Resident L's family member, on 12/08/16 at 3:14 PM, revealed she was aware he/she got agitated, but did not think the staff used the [MEDICATION NAME] IM if he/she did not want to get out of bed. Interview with LPN #8, on 12/06/16 at 4:55 PM, revealed she was unaware about consents for Antipsychotic Drugs or to discuss Risks and Benefits with the resident or responsible party. Interview with Social Services, on 12/06/16 at 5:30 PM, revealed she was unaware of the facility's policy to contact families or the responsible party to discuss Risks and Benefits or the Assessment of [MEDICAL CONDITION] Medications to complete for residents who were started on antipsychotic medications. Interview with the facility Pharmacy, on 12/08/16 at 12:53 PM, revealed the facility should not use [MEDICATION NAME] IM for the convenience of staff, and stated the medication should not be used for anxiety in the elderly population. In addition, she revealed other medications, such as Benzodiazepines, should be tried prior to the use of an antipsychotic medication, especially an IM medication. Interview with the resident's Physician, on 12/08/16 at 1:00 PM, revealed an antipsychotic IM medication should only be given if the resident was at risk of hurting himself/herself or others, or for extreme agitated behavior for a prolonged period of time. He further revealed increased anxiety was not a sufficient reason to give [MEDICATION NAME] IM. He stated he was not notified when [MEDICATION NAME] IM was administered, and expected to be called if there was an extreme situation which warranted the use of an agent like [MEDICATION NAME] IM. Interview with the Director of Nursing (DON), on 12/06/16 at 9:35 AM, revealed she had been at the facility for six (6) years and had never been required to use a consent or discuss the Risk and Benefits with the family/resident when obtaining an antipsychotic order. Further interview with the DON, on 12/07/16 at 8:20 AM, revealed the facility failed to follow the Antipsychotic policy. She stated [MEDICATION NAME] IM should not be administered as a first line choice for behaviors. Additional interview with the DON, on 12/08/16 at 4:20 PM, revealed a nurse should only give [MEDICATION NAME] IM for extreme agitation and not just for increased anxiety. She stated attention seeking, refusing a bath or refusing to get out of bed would not be an acceptable reason to administer [MEDICATION NAME] IM. She further revealed the [MEDICAL CONDITION] care plan should be individualized related to resident care. Interview with the Director of Clinical Education, on 12/08/16 at 8:28 AM, revealed the nurses should document more in depth when administering an IM antipsychotic medication.

Based on observation, interview, record review, and review of the facility's Standards of Practice, it was determined the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. Observation on 12/08/16 at 1:49 PM, of two (2) of four (4) medication carts for the South Wing of the facility revealed twelve (12) vials and pens of insulin opened and not dated when opened for four (4) sampled residents (Residents #6, #7, #17, and #18) in the selected sample of twenty-one (21) residents, and for five (5) Unsampled residents (Residents F, H, I, J, and M). The findings include: Review of the facility's Standards of Practice, titled Nursing Care Center Pharmacy (PharMerica), dated 2007, revealed Insulin products including vials and pens should be dated when opened and discarded according to manufacturer's guidelines. 1. Record review revealed the facility admitted Resident #6 on 06/25/15 with [DIAGNOSES REDACTED]. 2. Record review revealed the facility admitted Resident #7 on 08/19/15 with [DIAGNOSES REDACTED]. 3. Record review revealed the facility admitted Resident #17 on 12/02/16 with [DIAGNOSES REDACTED]. 4. Record review revealed the facility admitted Resident #18 on 01/10/16 with [DIAGNOSES REDACTED]. 5. Record review revealed the facility admitted Unsampled Resident F on 05/19/16 with [DIAGNOSES REDACTED]. 6. Record review revealed the facility admitted Unsampled Resident H on 10/08/16 with [DIAGNOSES REDACTED]. 7. Record review revealed the facility admitted Unsampled Resident I on 12/0216 with [DIAGNOSES REDACTED]. 8. Record review revealed the facility admitted Unsampled Resident J on 06/06/15 with [DIAGNOSES REDACTED]. 9. Record review revealed the facility admitted Unsampled Resident M on 07/16/14 with [DIAGNOSES REDACTED]. Observation of two (2) of four (4) medication carts, on 12/08/16 at 1:49 PM, revealed two (2) bottles of Humulin R Insulin, two (2) bottles of Novolin Insulin, two (2) bottles of Novolog Insulin, three (3) bottles of Lantus insulin and three (3) pens of Levemir Insulin were not dated when opened. Per Section 9.11 of the PharMerica guidelines, Humulin R should be discarded twenty-eight (28) days after being opened, Novolin-R should be discarded forty-two (42) days after being opened, Novolog should be discarded twenty-eight (28) days after being opened, Lantus should be discarded twenty-eight (28) days after being opened, and Levemir pens should be discarded forty-two (42) days after being opened. Interview with Licensed Practical Nurse (LPN) #9, on 12/08/16 at 9:55 AM, revealed insulins were to be dated when opened, and depending on the type of the insulin, it should not be left on the cart for use for longer than thirty (30) days unless otherwise specified. Interview with LPN #6, on 12/08/16 at 9:58 AM, revealed insulins were to be dated when opened and discarded after thirty (30) days or by manufacturer's recommendations. Interview with LPN #2, on 12/08/16 at 10:00 AM, revealed insulins were to be dated when opened and discarded after twenty-eight (28) to thirty (30) days after being opened depending on the type of insulin. Interview with LPN #3, on 12/08/16 at 10:03 AM, revealed insulins were to be dated when opened and discarded, depending on the insulin type, after twenty-eight (28) to thirty (30) days from the open date. Interview with LPN #10, on 12/08/16 at 10:06 AM, revealed insulins were to be dated when opened and should not be on the cart for longer than twenty-eight (28) to thirty (30) days depending on the type of insulin. Interview with the Assistant Director of Nursing (ADON), on 12/08/16 at 9:59 AM, revealed her expectations for the nursing staff were whomever opened the insulin should date it when it was opened to ensure it was not left on the cart for longer than thirty (30) days, unless otherwise specified. Interview with the Director of Nursing (DON), on 12/08/16 at 10:42 AM, revealed her expectation was the facility's policy should be followed related to dating insulin vials when opened and insulins were to be discarded after thirty (30) days and/or per the manufacturer's guidelines.

Based on observation, interview, record review, and review of the facility's policy and procedure, the facility failed to ensure each resident receives treatment with respect, dignity and care for each resident in a manner and in an environment which promotes, maintains or enhances his or her quality of care for one (1) Unsampled resident (Resident G), related to an indwelling catheter bag not covered by a dignity bag. The findings include: Review of the facility's policy titled Dignity, dated 02/24/15, revealed all residents will be treated in a manner and in an environment that maintains and enhances each resident's dignity and respect in full recognition of his or her individuality. Under Maintaining Dignity, the policy states through example, education, and monitoring, the Social Services staff will promote the following types of staff interactions with residents, which maintain their dignity: assisting residents with daily care in a dignified manner (e.g., pushing residents forward in wheelchairs, covering appliances attached to resident, ensuring residents are not exposed). Record review revealed the facility admitted Unsampled Resident G on 09/07/12 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the Brief Interview for Mental Status (BIMS)score was fifteen (15), indicating the resident was cognitively intact and interviewable. Review of the physician's orders [REDACTED]. Observation on the initial tour, on 12/06/16 at 9:00 AM, revealed an indwelling catheter bag with a total of 600 milliliters (ml) of dark yellow urine. The catheter bag could be easily observed from the doorway, which was open to the hall. The catheter bag was in full sight of anyone walking by the room. Interview with the resident, on 12/08/16 at 1:30 PM, revealed he/she has had a catheter for several years. He/she revealed the catheter bag needed to be covered and stated, Who wants to look at their urine in a bag? Interview with the Director of Nursing (DON), on 12/08/16 at 3:10 PM, revealed her expectations were for all residents to have a dignity bag covering his/her indwelling catheter bag, and it was the responsibility of all nursing staff to ensure the dignity bags were in place.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure one (1) sampled resident (Resident #8), in the selected sample of twenty-one (21) residents, who was incontinent of bowel and bladder, received the appropriate treatment and services to prevent urinary tract infections (UTIs). An observation on 12/07/16 at 10:30 AM revealed Certified Nurse Aide (CNA) #2 provided inappropriate catheter care for Resident #8 by wiping up and down the tubing to the urethra with the same washcloth. The findings include: Review of the facility's policy, titled Catheter Care, Indwelling Catheter, dated 2006, revealed to wash the perineum well with soap and water, taking care to wash from front to back to cleanse the area well at the catheter insertion, taking care not to pull on the catheter or advance the catheter further into the urethra. All debris must be removed from the catheter at the insertion site. Record review revealed the facility admitted Resident #8 on 11/06/14 with [DIAGNOSES REDACTED]. Review of the Minimum Data Sets (MDS) assessment, dated 11/03/16, revealed the resident was in a vegetative state, and was totally dependent on staff for toileting and had an indwelling catheter. Review of Resident #8's Care Record, no date, revealed he/she had a catheter, and review of a Urinary Tract Infection [MEDICAL CONDITION] Care Plan, dated 11/06/14, revealed he/she was to receive catheter care as ordered. Review of the physician's orders [REDACTED]. Review of the resident's labs revealed a urinalysis collected on 08/01/16 grew Escherichia Coli (Ecoli) and Proteus Mirabilis and the resident was placed on Augumentin (antibiotic) 875-125 milligrams (mg) twice a day per Gastrostomy tube for ten (10) days. Observation, on 12/07/16 at 10:30 AM, revealed CNA #2 provided catheter care to Resident #8 and wiped the catheter tubing from the urethra down the catheter tubing then back up to the urethra several times with the same washcloth. Interview with CNA #2, on 12/07/16 at 10:36 AM, revealed she realized what she had done wrong stating she should not wipe from the urethra up the catheter tubing then back down with the same washcloth. She further revealed that was a risk for infection and she knew it when she messed up. Interview with Licensed Practical Nurse (LPN) #2, on 12/08/16 at 8:15 AM, revealed CNAs have yearly competencies for catheter and perineal care. She further stated she expected the CNAs to clean from the urethra (the opening) down the catheter tubing and not go back up the catheter tubing and either fold over the washcloth and wipe again, or obtain a clean washcloth to prevent infection and contamination during catheter care. Interview with the Director of Clinical Education, on 12/08/16 at 8:29 AM, revealed she expected catheter care to be performed per the facility policy to aid in the prevention of infection. Interview with the Director of Nursing (DON), on 12/08/16 at 10:45 AM, revealed her expectations were for the CNAs to use disposable wipes with catheter care or use a clean washcloth with each swipe down the catheter tubing or flip over the washcloth and use the clean side and then dispose of the soiled wash cloth in a plastic bag on the floor. Additionally, she stated if this procedure was not followed there was a risk for infection.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure the care plan was reviewed and revised by the Interdisciplinary team after each assessment and change in the resident for one (1) sampled resident (Resident #7), in the selected sample of twenty-one (21) residents, and for two (2) Unsampled residents (Residents K and L), related to behaviors, reasons for medication, and interventions. The findings include: Review of the facility's policy Antipsychotic Medication Review, dated 03/17/16, revealed any resident who received antipsychotic medication should contain documentation supporting the appropriateness and necessity for the use of the drug. Further review revealed the care plan should contain the following information to include the antipsychotic medication, reason (purpose) for the medication, side effects, behaviors, and suggested interventions. Ensure a consent form or documentation noting the risks and benefits for the use of an antipsychotic medication have been discussed with the Resident/Responsible Party. Review of the facility's Care Plan Policy, Resident Assessment Instrument (RAI), Chapter Four (4), dated 08/2010, revealed facilities were responsible for assessing and addressing all care issues that are relevant to individual residents, a well-developed and executed assessment and care plan re-evaluated the resident's status at prescribed intervals (quarterly, annually, of if a significant change occurred) using the RAI and then modified the individualized care plan as appropriate and necessary. 1. Record review revealed the facility admitted Resident #7 on 08/12/15 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed the resident was interviewable with a Brief Interview for Mental Status (BIMS) score of fourteen (14). Review of a physician's orders [REDACTED]. Review of the Anti-psychotic Medication Care Plan, dated 08/13/15, revealed no list of medications, side effects, behaviors, or interventions to be used prior to administration. Review of Nurses' Progress Notes and Medication Administration Record [REDACTED]#7. Further review revealed no documentation of an assessment conducted to determine the need for the administration of the medication. In addition, there was no documented evidence the physician was notified or a least restrictive measure was attempted. Interview with Licensed Practical Nurse (LPN) #4, on 12/08/16 at 2:56 PM, revealed Resident #7 was hard to deal with, restless, and would call out. If trying to distract and talk to the resident did not work, then [MEDICATION NAME] IM was administered. Interview with LPN #5, on 12/08/16 at 3:00 PM, revealed Resident #7 received [MEDICATION NAME] IM for behaviors. She stated she would speak to the resident first and redirect him/her, but if that did not work, then she would administer a shot. 2. Record review revealed the facility admitted Unsampled Resident K on 03/12/15 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the resident was interviewable with the ability to understand, and understand others, with a BIMS score of eleven (11). Review of a physician's orders [REDACTED]. Review of the Anti-psychotic Medication Care Plan, dated 06/09/15, revealed no list of medications, side effects, behaviors, or interventions to be used prior to administration. Review of the MAR, dated 09/21/16 and 09/24/16, revealed Unsampled Resident K received [MEDICATION NAME] ten (10) mg IM for anxiety. Further review revealed there was no documented evidence the physician was notified or a least restrictive measure was attempted. Interview with LPN #1, on 12/08/16 at 3:30 PM, revealed when she administered the medication on both days, the resident was calling the nurse into his/her room about the heater and the lights, wanting them turned off then back on. She further stated the resident seemed to be in fear of being alone and wanted her to stay with him/her. She stated the resident did not curse, cry, or act out. She revealed she felt the resident would have been miserable if the [MEDICATION NAME] was not administered. She stated the resident does have behaviors when he/she had a Urinary Tract Infection [MEDICAL CONDITION], such as circling letters on a book or magazine. Interview with the resident's family member, on 12/08/16 at 2:26 PM, revealed he/she was placed on [MEDICATION NAME] when she/he was in the hospital. The family member stated the resident took the medication because he/she was unable to sleep. 3. Record review revealed the facility admitted Unsampled Resident L on 08/12/14 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the resident was coded as 00, indicating the resident was not interviewable. Review of the physician's orders [REDACTED]. Review of the Anti-psychotic Medication Care Plan, dated 08/25/14, revealed no list of medications, side effects, behaviors, or interventions to be used prior to administration. Review of the Nurses' Progress Notes and MAR indicated [REDACTED]. In addition, there was no documented evidence the physician was notified after the initial order was obtained on 10/22/16, or a least restrictive measure was attempted. Interview with LPN #3, on 12/08/16 at 2:05 PM, revealed she had administered [MEDICATION NAME] IM to Resident L because he/she would get figity, and tried to climb out of the bed. She further revealed the resident would usually exhibit behaviors and got all tore up before a bath. She stated the Nurses' Notes should be more descriptive as to what occurred in order to determine if the medication was warranted. She stated the Nurse Aides would ask if Resident L could be given something, so she would administer [MEDICATION NAME] IM. Interview with Resident L's family member, on 12/08/16 at 3:14 PM, revealed she was aware he/she got agitated, but did not think the staff used the [MEDICATION NAME] IM if he/she did not want to get out of bed. Interview with Social Services, on 12/06/16 at 5:30 PM, revealed she was unaware of the facility's policy to contact families or the responsible party to discuss Risks and Benefits or the Assessment of [MEDICAL CONDITION] Medications to complete for residents who were started on antipsychotic medications. Interview with the resident's Physician, on 12/08/16 at 1:00 PM, revealed an antipsychotic IM medication should only be given if the resident was at risk of hurting himself/herself or others, or for extreme agitated behavior for a prolonged period of time. He further revealed increased anxiety was not a sufficient reason to give [MEDICATION NAME] IM. He stated he was not notified when [MEDICATION NAME] IM was administered, and expected to be called if there was an extreme situation which warranted the use of an agent like [MEDICATION NAME] IM. Interview with the Director of Nursing (DON), on 12/06/16 at 9:35 AM, revealed she had been at the facility for six (6) years and had never been required to use a consent or discuss the Risk and Benefits with the family/resident when obtaining an antipsychotic order. Further interview with the DON, on 12/07/16 at 8:20 AM, revealed the facility failed to follow the Antipsychotic policy. She stated [MEDICATION NAME] IM should not be administered as a first line choice for behaviors. Additional interview with the DON, on 12/08/16 at 4:20 PM, revealed a nurse should only give [MEDICATION NAME] IM for extreme agitation and not just for increased anxiety. She stated attention seeking, refusing a bath or refusing to get out of bed would not be an acceptable reason to administer [MEDICATION NAME] IM. She further revealed the [MEDICAL CONDITION] care plan should be individualized related to resident care.

Based on interview and record review, it was determined the facility failed to ensure services were provided by the facility in accordance with each resident's written Plan of Care for one (1) of three (3) sampled residents (Resident #1). Resident #1 was care planned as having a physical functioning deficit related to mobility impairment and had an intervention to utilize a padded foot rest with protective bolsters to the top the leg rest when the resident was up in a wheelchair. On 04/25/13, Resident #1 suffered a right leg distal tibia spiral fracture when Resident #1's right foot was outside of the foot positioning assistive device and got caught on the outside door facing when propelled, by the Certified Nursing Assistant (CNA) via wheelchair through the doorway of the resident's room. The findings include: Interview, on 06/21/13 at 8:10 AM, with the Executive Director revealed the facility did not have policies on care plans and as a practice did not use policies, but instead used the Centers for Medicare and Medicaid Services (CMS) Regulations and provided guides for their staff. Review of Resident #1's medical record revealed the facility admitted the resident on 08/31/11 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Resident Assessment and Care Screening, dated 02/20/13, revealed the facility assessed Resident #1 as rarely/never able to make themselves understood or understood others and had severely impaired cognitive skills. Continued review of the MDS, under Functional Status, revealed Resident #1 was assessed as non-ambulatory and needing extensive assistance from staff for transfers and locomotion. Under mobility devices, the assessment indicated the resident used a wheel chair for mobility. Continued review or Resident#1's medical record revealed the resident was care planned as having a physical functioning deficit related to mobility impairment. Review of the Comprehensive Plan of Care, undated but according to interview was the care plan in effect for Resident #1 on 04/25/13, revealed an intervention to utilize a padded foot rest with protective bolsters to the top of the leg rests when the resident was up in a wheelchair. Interview, on 06/21/13 at 11:00 AM, with the MDS Coordinator revealed the purpose of the care plan was to guide care. The MDS Coordinator stated Resident #1's feet were unable to reach the wheelchair foot pedals so the padded foot rest (padded contoured leg trough) was ordered to keep the resident's legs/feet in position while in the wheelchair. She said the intervention to utilize the padded foot rest with protective bolsters to the top of the leg rests when up in the wheelchair was listed under the resident's ambulation care plan. Interview, on 06/21/13 at 10:35 AM, with Licensed Practical Nurse (LPN) #1 revealed the resident had involuntary jerky movements at times and thought Resident #1's foot cradle device (contoured leg trough) was for positioning and the safety of the resident. LPN #1 stated the use of the foot cradle was something normally put on the care plan so staff knew about it especially the nurse assistants. She further stated, after review of the aide care plan, the foot cradle was listed. Further review of Resident #1's medical record revealed on 04/25/13 a Change of Condition Progress Note, timed 2:45 PM, which stated staff was taking Resident #1 to his/her room (via wheelchair) and the resident threw his/her right leg over the wheelchair pedal (contoured leg trough device) and staff was unaware (the right leg was outside). The Note indicated the resident's right lower extremity became caught between the wheelchair pedal and door frame. Further review of the Note revealed staff stated they heard a pop and the resident began to yell out. Interview, on 06/20/13 at 2:10 PM and on 06/21/13 at 10:15 AM and 2:35 PM, with CNA #2 revealed she observed Resident #1 had his/her right leg outside of the wheelchair's leg positioning device, at times, when the resident was in the dinning room. CNA #2 explained she had not told anyone, because she thought everyone knew about it. The CNA further stated she had never seen the resident move his/her feet out of the positioning device. When asked about the event on 04/25/13, she stated prior to transporting the resident back to his/her room, from the dinning room she noticed the resident's right leg was out of the position device and she put the leg back into the positioning device. She further stated she was pushing the wheelchair, and CNA #5 was with her, and during the transport from the dining room and the doorway the resident's right leg had completely come out of the positioning device. She revealed she had not noticed the leg out because she had just put his/her right foot back into the positioning device, but as she went into the resident's room the front of the right tennis shoe caught the outer door facing and his/her right leg twisted. She further stated she thought the accident was avoidable, but she was not aware the resident's foot had flopped out of the device. Interview, on 06/21/13 at 8:45 AM, with CNA #1 revealed they received training on the use of the foot cradle positioning device (contoured leg trough); it sat on the wheel chair foot rest and the purpose was to keep the resident's feet in place. The CNA stated she would watch to make sure Resident #1 would not move his/her feet out of the foot cradle when transporting the resident in the wheelchair. The CNA further stated she had observed the resident's leg being outside of the positioning device when the resident was seated in his/her wheelchair at the dining room table, but had not observed the resident move his/her feet out of the positioning device when transporting the resident. Interview, on 06/21/13 at 1:10 PM, with the MDS Coordinator revealed the care plan at the time of the event (04/25/13) included the intervention to utilize the padded foot rest with protective bolsters when the resident was up in the wheelchair. She stated the resident's feet were supposed to be in the padded foot rest device and if Resident #1's (right) foot was outside of the foot rest device, staff was not following the care plan. Interview, on 06/21/13 at 11:40 AM, with the Director of Nursing Services (DNS) revealed Resident #1 had conditions which could impact his/her safety, a [MEDICAL CONDITION] disorder and severe mental [MEDICAL CONDITION], and had involuntary startle reflex movements when sitting. She stated the positioning devices were to help keep the resident in a correct position and keep his/her feet safe. In addition, the DNS stated if she had known the resident was moving his/her foot out of the cradle device that would have been care planned for the resident's safety.

Based on observation, interview, and record review, it was determined the facility failed to ensure an environment that is free from accident hazards over which the facility has control and failed to to provide supervision and assistive devices to each resident to prevent accidents for one (1) of three (3) sampled residents (Resident #1). On 04/25/13, Resident #1 suffered a a right leg distal tibia spiral fracture during wheelchair transport, by Certified Nursing Assistant (CNA) #2. Resident #1's right foot was outside of the foot positioning assistive device, provided by the facility, and got caught on the outside door facing when being propelled, by the CNA, at an angle through the doorway of the resident's room. The findings include: Interview, on 06/21/13 at 8:10 AM, with the Executive Director revealed the facility did not have policies on care plans or accidents and as a practice did not to use policies, but instead used the Centers for Medicare and Medicaid Services (CMS) Regulations and provided guides for their staff. Observation, on 06/20/13 at 9:50 AM and 11:00 AM, revealed Resident #1 had a below the knee cast to his/her right lower extremity and a wheelchair with a padded foot board device. Review of Resident #1's medical record revealed the facility admitted the resident on 08/31/11 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment and Care Screening, dated 02/20/13, revealed the facility assessed Resident #1 as rarely/never able to make themselves understood or understood others and had severely impaired cognitive skills. Under the MDS Functional Status, the resident was assessed as non-ambulatory and needing extensive assistance from staff for transfers and locomotion. Under mobility devices the resident used a wheel chair. Continued review or Resident#1's medical record revealed the resident was care planned as having a physical functioning deficit related to mobility impairment. Review of the Comprehensive Plan of Care (undated but according to interview was the care plan in effect for Resident #1 on 04/25/13) revealed an intervention to utilize a padded foot rest with protective bolsters to the top of the leg rests when the resident was up in a wheelchair. Further review of Resident #1's medical record revealed on 04/25/13 a change of Condition Progress Note, timed 2:45 PM, which stated staff was taking the resident to his/her room (via wheelchair) and the resident threw his/her right leg over the wheelchair pedal (contoured leg trough device) and staff was unaware. The Note indicated the resident's right lower extremity became caught between the wheelchair pedal and door frame of his/her room. Further review of the Note revealed staff stated they heard a pop and the resident began to yell out. Another progress Note, on 04/25/13 at 2:50 PM, revealed Emergency Medical Services transported the resident to the Hospital emergency room . Review of the History and Physical (H&P), dated 04/25/13, from the hospital revealed imaging x-ray of the right lower extremity demonstrated a spiral fracture of the distal third of the tibia shaft. The H&P noted the resident got his/her legs stuck between a wheelchair and the wall. The H&P indicated Orthopedics was to see the patient and cast the right lower extremity. Review of one of the facility's medical equipment catalogs, revealed the foot rest device used by Resident #1 on 04/25/13 was a padded contoured leg trough which attached to the wheelchair foot rest with straps. Observation, on 06/21/13 at 2:35 PM, of the same type of foot rest, only with shorter sides, revealed the device had raised padded sides which extended up from the base at least eight (8) inches high and open front. Interview, on 06/20/13 at 2:10 PM and 06/21/13 at 10:15 AM and 2:35 PM, with CNA #2 revealed she observed Resident #1 had his/her right leg outside of the wheelchair's leg positioning device, at times, when the resident was in the dinning room. CNA #2 explained she had not told anyone, because she thought everyone knew about it. The CNA further stated she had never seen the resident move his/her feet out of the positioning device. When asked about the event on 04/25/13, she stated prior to transporting the resident back to his/her room, from the dinning room, she put the resident's leg back in the positioning device. She further stated she was pushing the wheelchair, and CNA #5 was with her, and during the transport from the dining room and the doorway the resident's right leg had completely come out of the positioning device. She revealed she had not noticed the resident's leg out because she had just put his/her right foot back into the positioning device, but as she went into the room, the resident's front right tennis shoe caught the outer door facing and his/her leg twisted. When asked if it could have been avoided, the CNA stated she thought the accident was avoidable, but she was not aware the resident's foot had flopped out of the device. Interview, on 06/21/13 at 9:15 AM, with the Clinical Education Nurse revealed they trained staff on how to transport residents in a wheelchair and resident safety was first and foremost. The Educator stated staff was to make sure the resident's arms and legs were inside and was suppose to watch the resident when transporting. She further stated when going through the doorway with the wheelchair, they were trained to go straight through the door, because there was less chance of bumping into something. Interview, on 06/20/13 at 11:40 AM and on 06/21/13 at 8:35 AM, with Physical Therapy Assistant (PTA) #1 revealed Resident #1 had only reflexive type movements at the time, no voluntary leg movement. PTA #1 stated Resident #1 had a padded foot cradle position device (contoured leg trough) for his/her wheel chair to keep the resident's legs/feet properly positioned and help prevent injuries when being transported. She stated aides were shown how to put the device on the wheelchair and how to place the resident's legs in the device. The PTA further stated aides were suppose to supervise the residents when transporting. During observation and interview, on 06/21/13 at 2:35 PM, CNA #2 demonstrated how she transported Resident #1 into room 104 to bed one (1) and the position of the resident's foot when the accident occurred. Observation revealed the bed used by Resident #1, at the time, was close to the wall by the door. CNA #2 approached the room doorway at an angle, which brought the right side of the wheelchair close to the room's outside door facing. The CNA stated she went through the doorway at an angle because it allowed them to better position the wheelchair next to the side of the bed nearest the door wall. She further stated if she took the wheelchair straight into the room, she would have to lift the back of the wheelchair in order to pivot the chair so it was turned in the position needed for the transfer; and, it was a safety issue for her to lift the wheelchair. When asked about moving the end of the bed over, CNA #2 stated if the end of the bed was moved over it allowed the wheelchair to go in straight without having to pivot the wheelchair. CNA #2 also verified when angling the wheelchair into the room, the right side of the footpedal was near the outer door frame and if pushing straight through the door frame it (right footpedal) was further from the door frame. Interview, on 06/21/13 at 10:35 AM, with Licensed Practical Nurse (LPN) #1 revealed the resident had involuntary jerky movements at times and thought the resident's foot cradle device (contoured leg trough) was for positioning and the safety of the resident. The LPN stated the use of the foot cradle device was on the aide care plan. She further stated when aides were transferring residents in wheelchairs they were to supervise the resident's safety. Interview, on 06/20/13 at 12:15 PM, with Restorative Aide #1 revealed Resident #1 would not respond to verbal commands to move his/her legs, but was able to kick his/her legs out of the positioning device at times when in his/her wheelchair. She stated she saw the resident's legs outside of the positioning device at times. Interview, on 06/19/13 at 11:40 AM and on 06/20/13 at 1:00 PM, with Resident #1's mother revealed the resident could not move his/her legs a lot but would move them outside of the wheelchair footrest cushion (foot trough) on occasion. She stated the resident moved his/her right leg out of the positioning device. Interview, on 06/20/13 at 5:15 PM, with CNA #3 revealed he had taken care of Resident #1 routinely. He stated the resident had a padded footboard device for his/her wheelchair. CNA #3 stated Resident #1 occasionally had movements of his/her legs, kind of seizure like movements. CNA #3 further stated sometimes the resident's legs came out of the padded footboard device (contoured leg trough) and his/her foot was outside of the device. He stated when they noticed the foot was outside the positioning device they placed the foot back into the device prior to transport and when he transported the resident in his/her wheelchair he would watch to make sure the resident did not jerk his/her leg out of the device. He stated when transporting Resident #1, he could not recall the resident's leg coming out of the device. In addition, CNA #3 stated when he took the resident through a doorway in his/her room he went straight through the doorway with the wheelchair. He further stated prior to going into the resident's room with the wheelchair, they would move the foot of the bed away from the door so they were able to position the wheelchair next to the bed after entering. Interview, on 06/21/13 at 8:45 AM, with CNA #1 revealed they received training on the use of the foot cradle positioning device; it sat on the wheel chair foot rest and the purpose was to keep the resident's feet in place. CNA #1 stated they would make sure Resident #1's feet were in the foot cradle prior to transporting the resident in the wheelchair and the resident had never moved his/her leg out of the device when she transported the resident. CNA #1 further stated she had observed the resident's leg being outside of the positioning device when the resident was seated in his/her wheelchair at the dining room table. She stated she was working on 04/25/13 when the accident happened and heard the resident crying out. She further stated the aides (CNA #2 and CNA #5) reported when they were transporting the resident through the door (to his/her room) the resident threw his/her leg outside of the foot cradle and the resident's foot hit the door facing. Interview, on 06/21/13 at 9:25 AM, with CNA #5 revealed when they transported a resident in his/her wheelchair they were suppose to make sure the residents were back in the chair, their feet were on the foot pedals (if on), and their arms were inside. She stated they did not want the residents to get hurt, the number one priority when transporting a resident was their safety. She further stated Resident #1 had a contoured leg trough on his/her wheelchair and they had been trained how and why it was used. CNA #5 reported she felt the device helped, but at times the resident's legs were outside the device and they had to make sure his/her legs were inside the device when transporting. She stated she was not sure if the resident's leg movement was voluntary or involuntary. She further revealed they (CNA #2 and herself) were transporting Resident #1 to his/her room on 04/25/13 and had put the resident's foot back inside the contoured leg trough on his/her wheelchair prior to transport and somewhere between the dinning room table and the door frame to his/her room the resident's right foot came out of the device. CNA #5 stated she was walking behind CNA #2 so she did not see the foot out of the cradle, but heard it (the foot) hit the door facing and told the other CNA what happened. Continued interview with CNA #5 revealed when they took Resident #1 through the doorway to his/her they entered at an angle and not straight through the door. She stated because the resident's bed was near the door, they went at an angle to get the wheelchair between the bed and wall in order to transfer the resident from the wheelchair to the bed. Further interview, on 06/21/13 at 1:15 PM, with PTA #1 revealed if staff was aware the resident's feet were coming out of the "foot cradle" device she would have expected them to have let therapy know so they could have assessed the situation to determine if another device may have kept the resident's feet positioned properly in the wheelchair. Interview, on 06/21/13 at 2:50 PM, with Physical Therapist (PT) #1 revealed he had not worked much with Resident #1, but was aware the resident had a padded foot cradle position device (contoured leg trough) for the wheel chair which was used to keep his/her feet in place. PT #1 stated if the resident's leg was moving out of the positioning device it put the resident's leg in an unsafe position, Physical Therapy should have been notified to assess the situation to see what could be more effective for Resident #1. Interview, on 06/21/13 at 11:40 AM, with the Director of Nursing Services (DNS) revealed Resident #1 had conditions which could impact his/her safety, a seizure disorder and [DIAGNOSES REDACTED], and had involuntary startle reflex movements when sitting. She stated the positioning devices were to help keep the resident in correct position and keep his/her feet safe. The DNS also stated during transport of a resident, in his/her wheelchair, staff was suppose to supervise the resident to make sure the resident's arms and legs were in the wheelchair and look for obstacles in the way. She further stated if staff was aware Resident #1's feet were coming out of the foot cradle device she would have expected staff to let someone like the Charge Nurse know, who then could have discussed the issue with Therapy. In addition, the DNS stated if she had known the resident was moving his/her foot out of the cradle device it would have been care planned for the resident's safety. Continued interview with the DNS revealed she felt the event was an accident. She stated the CNAs called her over after the event and told her the resident had kicked his/her foot out of the positioning device as they were going through the door. She stated the CNA had backed the wheelchair away from the door prior to her coming over. She further stated she assessed the leg and stayed with the resident until they got her positioned correctly in bed, while other nurses called the ambulance. The DNS stated she was informed, by the CNAs, they had angled the wheelchair in order to get the chair to the side of the bed, she would not expect them to go through the door at an angle.

Based on interview, review of facility policy, and a review of facility in-services it was determined the facility failed to ensure each resident received adequate supervision. The facility failed to ensure detailed policies and procedures were in place and implemented to provide supervision to residents in the event of an emergency and failed to have an effective system in place to ensure all staff was trained and knowledgeable of emergency procedures. On 02/29/12, the facility was informed of a tornado warning; however, as a result of the facility's failure not all residents were evacuated to safety. The facility's failure caused or was likely to cause serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy and Substandard Quality of Care (SQC) were determined to exist on 02/29/12. An Allegation of Compliance (AOC) was received on 03/11/12 which alleged removal of Immediate Jeopardy on 03/10/12. The State Agency determined the Immediate Jeopardy was removed on 03/10/12 as alleged, which lowered the scope and severity to "E" while the facility monitors the effectiveness of the systemic changes and quality assurance activities. The findings include: A review of the facility's policy entitled "Tornado," (undated) revealed in all cases of a tornado warning all employees should remain calm and follow the instructions of the Executive Director (ED), shift supervisor, or charge nurse, who would provide assignments to employees. However, the policy did not detail who would announce the warning and how all facility staff would be made aware that a warning was issued to provide safety for the residents. A review of training records revealed staff had received a computerized in-service training in June 2011 which provided information on tornado watches and warnings. Continued review of the training revealed staff was trained to go to the basement or safe area of the facility, to cover the patients with thick padding, and to move residents/themselves away from glass. However, it could not be determined by a review of the in-service training that staff had been provided direction on who would provide the facility with information related to a tornado warning, who was to be informed of the warning after it was received, and on what procedures to take to ensure the safety of residents. Minutes from a monthly "huddle in-service" meeting conducted by the Education Director were reviewed and revealed on 08/01/11, prior to the start of each shift, staff was instructed that yellow "code" tags were to be worn at all times when staff was on duty. Documentation from the minutes revealed the yellow tags listed codes to "call" in the event of an emergency. However, there was no documented evidence that staff had been trained on who was to page the codes, when to page the codes, or on what procedures to follow when a code had been called. An interview conducted on 03/08/12, at 3:40 PM, with a representative of the National Weather Service revealed a tornado warning had been issued on 02/29/12, from 12:40 PM through 1:15 PM for the facility's community. Admissions staff member #1 was interviewed on 03/07/12, at 1:25 PM, and stated when a tornado warning was issued for the community, an automated phone call would be received by the facility from the National Weather Service to alert facility staff of the warning. Further interview with Admissions staff member #1 revealed a nurse in the facility had called her on 02/29/12 to inform her that a tornado warning had been shown on the television and had asked the Admissions staff member if a tornado warning had been issued for the facility. At the time the nurse called, Admissions staff member #1 stated she had not received a call from the National Weather Service related to a tornado warning. Admissions staff member #1 stated when the call with the nurse ended, she received an automated call from the National Weather Service of the tornado warning on 02/29/12 and immediately notified the ED as outlined in the facility's policy. Interview further revealed Admissions staff member #1 was informed after the warning on 02/29/12 that she should have called a "code wind" upon notification of a tornado warning to alert all staff of a tornado warning. Admissions staff member #1 stated she was not aware of how long "code wind" had been in effect and stated she had not been trained on the procedure. Admissions staff member #1 stated she had been employed at the facility for [AGE] years and stated when she and/or staff became aware of a tornado warning, either by television or a call from the automated system, they notified each other by "word of mouth." A review of the June 2011 computerized in-service and the August 2011 "huddle in-service" revealed Admissions staff member #1 had attended the in-services. Interview on 03/07/12, at 3:25 PM, with Licensed Practical Nurse (LPN) #5, the facility charge nurse on 02/29/12, revealed at lunch time on 02/29/12 facility staff had the weather radio and a television on to stay informed of changes in the weather conditions because the community was under a tornado watch. Further interview revealed LPN #5 became aware a tornado warning had been issued for the community on 02/29/12 from a staff person that had overheard the warning on a television or radio and confirmed the information by calling the 911 non-emergency number. LPN #5 stated after she received the information from the non-emergency number, she instructed staff on the North side of the building to start evacuating residents to safety while she called staff on the South side of the building to alert them of the warning. LPN #5 stated she had been employed at the facility for [AGE] years and in the past when a tornado warning was issued the charge nurse would call staff on each side of the building to alert them of the warning. Interview with LPN #5 on 03/08/12, at 1:45 PM, revealed she was informed by the Director of Nursing on 02/29/12, after the tornado warning was over, "When anything like this happens you need to tell (the ED); if she isn't here tell me; if I'm not here tell (the Assistant Director of Nursing)." A review of the June 2011 in-service revealed LPN #5 had taken the test related to the material on tornados. However, a review of the August 2011 "huddle in-service" revealed LPN #5 had not been in-serviced on the "code" badges. LPN #5 acknowledged in an interview conducted on 03/08/12, at 1:45 PM, that the yellow badge did list a "code wind" and that she understood what the code was; however, LPN #5 stated she had "never used it before." An interview with State Registered Nurse Aide (SRNA) #3 on 03/07/12, at 3:43 PM, revealed she was working on the South side of the building on 02/29/12 when LPN #5 called to inform them a tornado warning had been issued and that the residents needed to be evacuated to safety. Further interview revealed SRNA #3 informed the ED, who was on the South side of the building, that she had just been informed a tornado warning was issued. SRNA #3 stated she was told by the ED "not to evacuate these residents," "residents need to be fed first." Per interview, residents on the South side of the building were not evacuated. An interview with SRNA #6 on 03/07/12, at 3:54 PM, revealed she was on the South side of the building during lunch time on 02/29/12 and SRNA #3 reported LPN #5 informed SRNA #3 that a tornado warning had been issued. SRNA #6 also stated the ED informed them not to evacuate, that she (the ED) would "let them know," and until further notice to "go on and feed." Interview with the Director of Nursing (DON) on 03/08/12, at 2:41 PM, revealed on 02/29/12, between 11:45 AM and 1:15 PM, she was on the South side of the facility and was "paged" by the ED to call the North side of the building. The DON stated she went to the North side of the building and observed facility staff evacuating residents into the hall. Continued interview revealed the DON was asked by the ED if she had called a "code wind" to alert staff of a tornado warning. According to the DON, she informed the ED she was not aware a tornado warning had been issued. The DON stated she was instructed by the ED to "leave everything the way it was" and not evacuate the South side of the building. Interview with the ED on 03/07/12, at 12:50 PM, revealed on 02/29/12, between 11:45 AM and 1:15 PM, she went to the North side of the building and observed facility staff evacuating residents into the hallway. The ED asked facility staff "what is going on, who called the warning, because no one had informed me and that is the chain of command." Further interview revealed facility staff told her they had been informed from various people that a tornado warning had been called for the community and were evacuating the residents to safety. The ED further stated, "I explained to them that there was a chain of command that had to be followed and not just anyone could call a warning." Interview further revealed the ED did find out "later" a tornado warning had been called at the time facility staff on the North side of the building was evacuating residents. The ED stated a call from the National Weather Service had been received by someone in the front office, and they informed "someone" from the North side but had not called a "code wind" to alert all staff of the warning. A joint interview was conducted on 03/07/12, at 3:15 PM, with the ED and Admissions staff member #1. Admissions staff member #1 reiterated she had informed the ED immediately after she had received the call from the Weather Service that a tornado warning had been issued. At that time the ED stated, "I do remember her calling," "if she says she did she did." However, further interview revealed the ED did not call a "code wind" upon learning of the tornado warning and had failed to alert staff that the National Weather Service had issued a tornado warning for the community. The ED stated facility staff did not follow facility policies/procedures and should have alerted staff by paging a "code wind" when they became aware a tornado warning had been issued. However, review of the tornado warning policy revealed no instructions or procedures related to a "code wind." Interviews conducted with facility staff on 03/07/12 and 03/08/12 revealed staff was not knowledgeable of the facility's policies and procedures and/or gave conflicting statements related to their responsibilities when a tornado warning had been issued. Interview conducted on 03/07/12, at 1:58 PM, 2:07 PM, 2:51 PM, 1:25 PM, 3:43 PM, and 3:54 PM, with LPN #1, LPN #2, Housekeeper #2, Admissions staff member #1, SRNA #3, and SRNA #6 revealed if staff became aware the facility was under a tornado warning, they were to notify the ED or DON. Interview with SRNA #5 on 03/07/12, at 2:16 PM, revealed SRNAs do not call a "code wind" when a tornado warning was issued but were to inform the charge nurse. Interview on 03/07/12, at 2:25 PM, 2:34 PM, 3:08 PM, and 3:38 PM, with LPNs #3 and #4 and Dietary staff members #1 and #2 revealed staff was to page a "code wind" to alert staff a tornado warning had been issued. Interview on 03/08/12, at 1:57 PM and 12:57 PM, with LPN #6 and SRNA #8 revealed if a tornado warning was issued a "code wind" was to be paged overhead. Interview with SRNA #9 on 03/08/12, at 1:18 PM, revealed she did not know whether to page a "code wind" or to inform the ED or a nurse. --A review of the AOC revealed the following: On 03/09/12 an all staff in-service was initiated, including Nursing, Laundry, Dietary, Housekeeping, Therapy, and Administration. The in-service included the difference in a tornado watch and warning and the procedures to follow for a watch and warning. In-servicing was completed by the ED, DON, Assistant Director of Nursing (ADON), Director of Clinical Education, and Department Head Managers. All staff completed a post test for validation of their understanding and knowledge. Any staff members on leave of absence will be educated before they are allowed to work. A tornado watch and warning drill was completed during the 3:00 PM-11:00 PM shift on 03/08/12, and the 7:00 AM-3:00 PM and 11:00 PM-7:00 AM shifts on 03/09/12, to validate staff compliance and working knowledge of the tornado watch and warning procedures. Drills were monitored by the ED, DON, ADON, Director of Clinical Education, and the Maintenance Director. All resident families and/or responsible parties were notified on 03/07/12 and 03/08/12 of the policy and procedures the facility follows for a tornado watch and warning, by the Business Office Manager, Admissions Director, Social Services, Activities Director, and the Minimum Data Set (MDS) Coordinator. A resident council meeting was held on 03/08/12 to inform the residents of the tornado watch and warning policy and procedures and to answer their questions and/or concerns. Alert and oriented residents who did not attend the resident council, with a brief interview for mental status (BIM) score of 13-15, were informed of the facility's policy and procedures for tornado watch and warning by the MDS Coordinator. The Medical Director was made aware of the 02/29/12 event and the Immediate Jeopardy on 03/08/12. On 03/07/12 the District Clinical Nurse (DCN) re-educated the ED, DON, ADON, and the Director of Clinical Education on the tornado watch and warning policy and procedure. On 03/07/12 the Education Director re-educated the Dietary, Housekeeping, and Rehabilitation Managers on the tornado watch and warning policy and procedure. A Quality Assurance meeting was held on 03/09/12 to review for compliance and completion of the above, attendance by the ED, DON, ADON, and Director of Clinical Education, Department Head Managers, District Clinical Nurse, and the Director of Operations. On 03/08/12 and 03/09/12 the staff was given a post test to assure a uniform understanding of the tornado watch and warning policy and procedures by the DON, ADON, Director of Clinical Education, and Department Head Managers. The Corporate tornado warning and watch policy for the facility was not revised. However, on 03/07/12 an addendum was made to the facility's procedures that emphasized notification of the center throughout in the event of a tornado watch and warning before notification of the ED or DON. Also, the code "wind" was reflected in procedure for staff notification of tornado warning so as not to alarm residents. A Quality Assurance meeting was held on 03/08/12 to review revisions of the procedure with the ED, DON, Medical Director, and Life Safety. --The surveyor validated the corrective actions taken by the facility as follows: Interview on 03/13/12 with facility staff and review of facility in-service dated 03/07/12 revealed staff had been in-serviced and taken a post test on tornado watch and warning and the procedures to follow for each. Interview on 03/13/12 with facility staff and review of tornado drill documentation revealed tornado drills were completed and monitored on 03/08/12 during the 3:00 PM-11:00 PM shift, and again on 03/09/12 during the 11:00 PM-7:00 AM shift and the 7:00 AM-3:00 PM shift. Interview on 03/13/12 with resident family members/responsible parties and facility staff revealed the family/responsible parties had been notified of the policy and procedures the facility followed in the event of a tornado watch or warning. Interview on 03/13/12 with the resident council president and the Activities Director revealed a resident council meeting was held on 03/08/12 and the procedures for a tornado watch and warning were discussed. Interview on 03/13/12 with alert and oriented residents and facility staff revealed the residents were informed of the facility's policy and procedures for a tornado watch and warning. Interview with the ED on 03/13/12, at 1:45 PM, revealed she had spoken with the Medical Director on 03/08/12 and informed him of the events related to the tornado warning. A review of the facility's in-service and interview on 03/13/12, at 7:44 PM, with the ED, at 7:41 PM with the DON, and at 2:55 PM with the Education Director revealed the District Clinical Nurse did re-educate them on the facility's tornado watch and warning policy and procedures. A review of facility's in-service and interview on 03/13/12, at 6:41 PM, with the Rehabilitation Manager, at 2:44 PM with the Housekeeping Manager, and at 2:47 PM with the Dietary Manager revealed they had been re-educated on the facility's tornado watch and warning policy and procedures. Tornado drills were conducted on 03/08/12 and 03/09/12. A review of the 03/09/12 Quality Assurance (QA) meeting minutes and interviews conducted on 03/13/12, at 7:44 PM, with the ED, at 7:41 PM with the DON, at 2:55 PM with the Education Director, and at 7:36 PM with the District Clinical Nurse revealed a QA meeting was held and the Jeopardy tags were reviewed along with a review for completion and compliance with the AOC. A review of the 03/08/12 QA meeting minutes and interview on 03/13/12, at 7:44 PM, with the ED, and at 7:41 PM with the DON, revealed a QA meeting had taken place and the revisions of the procedures for tornado watch and warning were reviewed. A review of the facility's policy addendum from 03/07/12 revealed in the event of a tornado warning facility staff was to page a "code wind" overhead, begin evacuation of the residents to safety, and notify the ED and DON.

Based on interview and review of the facility policy it was determined the facility failed to be administered in a manner which enabled resources to be used effectively and efficiently to ensure the residents' highest practicable physical, mental, and psychosocial well-being was attained or maintained. The facility failed to ensure detailed policies and procedures were in place and implemented to provide supervision to residents when a tornado warning was issued for the community where the facility was located. This failure resulted in all residents not being evacuated to safe areas of the building. The failure of the facility to have an effective system to provide appropriate interventions and supervision for residents caused or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy and Substandard Quality of Care (SQC) were determined to exist on 02/29/12. An Allegation of Compliance (AOC) was received on 03/11/12 which alleged removal of Immediate Jeopardy on 03/10/12. The State Agency determined the Immediate Jeopardy was removed on 03/10/12 as alleged, which lowered the scope and severity to "E" while the facility monitors the effectiveness of the systemic changes and quality assurance activities. The findings include: A review of the facility's policy entitled "Tornado," (undated) revealed in all cases of a tornado warning all employees should remain calm and follow the instructions of the Executive Director (ED), shift supervisor, or charge nurse, who would provide assignments to employees. Interview with the National Weather Service on 03/08/12, at 3:40 PM, revealed a tornado warning had been issued on 02/29/12, from 12:40 PM through 1:15 PM, for the facility's community. However, interviews revealed staff was not alerted of the tornado warning and all residents were not evacuated to safety. Interview with Admissions staff member #1 on 03/07/12, at 1:25 PM, revealed a nurse called her on 02/29/12 to inform her a tornado warning had been shown on the television. As soon as she ended the call with the nurse, she received an automated call from the National Weather Service regarding the tornado warning on 02/29/12 and immediately notified the ED. An interview on 03/07/12, at 3:26 PM, with Licensed Practical Nurse (LPN) #5, the facility charge nurse on 02/29/12, revealed a staff member informed her that a tornado warning had been shown on the television for the community. LPN #5 stated she called the Admissions office and was informed by Admissions staff member #1 that the facility had not received notification of warnings. According to LPN #5, at that time she called the 911 non-emergency number and was told a tornado warning had "just" been issued for the community. Interview further revealed the LPN instructed staff to begin evacuating residents into the halls away from windows and she called the other side of the facility (South side) to alert facility staff of the tornado warning. Interview with LPN #5 on 03/08/12, at 1:45 PM, revealed she was informed by the Director of Nursing on 02/29/12, after the tornado warning was over, "when anything like this happens you need to tell (the ED); if she isn't here tell me; if I'm not here tell (the Assistant Director of Nursing)." Interview with the Director of Nursing (DON) on 03/08/12, at 2:41 PM, revealed on 02/29/12, between 11:45 AM and 1:15 PM, she was on the South side of the facility and was "paged" by the ED to call the North side of the building. The DON stated she went to the North side of the building and observed facility staff evacuating residents into the hall. Continued interview revealed the DON was asked by the ED if she had called a "code wind" to alert staff of a tornado warning. According to the DON, she informed the ED she was not aware a tornado warning had been issued and had not "paged" a "code wind." The DON stated she was instructed by the ED to "leave everything the way it was" and not evacuate the South side of the building. Interview with the ED on 03/07/12, at 12:50 PM, revealed on 02/29/12, between 11:45 AM and 1:15 PM, she went to the North side of the building and facility staff was evacuating residents into the hallway. Further interview revealed facility staff told her they had been informed from various people that a warning had been called for the community and had therefore started evacuating the residents to safety. The ED further stated, "I explained to them that there was a chain of command that had to be followed and not just anyone could call a warning." Interview further revealed the ED did find out "later" a tornado warning had been called at the time facility staff on the North side of the building was evacuating residents but a "code wind" to alert all staff of a warning was not issued. A joint interview was conducted on 03/07/12, at 3:15 PM, with the ED and Admissions staff member #1. Admissions staff member #1 reiterated she had informed the ED immediately after she had received the call from the Weather Service that a tornado warning had been issued. At that time, the ED stated, "I do remember her calling," "if she says she did she did." However, further interview revealed the ED did not call a "code wind" upon learning of the tornado warning and had failed to alert staff that the National Weather Service had issued a tornado warning for the community. --A review of the AOC revealed the following: On 03/09/12 an all staff in-service was initiated, including Nursing, Laundry, Dietary, Housekeeping, Therapy, and Administration. The in-service included the difference in a tornado watch and warning, and the procedures to follow for a watch and warning. In-servicing was completed by the ED, DON, Assistant Director of Nursing (ADON), Director of Clinical Education, and Department Head Managers. All staff completed a post test for validation of their understanding and knowledge. Any staff members on leave of absence will be educated before they are allowed to work. A tornado watch and warning drill was completed during the 3:00 PM-11:00 PM shift on 03/08/12, and during the 7:00 AM-3:00 PM and 11:00 PM-7:00 AM shifts on 03/09/12, to validate staff compliance and working knowledge of the tornado watch and warning procedures. Drills were monitored by the ED, DON, ADON, Director of Clinical Education, and the Maintenance Director. All resident families and/or responsible parties were notified on 03/07/12 and 03/08/12 of the policy and procedures the facility follows for a tornado watch and warning, by the Business Office Manager, Admissions Director, Social Services, Activities Director, and the Minimum Data Set (MDS) Coordinator. A resident council meeting was held on 03/08/12 to inform the residents of the tornado watch and warning policy and procedures and to answer their questions and/or concerns. Alert and oriented residents who did not attend the resident council, with a brief interview for mental status (BIM) score of 13-15, were informed of the facility's policy and procedures for tornado watches and warnings by the MDS Coordinator. The Medical Director was made aware of the 02/29/12 event and the Immediate Jeopardy on 03/08/12. On 03/07/12 the District Clinical Nurse (DCN) re-educated the ED, DON, ADON, and the Director of Clinical Education of the tornado watch and warning policy and procedure. On 03/07/12 the Education Director re-educated the Dietary, Housekeeping, and Rehabilitation Managers on the tornado watch and warning policy and procedures. A Quality Assurance meeting was held on 03/09/12 to review for compliance and completion of the above, attended by the ED, DON, ADON, and Director of Clinical Education, Department Head Managers, District Clinical Nurse, and the Director of Operations. On 03/08/12 and 03/09/12 the staff was given a post test to assure a uniform understanding of the tornado watch and warning policy and procedure by the DON, ADON, Director of Clinical Education, and Department Head Managers. The Corporate tornado warning and watch policy for the facility was not revised. However, on 03/07/12 an addendum was made to the facility's procedures that emphasized notification of the facility throughout in the event of a tornado watch and warning before notification of the ED or DON. Also, the code "wind" was reflected in procedure for staff notification of a tornado warning, so as not to alarm residents. A Quality Assurance meeting was held on 03/08/12 to review revisions of the procedure with the ED, DON, Medical Director, and Life Safety. --The surveyor validated the corrective actions taken by the facility as follows: Interview on 03/13/12 with facility staff and review of facility in-service dated 03/07/12 revealed staff had been in-serviced and taken a post test on tornado watch and warning and the procedures to follow for each. Interview on 03/13/12 with facility staff and review of tornado drill documentation revealed tornado drills were completed and monitored on 03/08/12 during the 3:00 PM-11:00 PM shift, and again on 03/09/12 during the 11:00 PM-7:00 AM shift and the 7:00 AM-3:00 PM shift. Interview on 03/13/12 with resident family members/responsible parties and facility staff revealed the family/responsible parties had been notified of the policy and procedures the facility followed in the event of a tornado watch or warning. Interview on 03/13/12 with the resident council president and the Activities Director revealed a resident council meeting was held on 03/08/12 and the procedures for a tornado watch and warning were discussed. Interview on 03/13/12 with alert and oriented residents and facility staff revealed the residents were informed of the facility's policy and procedures for a tornado watch and warning. Interview with the ED on 03/13/1,2 at 1:45 PM, revealed she had spoken with the Medical Director on 03/08/12 and informed him of the events related to the tornado warning. A review of the facility's in-service and interview on 03/13/12, at 7:44 PM, with the ED, at 7:41 PM with the DON, and at 2:55 PM with the Education Director revealed the District Clinical Nurse did re-educate them on the facility's tornado watch and warning policy and procedures. A review of the facility's in-service and interview on 03/13/12, at 6:41 PM, with the Rehabilitation Manager, at 2:44 PM with the Housekeeping Manager, and at 2:47 PM with the Dietary Manager revealed they had been re-educated on the facility's tornado watch and warning policy and procedures. Tornado drills were conducted on 03/08/12 and 03/09/12. A review of the 03/09/12 Quality Assurance (QA) meeting minutes and interviews conducted on 03/13/12, at 7:44 PM, with the ED, at 7:41 PM with the DON, at 2:55 PM with the Education Director, and at 7:36 PM with the District Clinical Nurse revealed a QA meeting was held and the Jeopardy tags were reviewed along with a review for completion and compliance with the AOC. A review of the 03/08/12 QA meeting minutes and interview on 03/13/12, at 7:44 PM, with the ED, and at 7:41 PM with the DON, revealed a QA meeting had taken place and the revisions of the procedures for tornado watch and warning were reviewed. A review of the facility's policy addendum from 03/07/12 revealed in the event of a tornado warning facility staff was to page a "code wind" overhead, begin evacuation of the residents to safety, and notify the ED and DON.

Based on interview and review of facility policy it was determined the facility failed to have detailed written plans and procedures in place to meet all potential emergencies and disasters, such as severe weather. The facility failed to have an effective system in place to alert all staff and provide supervision of residents when a tornado warning was issued on 02/29/12. This failure resulted in all residents not being evacuated to safe areas of the building. The facility's failure caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy and Substandard Quality of Care (SQC) were determined to exist on 02/29/12. An Allegation of Compliance (AOC) was received on 03/11/12, which alleged removal of Immediate Jeopardy on 03/10/12. The State Agency determined the Immediate Jeopardy was removed on 03/10/12 as alleged, which lowered the scope and severity to "E" while the facility monitors the effectiveness of the systemic changes and quality assurance activities. The findings include: A review of the facility's policy entitled "Tornado," (undated) revealed in all cases of a tornado warning all employees should remain calm and follow the instructions of the Executive Director (ED), shift supervisor, or charge nurse, who would provide assignments to employees. The policy failed to provide detailed procedures for staff to follow in the event of a tornado warning. An interview with Admissions staff member #1 revealed the National Weather Service's automated voice recording called the facility on 02/29/12 to issue a tornado warning for the community. Admissions staff member #1 stated she immediately notified the Executive Director (ED) as outlined in the facility's policy. Interview further revealed Admissions staff member #1 was informed after 02/29/12 that she should have called a "code wind" upon notification of a tornado warning to alert all staff of a tornado warning. Admissions staff member #1 stated she was not aware of how long "code wind" had been in effect. An interview on 03/07/12, at 3:26 PM, with Licensed Practical Nurse (LPN) #5, the facility charge nurse, revealed she learned of the tornado warning on 02/29/12 from a staff person that had overheard the warning on a television or radio. According to the LPN, she instructed staff to begin evacuation of residents to safety and she also called staff on the other side of the building to alert them of the warning. LPN #5 stated when facility staff was made aware of a tornado warning they always called staff on the other side of the building to ensure all staff was aware. Per interview, LPN #5 thought she followed facility procedures when she alerted staff on the other side of the building of the tornado warning. However, after 02/29/12 she was instructed by the DON that when facility staff became aware a tornado warning had been issued they were to notify the ED or the Director of Nursing (DON), and then use the overhead paging system and call a "code wind." Interview with the ED on 03/07/12, at 12:50 PM, revealed on 02/29/12, between 11:45 AM and 1:15 PM, the staff person that received the call issuing a tornado warning had told "someone" from the North side that a tornado warning had been issued but did not call a "code wind" to alert all staff a warning had been issued. The ED stated facility staff did not follow facility policy/procedures and should have alerted staff by paging a "code wind" when they became aware a tornado warning had been issued. However, review of the tornado warning policy revealed no instructions or procedures related to a "code wind." Additional interviews conducted with facility staff on 03/07/12 and 03/08/12 revealed staff was not knowledgeable of the facility's policies and procedures and/or gave conflicting statements related to their responsibilities when a tornado warning had been issued. Interview on 03/07/12 at 1:58 PM, 2:07 PM, 2:51 PM, 1:25 PM, 3:43 PM, and 3:54 PM, with LPN #1, LPN #2, Housekeeper #2, Admissions staff member #1, State Registered Nurse Aide (SRNA) #3, and SRNA #6 revealed if staff became aware the facility was under a tornado warning, they were to notify the ED or DON. Interview with SRNA #5 on 03/07/12, at 2:16 PM, revealed SRNAs do not call a "code wind" when a tornado warning has been issued but were to inform the charge nurse. Interview on 03/07/12, at 2:25 PM, 2:34 PM, 3:08 PM, and 3:38 PM, with LPNs #3 and #4, and Dietary staff members #1 and #2, revealed staff was to page a "code wind" to alert staff a tornado warning had been issued. Interview on 03/08/12, at 1:57 PM and 12:57 PM, with LPN #6 and SRNA #8 revealed if a tornado warning was issued a "code wind" was to be paged overhead. Interview with SRNA #9 on 03/08/12, at 1:18 PM, revealed she did not know whether to page a "code wind" or inform the ED or a nurse. --A review of the AOC revealed the following: The Medical Director was made aware of the 02/29/12 event and the Immediate Jeopardy on 03/08/12. The Corporate tornado warning and watch policy for the facility was not revised. However, on 03/07/12 an addendum was made to the facility's procedures that emphasized notification of the facility throughout in the event of a tornado watch and warning before notification of the ED or DON. Also, the code "wind" was reflected in procedure for staff notification of a tornado warning, so as not to alarm residents. A Quality Assurance meeting was held on 03/08/12 to review revisions of the procedure with the ED, DON, Medical Director, and Life Safety. On 03/07/12 the District Clinical Nurse (DCN) re-educated the ED, DON, ADON, and the Director of Clinical Education of the tornado watch and warning policy and procedures. --The surveyor validated the corrective actions taken by the facility as follows: A review of the facility's policy addendum from 03/07/12 revealed in the event of a tornado warning facility staff was to page a "code wind" overhead, begin evacuation of the residents to safety, and notify the ED and DON. Interview with the ED on 03/13/12, at 1:45 PM, revealed she had spoken with the Medical Director on 03/08/12 and informed him of the events related to the tornado warning. A review of the facility's in-service and interview on 03/13/12, at 7:44 PM, with the ED, at 7:41 PM with the DON, and at 2:55 PM with the Education Director revealed the District Clinical Nurse did re-educate them on the facility's tornado watch and warning policy and procedures. A review of the 03/08/12 QA meeting minutes and interview on 03/13/12, at 7:44 PM, with the ED, and at 7:41 PM with the DON, revealed a QA meeting had taken place and the revisions of the procedures for tornado watch and warning were reviewed.

Based on interview, facility policy review, and review of facility in-services it was determined the facility failed to have an effective system in place to ensure employees were trained on emergency procedures. A tornado warning was issued on 02/29/12; however, facility staff lacked knowledge of the proper procedures to follow and as a result all residents were not evacuated to safety. The facility's failure to have an effective system in place to ensure all staff was trained and knowledgeable of emergency procedures caused or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy and Substandard Quality of Care (SQC) were determined to exist on 02/29/12. An Allegation of Compliance was received on 03/11/12, which alleged removal of Immediate Jeopardy on 03/10/12. The State Agency determined the Immediate Jeopardy was removed on 03/10/12 as alleged, which lowered the scope and severity to "E" while the facility monitors the effectiveness of the systemic changes and quality assurance activities. The findings include: A review of the facility's policy entitled "Tornado," (undated) revealed in all cases of a tornado warning all employees should remain calm and follow the instructions of the Executive Director (ED), shift supervisor, or charge nurse, who would provide assignments to employees. However, the policy did not detail who would announce the warning and how all facility staff would be made aware that a warning was issued to provide safety for the residents. A review of training records revealed staff had received a computerized in-service training in June 2011. A review of the computerized in-service training revealed staff was provided information related to the definition of a tornado, the difference between a tornado watch and a tornado warning, and what to do in the event a tornado warning was issued. Continued review of the training revealed staff was trained to go to the basement or safe area of the facility, to cover the patients with thick padding, and to move residents/themselves away from glass. Documentation also revealed after staff had completed the training they were given a "quiz" to confirm their knowledge of the training. However, it could not be determined by a review of the computerized in-service training that staff had been provided direction on who would provide the facility with information related to a tornado warning, who was to be informed of the warning after it was received, and on what procedures to take to ensure safety of residents. A review of minutes from a monthly "huddle in-service" meeting conducted by the Education Director revealed on 08/01/11, prior to the start of each shift, staff was instructed that the yellow "code" tags were to be worn at all times when the staff was on duty. Continued review of the minutes of the meeting revealed the yellow tags listed codes to "call" in the event of an emergency. Meeting minutes revealed staff was also in-serviced on how to use the overhead paging system to announce a "code." However, there was no documentation provided that staff had been trained on who was to page the codes, when to page the codes, or on what procedures to follow when a code had been called. Interview with Admissions staff member #1 on 03/07/12, at 1:25 PM, revealed on 02/29/12 a tornado warning was issued for the community and Admissions staff member #1 notified the ED immediately upon receipt of the information. Interview on 03/07/12, at 3:15 PM, with Admissions staff member #1 revealed after she had informed the ED of the tornado warning, other facility staff was notified by "word of mouth." Interview with Admissions staff member #1 further revealed when the tornado warning ended on 02/29/12, she was informed that she should have announced a "code wind" over the loud speaker to alert all staff of the warning. A review of the June 2011 computerized in-service and the August 2011 "huddle in-service" revealed Admissions staff member #1 had attended the in-services. However, Admissions staff member #1 stated she had never been in-serviced related to "code wind." Interview on 03/07/12, at 3:25 PM, with Licensed Practical Nurse (LPN) #5 revealed she became aware a tornado warning had been issued for the community on 02/29/12 from a staff person that had overheard the warning on a television or radio and confirmed the information by calling the 911 non-emergency number. LPN #5 instructed staff on the North side of the building to start evacuating residents to safety while she called staff on the South side of the building to alert them of the warning. LPN #5 stated in the past when a tornado warning was issued the charge nurse would call from side to side of the building and alert all staff of the warning. Interview further revealed LPN #5 was informed on 02/29/12, after the tornado warning, that she should have paged a "code wind" over the loudspeaker after she had informed the ED/DON that a tornado warning had been issued. A review of the June 2011 in-service revealed LPN #5 had taken the test on the tornado material. However, a review of the August 2011 "huddle in-service" revealed LPN #5 had not been in-serviced on the "code" badges. An interview with LPN #5 on 03/08/12, at 1:45 PM, revealed there was a "code wind" on the yellow badge; she understood what it meant, but stated she had "never used it before." Additional interviews conducted with facility staff on 03/07/12 and 03/08/12 revealed staff was not knowledgeable of the facility's policies and procedures and/or gave conflicting statements related to their responsibilities when a tornado warning had been issued. Interview on 03/07/12, at 1:58 PM, with LPN #1, at 2:07 PM with LPN #2, at 2:51 PM with Housekeeper #2, at 1:25 PM with Admissions staff member #1, at 3:43 PM with State Registered Nurse Aide (SRNA) #3, and at 3:54 PM with SRNA #6 revealed if staff became aware the facility was under a tornado warning they were to notify the ED or DON. Interview with SRNA #5 on 03/07/12, at 2:16 PM, revealed SRNAs do not announce a tornado warning and were to inform the charge nurse. Interview on 03/07/12, at 2:25 PM, with LPN #3, at 2:34 PM with LPN #4, at 3:08 PM with Dietary staff member #1, and at 3:38 PM with Dietary staff member #2 revealed staff was to page a "code wind" to alert staff that a tornado warning had been issued. Interviews on 03/08/12, at 1:57 PM, with LPN #6 and at 12:57 PM with SRNA #8 revealed if a tornado warning was issued a "code wind" was to be paged overhead. Interview with SRNA #9 on 03/08/12, at 1:18 PM, revealed she did not know if she was to page a "code wind," inform the ED, or inform a nurse that a tornado warning had been issued. Interview with the Education Director on 03/07/12, at 5:18 PM, revealed staff was in-serviced on emergency preparedness on an annual basis and at other times throughout the year if needed. The Education Director confirmed the facility provided staff education on "codes" and had provided all staff with yellow "code" badges in August 2011. Further interview revealed staff was instructed that the yellow "code" tags were to be worn at all times when the staff was on duty and was also in-serviced on how to use the overhead paging system to announce a "code." Interview further revealed staff had been instructed that they were to announce a "code wind" as soon as they became aware a tornado warning had been issued. The Education Director further stated SRNAs were instructed to inform the charge nurse if they became aware a warning had been issued and the charge nurse could send another staff member to alert the ED/DON that a warning had been issued. However, although the Education Director stated staff had received in-service training related to "code wind," the Education Director could not provide documentation that facility staff had been in-serviced on the details of a "code wind" such as who could announce the "code" and whether to announce the "code" first or notify the ED/DON first. Interview with the ED on 03/07/12, at 12:50 PM, revealed she became employed at the facility in August 2011 and had been in-serviced on the policy and procedures of the facility. The ED stated she became aware a tornado warning was issued when staff on the North side of the building was evacuating residents to safety. The ED stated by the time she went to her office and confirmed a tornado warning had been issued the warning had been removed. However, a joint interview on 03/07/12, at 3:15 PM, with Admissions staff member #1 and the ED revealed Admissions staff member #1 called the ED immediately upon notification that a warning was issued for the facility. Interview with the ED revealed she did not call a "code wind" nor did she inform staff of the warning in order for the staff to evacuate residents to safety. Interview further revealed "we did not follow procedure on Wednesday when the warning came," "'code wind' should have been called overhead three times." --A review of the AOC revealed the following: On 03/09/12 an all staff in-service was initiated, including Nursing, Laundry, Dietary, Housekeeping, Therapy, and Administration. The in-service included the difference in a tornado watch and warning and the procedures to follow for a watch and warning. In-servicing was completed by the ED, DON, Assistant Director of Nursing (ADON), Director of Clinical Education, and Department Head Managers. All staff completed a post test for validation of their understanding and knowledge. Any staff members on leave of absence will be educated before they are allowed to work. A tornado watch and warning drill was completed during the 3:00 PM-11:00 PM shift on 03/08/12, and again during the 7:00 AM-3:00 PM and 11:00 PM-7:00 AM shifts on 03/09/12, to validate staff compliance and working knowledge of the tornado watch and warning procedures. Drills were monitored by the ED, DON, ADON, Director of Clinical Education, and the Maintenance Director. The Medical Director was made aware of the 02/29/12 event and the Immediate Jeopardy on 03/08/12. On 03/07/12 the District Clinical Nurse (DCN) re-educated the ED, DON, ADON, and the Director of Clinical Education on the tornado watch and warning policy and procedures. On 03/07/12 the Education Director re-educated the Dietary, Housekeeping, and Rehabilitation Managers on the tornado watch and warning policy and procedures. A Quality Assurance meeting was held on 03/09/12 to review for compliance and completion of the above, attended by the ED, DON, ADON, Director of Clinical Education, Department Head Mangers, District Clinical Nurse, and the Director of Operations. On 03/08/12 and 03/09/12 the staff was given a post test to assure a uniform understanding of the tornado watch and warning policy and procedure by the DON, ADON, Director of Clinical Education, and Department Head Managers. --The surveyor validated the corrective actions taken by the facility as follows: Interviews on 03/13/12 with facility staff and a review of facility in-service dated 03/07/12 revealed staff had been in-serviced and taken a post test on tornado watch and warning and the procedures to follow for each. Interviews on 03/13/12 with facility staff and review of drill documentation revealed tornado drills were completed and monitored on 03/08/12 during the 3:00 PM-11:00 PM shift, and again on 03/09/12 during the 11:00 PM-7:00 AM shift and the 7:00 AM-3:00 PM shift. Interview with the ED on 03/13/12, at 1:45 PM, revealed she had spoken with the Medical Director on 03/08/12 and informed him of the events related to the tornado warning. A review of the facility in-services and interview on 03/13/12, at 7:44 PM, with the ED, at 7:41 PM with the DON, and at 2:55 PM with the Education Director revealed the District Clinical Nurse did re-educate them on the facility's tornado watch and warning policy and procedures. A review of facility in-services and interview on 03/13/12, at 6:41 PM, with the Rehabilitation Manager, at 2:44 PM with the Housekeeping Manager, and at 2:47 PM with the Dietary Manager revealed they had been re-educated on the facility tornado watch and warning policy and procedure. A review of the 03/09/12 Quality Assurance (QA) meeting minutes and interview on 03/13/12, at 7:44 PM, with the ED, at 7:41 PM with the DON, at 2:55 PM with the Education Director, and at 7:36 PM, with the District Clinical Nurse revealed a QA meeting was held and the Jeopardy tags were reviewed along with review for completion and compliance with the AOC. Tornado drills were conducted on 03/08/12 and 03/09/12.