Every finding on record at Senior Suites Healthcare

Based on record review and interview, the facility failed to ensure an explicit statement was included in the arbitration agreement which stated the residents were not required to sign to be admitted for 3 (#47, 67, and #95) of 3 sampled residents reviewed for binding arbitration agreements.The administrator identified 74 residents resided in the facility.Findings:A Binding Arbitration Agreements policy, dated 11/2023, read in part, Binding arbitration agreements are voluntary for the residents. Residents are not compelled, pressured, or coerced to enter into a binding arbitration agreement. It is unambiguously communicated to residents (or representatives) that binding arbitration agreements are optional and not required as a condition of admission or to receive care at this facility.1. A facility arbitration agreement for Res #95, dated 04/02/25, was signed by the resident's representative on 04/15/25. The agreement, read in part, the execution of this Arbitration agreement is not precondition to the furnishing of services to the Resident by the Facility.2. A facility arbitration agreement for Res #67, dated 07/28/25, showed the resident's representative refused to sign the document as noted by the SSD. The agreement, read in part, the execution of this Arbitration agreement is not precondition to the furnishing of services to the Resident by the Facility.3. A facility arbitration agreement for Res #47, dated 01/07/26, was signed by the resident on 01/07/26. The agreement, read in part, the execution of this Arbitration agreement is not precondition to the furnishing of services to the Resident by the Facility.On 02/12/26 at 12:34 p.m., the SSD stated the portion of the facility's binding arbitration agreement that used the language furnishing of services did not clearly state admissions to the facility was not dependent on signing the agreement instead of general services offered by the facility. They stated their wording was not clear enough.

Based on observation, record review, and interview, the facility failed to use enhanced barrier precautions when performing peg tube (a type of feeding tube inserted into the stomach through the abdominal wall) care, peg tube feeding, and the administration of medication via peg tube for 1 (#86) of 1 sampled resident reviewed for a feeding tube.The DON identified two residents had a feeding tube.Findings:On 02/11/26 at 8:37 a.m., Res #86 was observed in bed sleeping. Res #86's room had no signage for enhanced barrier precautions, and no personal protective equipment was readily accessible to staff near the room.On 02/11/26 at 1:25 p.m., LPN #2 was observed to enter Res #86's room, performed hand hygiene, applied gloves, and checked for peg tube placement. LPN #2 inserted a syringe into the peg tube to check for residual. LPN #2 returned the residual into the peg tube and flushed with 50 cc of water. LPN #2 held the feeding since the residual was over 100 cc. LPN #2 did not wear a gown, the required enhanced barrier precautions for the attempted feeding.On 02/12/26 at 8:26 a.m., RN #1 was observed to enter Res #86's room, washed their hands, applied gloves, and used a syringe check for residual through the peg tube. RN #1 administered scheduled medication and feeding via the peg tube. RN #1 discarded their gloves and supplies into the trash, washed their hands, and exited the resident's room. RN #1 did not wear a gown for the required enhanced barrier precautions.On 02/12/26 at 12:30 p.m., RN #1 was observed to enter Res #86's room, washed their hands, applied gloves, and performed a dressing change to the peg tube site. RN #1 discarded their gloves and supplies into the trash, washed their hands, and exited the room. RN #1 did not wear a gown for the required enhanced barrier precautionsAn Enhanced Barrier Precautions policy, dated 04/01/25, showed enhanced barrier precautions apply when a resident had a wound or an indwelling medical device. The policy showed indwelling medical devices included feeding tubes. The policy showed a gown and gloves were required to be worn for feeding tube care or use.A physician's order for Res #86, dated 07/24/25, showed for feeding tube check residuals by aspiration of stomach contents four times a day before feedings.A physician's order for Res #86, dated 07/25/25, showed to cleanse the peg tube site with dermal wound cleanser, pat dry, and apply a drain sponge, and secure with tape every shift.A quarterly assessment for Res #86, dated 11/06/25, showed the resident's cognition was severely impaired and the BIMS could not be scored. The assessment showed a feeding tube and a diagnosis of a transient ischemic attack (ministroke).A treatment administration record for Res #86, dated 02/01/26 through 02/28/26, showed no order for enhanced barrier precautions.On 02/12/26 at 11:55 a.m., the DON stated enhanced barrier precautions should be used for residents with peg tubes when providing direct care, administering medication via the peg tube, and performing a peg tube feeding. The DON stated Res #86 required enhanced barrier precautions (gown and gloves) to be worn by staff when care was performed.On 02/12/26 at 12:30 p.m., RN #1 stated they failed to wear a gown when performing Res #86's peg tube dressing change, feeding, and medication administration. RN #1 stated enhanced barrier precautions should have been used for Res #86.

Based on record review and interview, the facility failed to ensure binding arbitration agreements provided to residents and/or representative to sign including a stipulation for a neutral arbitrator to be chosen by both parties and for a venue for the arbitration at a location that is convenient to both parties for 3 (#47, 67, and #95) of 3 sampled residents reviewed for binding arbitration agreements.The administrator identified 74 residents resided in the facility.Findings:A Binding Arbitration Agreements policy, dated 11/2023, read in part, Arbitration agreements provide for the selection of a neutral arbitrator, which is agreed upon by both parties. A neutral arbitrator is an impartial, unbiased, third-party decision maker, without the appearance of any conflicts of interest, contracted with and agreed to by moth parties to resolve their dispute.Arbitration agreements provide for the selection of a venue that is convenient to and suitably meets the needs of bother parties. The venue will be agreed upon by both parties. When selecting a venue for consideration, 'convenience' for the resident (or representative) may be determined by his or her ability to get to the venue.1. A facility arbitration agreement for Res #95, dated 04/02/25, was signed by the resident's representative on 04/15/25. A review of the agreement showed there was no stipulation in the document regarding the mutual selection of an arbitrator between the facility and the resident. The agreement did show that if neither party agreed on a venue site the arbitration would occur at the facility.2. A facility Arbitration Agreement for Res #67, dated 07/28/25, showed the resident's representative refused to sign the document as noted by the SSD. A review of the agreement showed there was no stipulation in the document regarding the mutual selection of an arbitrator between the facility and the resident. The agreement did show that if neither party agreed on a venue site the arbitration would occur at the facility.3. A facility arbitration agreement for Res #47, dated 01/07/26, was signed by the resident on 01/07/26. A review of the agreement showed there was no stipulation in the document regarding the mutual selection of an arbitrator between the facility and the resident. The agreement did show that if neither party agreed on a venue site the arbitration would occur at the facility. On 02/12/26 at 12:34 p.m., the SSD was asked to review the facility's binding arbitration agreement and to describe the portions regarding arbitrator and venue selection. They stated they did not read anything about the process of choosing an arbitrator. They stated the venue would be selected mutually but if they could not agree arbitration would occur at the facility.

Based on record review and interview, the facility failed to ensure quarterly care plan meetings were held for 2 (#34 and #45) of 2 sampled residents reviewed for care plan meetings.The administrator identified 74 residents resided in the facility. Findings: A Resident Participation – Assessment/Care Plans policy, dated 11/01/25, showed the resident and/or the resident's representative were encouraged to participate in the development and implementation of the resident's care plans. 1. An admission record, dated 07/21/17, showed Res #34 had diagnoses which included multiple sclerosis and dementia. An annual assessment, dated 10/28/25, showed Res #34 had a BIMS score of 14 which indicated they were cognitively intact. A review of the health record for Res #34 showed their last care plan meeting was held on November 2024. On 02/09/26 at 11:06 a.m., Res #34 stated the facility had not been having care plan meetings. On 02/11/26 at 1:51 p.m., the SSD stated they had not completed quarterly care plan meetings as required. On 02/12/26 at 10:40 a.m., the DON stated care plan meetings should be held upon admission, every quarter, and as needed. 2. A quarterly assessment, dated 01/02/26, showed Res #45 had a BIMS score of 13 which indicated they were cognitively intact. The assessment showed Res #45 had diagnoses which included stroke and hypertension. The health record for Res #45 showed the last care plan meeting was held on 05/03/24. On 02/09/26 at 2:11 p.m., Res #45's family member stated they had not had any care plan meetings. They stated a care plan meeting was scheduled for last month but was canceled because no staff were available to attend at the scheduled time. Res #45's family member stated they were informed by staff they were trying to get back to having regular care plan meetings. On 02/11/26 at 1:51 p.m., the SSD stated they have not been having quarterly care plan meetings as required. On 02/12/26 at 10:40 a.m., the DON stated care plan meetings should be held upon admission, every quarter, and as needed.

Based on record review and interview, the facility failed to ensure resident assessments were accurate for 4 (#44, 57, 69 and #87) of 21 sampled residents reviewed for MDS accuracy.The administrator identified 74 residents resided in the facility.Findings:A facility document titled MDS Completion and Submission Timeframes, dated October 2023, read in part, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes.1. A quarterly assessment for Res #57, dated 11/01/25, showed section C: cognitive patterns had not been completed.On 02/12/26 at 9:57 a.m., the MDS coordinator stated Res #57's section C of the MDS was answered not assessed. The MDS coordinator stated they should have been answered and assessed.2. An admission assessment for Res #87, dated 11/21/25, showed section C: cognitive patterns had not been completed.On 02/12/26 at 9:46 a.m., the MDS coordinator stated Res #87's section c of the MDS was answered not assessed. The MDS coordinator stated they should have been answered and assessed.3. An annual assessment for Res #44, dated 12/11/25, showed section C: cognitive patterns had not been completed.On 02/12/26 at 9:51 a.m., the MDS coordinator stated Res #44's section C of the MDS was answered not assessed. The MDS coordinator stated they should have been answered and assessed.4. A quarterly assessment for Res #69, dated 12/12/25, showed section C: cognitive patterns had not been completed.On 02/12/26 at 9:54 a.m., the MDS Coordinator stated Res #69's section C of the MDS was answered not assessed. The MDS coordinator stated they should have been answered and assessed.On 02/12/26 at 1:31p.m., the DON stated they could not explain why section C was not completed. The DON stated section C should have been assessed and answered correctly.

Based on record review and interview, the facility failed to electronically submit resident assessments to CMS for 2 (#13 and #27) of 2 sampled residents reviewed for MDS submission.The administrator identified 74 residents resided in the facility.Findings:A MDS Completion and Submission Timeframes policy, dated 10/01/23, read in part, The assessment coordinator or designee is responsible for ensuring resident assessments are submitted to CMS' Internet Quality Improvement Evaluation System in accordance with current federal and state guidelines.1. A discharge assessment for Res #27, dated 11/07/25, showed the assessment had not been submitted to CMS.2. An annual assessment for Res #13, dated 12/30/25, showed the assessment had not been submitted to CMS.On 02/10/26 at 1:55 p.m., the MDS coordinator stated the MDS assessments for Res #13 and Res #27 were not submitted to CMS by the RN who reviewed and signed the assessments.

Based on observation, record review, and interview, the facility failed to ensure refrigerator temperatures were recorded for 1 (medication room [ROOM NUMBER]) of 2 medication refrigerators observed for safe storage of medication.The DON identified two medication rooms with medication storage refrigerators in the facility.Findings:On 02/10/26 at 9:33 a.m., medication room [ROOM NUMBER] was observed with the DON. Inside the medication room was a full-size refrigerator that contained medications and did not have a temperature record log attached for February 2026. A facility Storage of Medications policy, dated 2001, read in part, Drugs and biologicals used in the facility are stored in locked compartments and under proper temperature, light and humidity controls.On 02/10/26 at 10:11 a.m., the DON stated they searched and were unable to locate the missing temperature log for the medication refrigerator located in medication room [ROOM NUMBER]. They stated the log should have been kept on the refrigerator and filled out completely.

Based on observation and interview, the facility failed to ensure a urine sample was not stored in a refrigerator used to store resident food for 1 (medication room [ROOM NUMBER]) of 2 sampled medication room food storage refrigerators observed for infection control.The administrator identified 74 residents resided in the facility.Findings: On 02/10/26 at 9:33 a.m., a mini refrigerator located in medication room [ROOM NUMBER] was observed to have a box of bacon, two protein shakes, one individual sized ice cream, two mighty shakes, and one urine specimen cup filled halfway with a yellow substance and sealed in a plastic lab bag. The cup had the name of a former resident written on it. The specimen cup and bag were laying on top of the ice cream and mighty shakes container. On 02/10/26 at 9:37 a.m., DON stated the food inside the mini refrigerator located in medication room [ROOM NUMBER] was to store resident food items. They stated the urine specimen cup should not have been stored in that refrigerator. They stated it was an infection control issue.

Based on observation, record review, and interview, the facility failed to have a qualified activity director. The administrator identified 74 residents resided in the facility.Findings:On 02/09/26 at 2:42 p.m., residents were observed in the dining area playing bingo with an automated bingo machine that was calling the bingo numbers with CMA #3 sitting at the table.On 02/11/26 at 12:02 p.m., the activity board was observed. The board showed the facility was to have coffee and conservations every Monday and Friday at 10:45 a.m., bible study every Tuesday at 10:45 a.m., and stretch every Thursday at 10:45 a.m.On 02/11/26 at 1:15 p.m., residents were observed sitting at various tables playing bingo with an automated game that called out the numbers for the game.An undated facility Resident Rights poster showed the facility would provide a program of activities designed to meet the residents needs and interests.On 02/11/26 at 1:40 p.m., the social worker stated either they or another staff member would assist with activities. They stated they did not know how long the facility had been without an activity director.On 02/11/26 at 1:45 p.m., the administrator stated currently they did not have a fulltime activity director. The administrator stated it had been some weeks since they had an activity director. They stated they were in the process of hiring an activity director.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed for 1 (#91) of 20 sampled residents reviewed for comprehensive care plans.The administrator identified 74 residents resided in the facility.Findings:A facility Care Plans, Comprehensive, Person-Centered policy, dated March 2022, read in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy showed the comprehensive care plans were to be completed within seven days of completion of the required MDS assessment and no more than 21 days after admission to the facility.An admission record for Res #91, dated 10/07/25, showed the resident had been admitted to the facility on [DATE] and discharged on 11/23/25.An admission assessment for Res #91, dated 10/14/25, showed the resident was admitted to the facility on [DATE]. A review of the electronic medical record of Res #91 showed no comprehensive care plan had been developed.On 02/11/26 at 12:24 p.m., the MDS coordinator was asked to locate Res #91's comprehensive care plan. The MDS coordinator stated they could not find a comprehensive care plan in Res #91's electronic medical record. They stated the resident had been in the facility long enough where the care plan should have been developed. They stated the care plan should have been completed no later than 14 days after the admission MDS assessment had been completed.On 02/11/26 at 12:48 p.m., the DON stated they could not locate a comprehensive care plan for Res #91. They stated their expectation and facility policy mandated the comprehensive care plan would be developed within 14 days of the completion of a resident's comprehensive assessment.

Based on record review and interview, the facility failed to provide a written notice of transfer to a resident discharged to an acute care facility prior to transfer for 1 (#92) of 3 sampled residents reviewed for discharges.The DON identified 60 residents discharged during the three months prior to the survey.Findings:A facility Transfer or Discharge policy, dated April 2025, did not include the requirement to notify the resident or their representatives in writing prior to transfer or discharge.A nurse's note for Res #92, dated 01/03/26, showed at 11:23 a.m., the resident was sent to an acute care hospital for behaviors.On 02/11/26 at 1:19 p.m., LPN #1 stated they had not heard of a written notice of transfer and had never given one to any of the residents they had transferred or discharged .On 02/11/26 at 1:22 p.m., the DON stated they were unaware of the requirement for a written notice of transfer to be given to a resident or their representative prior to transfer or discharge. They stated they had not been providing those notices to residents.

Based on record review and interview, the facility failed to ensure an allegation of abuse was investigated timely and the alleged perpetrator was prevented from working with the alleged victim until the conclusion of the investigation for 1 (#10) of 3 sampled residents reviewed for abuse.The administrator identified 74 residents resided in the facility.Findings:A facility Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation - F609 policy, dated 2001, read in part, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as require by current regulations) and thoroughly investigated by facility management. The policy showed staff was to ensure the alleged perpetrator and victim were kept apart and the alleged perpetrator was to be placed on leave until completion of an investigation.An initial incident report form, incident date 01/27/26, showed on 01/27/26 facility staff were made aware by a family member of an alleged act of abuse against Res #10. The incident report showed the administrator reported the incident to the OSDH and local law enforcement on 02/03/26.A facility document titled Individual Timesheet, dated 02/04/26, showed CNA #1 had worked at the facility on 01/29/26, 01/30/26, and 01/31/26. Those dates followed the date the DON had been made aware of the allegation of abuse against CNA #1 and before the administrator began their investigation on 02/03/26. On 02/04/26 at 11:48 a.m., the DON stated they had learned about the accusation of abuse during a care plan meeting on 01/27/26. They stated they were informed by the family member the alleged perpetrator was CNA #1. The DON stated they had told the administrator about the incident but could not recall what day they had done so.On 02/04/26 at 12:30 p.m., the administrator stated they learned of the allegation against CNA #1 on 02/03/26 during a morning staff meeting by the DON. They stated when the DON had informed them on 02/03/26 they suspended the CNA #1 while they performed the investigation.On 02/04/26 at 12:42 p.m., the DON stated CNA #1 had not worked at the facility since their shift on 01/31/26. They stated they should have begun the investigation when they first learned about the allegation and immediately suspended the nurse aide.

Based on record review and interview, the facility failed to ensure an allegation of abuse was reported to the OSDH and local law enforcement within two hours of becoming aware of the allegation for 1 (#10) of 3 sampled residents reviewed for abuse.The administrator identified 74 residents resided in the facility.Findings:A facility Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation - F609 policy, dated 2001, read in part, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as require by current regulations) and thoroughly investigated by facility management. The policy showed reports of allegations of abuse would be made within two hours.An initial incident report form, incident date 01/27/26, showed on 01/27/26 the facility staff were made aware by a family member of an alleged act of abuse against Res #10. The incident report showed the administrator reported the incident to the OSDH and local law enforcement on 02/03/26.On 02/04/26 at 12:30 p.m., the administrator stated they were made aware of the allegation on 02/03/26 during a morning staff meeting by the DON. They stated the DON had reported finding out about the incident on 01/27/26. The administrator stated when they learned about the allegation, they immediately made the required reports on 02/03/26. They stated the reports should have occurred on 01/27/26 when staff were informed by the family.On 02/04/26 at 12:32 p.m., the DON stated they told the administrator of the alleged abuse regarding Res #10 at the staff meeting on 02/03/26 and should have done it earlier.

Based on record review and interview, the facility failed to ensure ongoing side effect monitoring was completed for a resident receiving a psychotropic medication for 1 (#19) of 5 sampled residents reviewed for unnecessary medications.The DON identified 60 residents received psychotropic medications. Findings:An undated facility policy titled Monitoring and Reduction of Unnecessary Medications Related to Side Effects in Long-Term Care Residents, read in part, The facility is committed to minimizing unnecessary medications and ensuring that all medications are used safely, effectively, and in accordance with federal and state regulations. Staff must proactively monitor side effects, document findings, and collaborate with providers to adjust or discontinue medications when appropriate.A physician's order for Res #19, dated 08/29/25, showed the resident was to receive fluoxetine 10 milligrams (an antidepressant) by mouth every day.A quarterly assessment for Res #19, dated 12/12/25, showed the resident had a BIMS score of 12 which indicated moderate cognitive impairment. The assessment showed Res #19 routinely received an antidepressant.A care plan intervention for Res #19, dated 12/31/25, showed the resident had depression and medications were to be administered as ordered and side effects and effectiveness were to be monitored and documented.A treatment administration record for Res #19 was reviewed from 08/29/25 through 2/10/26. No documentation of side effect monitoring was located.On 02/11/26 at 2:21 p.m., the DON stated that no side effect monitoring took place for Res #19.

Based on observation, record review, and interview, the facility failed to ensure the call light was operational for 1 (#94) of 3 sampled residents whose call lights were tested.The administrator identified 74 residents resided in the facility.Findings:On 02/10/26 at 9:05 a.m., Res #94 was observed to push their call light to test it. The light outside of the resident's room above the door did not light up or sound. The resident had no bell to ring for assistance.On 02/10/26 at 9:06 a.m., the monitor connected to the call lights at the nurses' station did not display Res #94's room number.On 02/11/26 at 9:24 a.m., an observation of the maintenance logbook at the nurses' station showed no call lights that needed to be fixed.On 02/11/25 at 9:25 a.m., CNA #5 was observed to document in the maintenance logbook that the call light in Res #94's room was not working, and the call light in room [ROOM NUMBER] was not working.An Answering the Call Light policy, dated 09/01/22, read in part, Ensure that the call light is plugged in and functioning at all times.Report all defective call lights to the maintenance director or administration to get them addressed promptly. A baseline care plan for Res #94, dated 02/06/26, showed the resident required stand-by assist with ambulation.On 02/10/26 at 9:05 a.m., Res #94 stated their call light did not work. Res #94 stated maintenance had replaced the cord, but it was still not working.On 02/10/26 at 9:08 a.m., CMA #3 stated when the call light was pushed, the light above the door would come on, and the room number was also displayed on the monitor at the nurses' station. CMA #3 stated the lights and monitors did not always work.On 02/11/26 at 9:23 a.m., Res #94 stated their call light was still not working.On 02/11/26 at 9:24 a.m., the DON stated a new maintenance logbook was put in use at each nurses' station to report things needing to be fixed.On 02/11/26 at 9:26 a.m., CNA #5 stated the call light in Res #94's room was not working. CNA #5 stated they had issues with the call lights not working almost daily.On 02/12/26 at 10:29 a.m., the administrator stated there were issues with the facility's call light system. The administrator stated residents were given a bell to ring if the call light could not be fixed.On 02/12/26 at 10:32 a.m., the DON stated no documentation was available of maintenance being notified previously of call lights not working. They stated it was done verbally. The DON stated Res #94's call light and the call light in room [ROOM NUMBER] had been fixed on 02/11/26 before 3:00 p.m.

Based on observation, record review and interview, the facility failed to ensure medications were secure for 1 (station 3 medication/treatment cart) of 2 medication/treatment carts on station 3. The administrator identifed 95 residents resided in the facility. Findings: On 05/30/25 at 9:15 a.m., the station 3 nurses medication/treatment cart was observed to be unlocked and unattended at the nurses station. On top of the cart was a bottle Hysept wound cleanser and a medicine cup containing an unidentified gel. An undated policy titled Medication Labeling and Storage, read in part, 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. On 05/30/25 at 9:20 a.m., CNA #1 locked the cart and stated they did not know where the nurse assigned to the cart was. On 05/30/25 at 9:30 a.m., the administrator stated the medication/treatment cart should have been locked without medications on top. On 05/30/25 at 9:36 a.m., RN #1, who was assigned to the medication/treatment cart, stated they should not have left the cart unlocked with medications on top. RN #1 stated residents or visitors could have obtained the medications.

Based on observation and interview, the facility failed to ensure protected health information was secure for 1 (station 3 medication/treatment cart) of 2 medication/treatment carts on station 3. The administrator identifed 95 residents resided in the facility. On 05/30/25 at 9:15 a.m., a computer on top of an unattended medication/treatment cart at nurses station 3, was observed to be open and showed protected health information. On 05/30/25 at 9:20 a.m., CMA #1 closed the computer and stated they did not know where the nurse assigned to the cart was. On 05/30/25 at 9:30 a.m., the administrator stated the computer should not have been left open with resident information visible. On 05/30/25 at 9:36 a.m., RN #1, who was assigned to the medication/treatment cart, stated the computer should have been closed and not showing protected health information.

Based on record review and interview, the facility failed to administer a cardiac medication as prescribed for one (#50) of 10 residents observed during a medication administration pass. The facility administrator identified 48 residents who were prescribed cardiac medications. Findings: Resident #50 had diagnoses which included atrial fibrillation. A physician's order, dated 09/12/24, documented the resident was to receive 100 milligrams amiodarone (antiarrhythmic medication) daily for atrial fibrillation. The order documented to monitor blood pressure for hypotension and heart rate for increased rate. The September 2024 MAR documented the resident missed six of 18 doses of amiodarone from 09/13/24 through 09/30/24. The October 2024 MAR documented the resident missed 11 of 31 doses of amiodarone. The November 2024 MAR documented the resident missed four of seven doses of amiodarone from 11/01/24 through 11/07/24. On 11/07/24 at 9:55 a.m., CMA #2 did not administer the amiodarone for Resident #50. On 11/07/24 at 1:10 p.m., CMA #2 stated the amiodarone was given to raise the resident's blood pressure and they had been instructed not to give it if the systolic (top or first number in a blood pressure reading) blood pressure was over 100 or the diastolic (lower or second number in a blood pressure reading) blood pressure was over 60. The CMA stated the resident's blood pressure was 115/58. On 11/07/24 at 2:50 p.m., LPN #1 stated they were not familiar with amiodarone, but thought it was a cardiac medication and so they would not administer the medication if the resident's systolic blood pressure was below 120, the diastolic blood pressure was below 60, or the heart rate was below 60 beats per minute. On 11/07/24 at 3:15 p.m., LPN #2 stated amiodarone was an anti-arrhythmia medication and so they would not administer the medication if the resident's systolic blood pressure was below 120, the diastolic blood pressure was below 60, or the heart rate was below 60 beats per minute. On 11/07/24 at 3:30 p.m., the DON stated the order for amiodarone should specify when to hold the medication and did not. The DON stated the physicians usually ordered to hold cardiac medications if the residents systolic blood pressure was below 120, the diastolic blood pressure was below 60, or the heart rate was below 60 beats per minute. The DON stated Resident #50 missing 20 doses of amiodarone from 09/13/24 to 11/07/24 was significant. On 11/07/24 at 5:15 p.m., the DON stated they contacted the physician, informed them of the missed doses of amiodarone, and received clarification on when to hold the medication. The DON stated they were to hold the amiodarone if the resident's heart rate was below 50 beats per minute. The DON stated the physician did not wish to order the amiodarone to be held if the resident's blood pressure was low.

Based on observation and interview, the facility failed to ensure the physical environment of the kitchen and kitchen equipment were kept clean and maintained in good repair. The administrator identified 83 residents ate meals prepared in the kitchen. Findings: On [DATE] at 10:15 a.m., cook #1 was observed to puree pork. [NAME] #1 placed cut pieces of pork into a bladed container, placed the container on the base, and the lid on top of the container. The container was observed to be cracked and missing sections of the bottom edge which secured the container to the base. On [DATE] at 10:15 a.m., cook #1 stated the container was broken and they had to hold the container down onto the base to get the unit to puree foods. On [DATE] at 10:20 a.m., observations of the kitchen and ice machine were conducted: a. there was standing water on the floor below the dish machine, the drying rack, the walk way in front of the drying rack, and to the dry goods storage room; b. a box fan with a screen was covered in dust. The box fan blew air across the food preparation stations; c. a ceiling return vent was thickly covered in dust; d. the exterior door had visible light penetration along the top and sides of the door, potentially allowing vermin access to the kitchen; e. there was faded yellow to rust colored dried water stains on the ceiling in the main food preparation area and dish machine area; f. there was dried red and brown food stains on the ceiling above the interior kitchen door; g. there was an approximately one inch in diameter hole through the drywall of the ceiling in the dish machine room; h. there was peeling paint from the ceiling in the dish machine room; i. there was missing drywall under the sink immediately to the right of the dish machine; j. there was peeling paint and exposed chips of drywall along the base boards in the main kitchen and dish machine room; k. there was a black substance covering the splash screen beside and behind the dish machine. The substance was easily removed with a finger nail; l. there was a lower cabinet door partially hung from the top hinge and supported on the opposite corner by the floor; m. there was dirt, food particles, and expired insects located along the baseboards in the dry goods room; n. there were streaks of grease and other liquids staining the walls of the dry storage room; o. there was a brown substance smeared on the wall and edge of the electrical outlet cover; p. there was white, black, and brown particles resting on the rails of the bread storage rack; q. there was white, black, brown particles, two large cookie sheets, a dusty white towel, and a caulking gun resting on top of the freezer in the dry goods room; r. there was white, black, brown particles, and dried food staining the wall and baseboards on the exposed areas near trash receptacles in the main kitchen/food preparation area; s. there was black a substance wiped from the interior of the ice storage box; and t. there was a black substance observed around the water reservoir and mechanical structures of the ice maker/ice machine. On [DATE] at 11:20 a.m., DA #1 stated a few months ago, the maintenance person used a broom handle to make a hole in the ceiling to locate the source of a water leak. The DA stated the hole was not repaired. On [DATE] at 11:25 a.m., the DM stated the kitchen staff were routinely assigned to pull out and clean around storage racks and moveable kitchen appliances and food preparation areas. The DM stated they were able to see light around the edges of the exterior door. The DM stated they were aware of the peeling paint, holes, and missing sheetrock in the dish machine room. The DM stated they were aware of the condition of the container used to puree foods but did not have the budget to replace it. The DM stated the drain in the floor in the dish machine room did not drain well and contributed to the standing water on the floor. The DM stated the black substance observed around the water reservoir and mechanical structures of the ice maker/ice machine was mold.

Based on observation, interview, and record review, the facility failed to ensure residents were assessed for the use of bed rails prior to installation for one (#11) of one resident who was reviewed for bed rails. The administrator identifed 52 residents using bed rails. Findings: Resident #11 had a diagnosis which included dementia. A review of Resident #11's medical record did not reveal the resident was assessed for the use of bed rails. On 11/06/24 at 2:18 p.m., bed rails were observed to be up on both sides of the resident's bed. On 11/07/24 at 4:07 p.m., the administrator stated the bed rail assessment page did not automatically populate, so the nurses had to manually pull that up. They stated it did not get done for Resident #11.

Based on record review and interview, the facility failed to provide adequate supervision to prevent injury/accident hazards for one (#1) of three sampled residents who were reviewed for supervision to prevent injury/accident hazards. Resident #1 was left unattended when they verbalized they were slipping out of their wheelchair. Resident #1 fell out of their wheelchair and sustained a laceration to the right medial thigh which required six sutures. The Resident Census and Condition of Residents form identified 63 residents who utilized a wheelchair all or most of the time. Findings: Resident #1 had diagnoses which included repeated falls and dementia. A certificate of completion, dated 12/17/20, documented transport driver #1 completed the training program for the Sure-Lok wheelchair securement and occupant restraint system. Transportation Competency Checkoff forms, dated 05/18/21 and 05/30/22, documented transport driver #1 had completed the tasks listed on the competency. The checklist did not include supervision to prevent injury/accident hazards. An ODH Form 283, with incident dated 08/29/22, documented resident #1 was transported to the facility from the hospital via facility van by transportation driver #1. The form documented upon arrival the resident notified the transportation driver they were sliding out of their wheelchair. The transportation driver left the resident in the van to seek assistance and upon return the resident was on the floor of the van. Part C of the ODH Form 283 documented when the resident had notified the transportation driver they were slipping the transportation driver told the resident they would be right back, released the resident's seatbelt, and entered the facility to find assistance. The form documented transportation driver #1 was going to repeat Sure-Lok training on 09/01/22 and another competency check off would be completed during his next transport. The form documented transportation driver #1 stated they were not sure why they had released the seat belt but realized it was not a good decision. A statement from transportation driver #1, dated 08/29/22, documented upon arrival to the facility with Resident #1 the resident had notified them they were slipping down in their wheelchair and they could see the resident was in fact sliding down in the chair because the resident had appeared to be lower than usual. The statement documented the transportation driver told the resident they would be right back and they believed this was when they released the resident's seat belt. The statement documented transportation driver #1 left the resident, entered the facility to seek assistance, and upon return discovered the resident was sitting on the floor of the van in front of their wheelchair. A physician progress note, dated 08/29/22, documented the resident was in the process of transferring out of the van into the building, caught her leg on a wheelchair, which resulted in a large laceration. An admission summary progress note, dated 08/29/22, read in part, .Resident arrived back at facility at [9:50 p.m.] .Resident received [six] sutures to right medial thigh . A baseline care plan, dated 08/30/22, documented the resident required two plus person physical assistance for transfers, utilized a wheelchair for mobility, and was alert and cognitively intact. On 09/07/22 at 9:57 a.m., resident #1 was asked about the incident in the transport van on 08/29/22. The resident stated they did not know what had happened. They stated they were sitting in the wheelchair in the transportation van and the next moment she was on the floor of the van. Resident #1 stated, I just wasn't secure I guess. On 09/07/22 at 2:15 p.m., CNA #2 was asked what had happened regarding the incident with resident #1 on 08/29/22. The CNA stated they were walking down the hall of the facility when transportation driver #1 had asked them for assistance. CNA #2 stated when they arrived to the transportation van the resident was observed on the floor. They stated CNA #1 and themselves removed the foot pedals, lifted the resident into the wheelchair and was taken into the facility. CNA #2 was asked what the protocol was if a resident fell . They stated they were to notify the nurse so they could assess the resident before the resident was moved. On 09/07/22 at 3:04 p.m., CNA #1 was asked what had happened regarding the incident with resident #1 on 08/29/22. CNA #1 stated transportation driver #1 reported to them the resident was slipping and they required assistance. The CNA stated they observed the resident in the transportation van sitting on the wheelchair's foot pedals. They stated they informed transportation driver #1 they would need assistance getting the resident into the wheelchair. CNA #1 stated CNA #2 assisted them in placing the resident back into the wheelchair. On 09/07/22 at 3:11 p.m., transportation #1 was asked about the incident regarding resident #1 on 08/29/22. They stated they were the back up transportation driver and had picked the resident up from the hospital for admission to the facility. Transportation driver #1 stated when they were going to get the resident from the van the resident reported to them they were slipping. The transportation driver #1 stated they observed the resident had slipped down in their wheelchair and since they were not a CNA they entered the facility to obtain the assistance from nursing staff. They stated they got CNA #1 to assist the resident and upon arrival to the transportation van the resident was observed on the floor of the van. They stated they then left CNA #1 with the resident and requested assistance from CNA #2. They stated they got the resident back into the wheelchair and took the resident to the charge nurse. Transportation driver #1 was asked if the resident's seatbelt was in use. They stated yes. They were asked if the seatbelt was still in use when the resident had slipped from the wheelchair to the floor of the van. They stated they did not remember if they had released the seatbelt before or after the fall. They stated they should have called for assistance on their cell phone and stayed with the resident. They were asked why they had not called for assistance rather than leaving the resident unattended and unsupervised. They stated in the past they had another resident who would slouch down in their wheelchair during transports and there had not been an issue or incident with that resident. They stated they would enter the facility to find assistance in repositioning that resident. Transportation driver #1 stated they observed Resident #1 slipping down in the wheelchair as a comfort/positioning issue, not as a fall risk. Transportation driver #1 was asked what education they had received regarding the transportation of residents. They stated they had to watch a video about the Sure-lok system, take a quiz, and the SSD observed them on their first transport. Transportation driver #1 was asked if adequate supervision to prevent injury/accident hazards had been provided to resident #1. They stated no. They stated the resident was unsupervised for only a minute but that was all it took. On 09/07/22 at 3:34 p.m., the ADON was asked about the incident with resident #1 on 08/29/22. They stated staff had brought the resident to RN #1 and notified them both of the incident. They stated the laceration to the right medial thigh was observed and the physician was notified with orders received to transport the resident to the ER for treatment. They stated they observed the van and wheelchair for any sharp/jagged areas and did not determine what cut the resident. The ADON was asked what interventions had been implemented to prevent recurrence. They stated they inserviced all aides regarding falls and transfers; immediately inserviced CNA #1, CNA #2, and transportation driver #1; and the SSD provided training for staff who conducted transports. They were asked how many CNA/CMAs had been inserviced. They reviewed the inservice dated 08/30/22 and stated 14. The ADON was asked if there were only 14 CNA/CMAs on staff at the facility. They stated no. They stated those 14 were the aides who were working at the time of the incident and the on-coming night shift. They were asked how they ensured all staff were provided education regarding supervision to prevent injury/accident hazards. They stated they provided monthly education and utilized an online system of required education. They were asked when the last education had been provided prior to 08/30/22. They stated the third week in August 2022. The ADON was asked what could have been implemented to potentially prevent resident #1's injury. They stated transportation driver #1 should have stayed with the resident, called for assistance, or honked the van's horn to get the attention of the staff. On 09/07/22 at 3:56 p.m., the SSD was asked what their role was regarding transports. They stated they were the transportation supervisor and provided initial training to staff who transported residents. They were asked if the training included providing supervision to prevent injury/accident hazards. They stated yes. They were asked where that information was documented. They stated it was a part of the competency checklist the facility provided. At 4:09 p.m., the SSD provided the surveyor with a copy of transportation driver #1's competency checklist. Review of the checklist did not reveal information regarding supervision to prevent injury/accident hazards. The SSD stated the competency did not cover supervision to residents but it was common knowledge to not leave the residents unsupervised/unattended. On 09/07/22 at 5:03 p.m., the administrator was asked about the incident regarding resident #1 on 08/29/22. They stated transportation driver #1 had left the resident unattended, after they had told them they were slipping, and fell sustaining a laceration to the thigh which required sutures. They stated they asked the transportation driver why they had unbuckled the seat belt and the transportation driver stated they did not know and it may have just been a habit to unbuckle the resident at that time. The administrator stated they asked transportation driver #1 why they had left the resident unattended and the transportation driver informed them they were only thinking of getting assistance at that time. The administrator was asked when transportation driver #1's competency had been completed. They stated May 2022 and they would complete another competency before they transported residents. The administrator stated the transportation driver should not have unbuckled the resident's seat belt and should not have left the resident unattended. On 09/07/22 at 5:53 p.m., transportation driver #1 was asked why the resident's seatbelt had been unbuckled when they had observed and was notified by the resident they were slipping. They stated they did not remember for sure when they had unbuckled the seat belt but they thought they unbuckled it, went to the back of the van to get the resident out, realized they were slipping, and went into the facility to get assistance. They stated that was likely what happened.

Based on observation, interview, and record review, it was determined the facility failed to ensure nurse aides were able to demonstrate competency in skills and techniques which resulted in a harm for one (#1) of three residents sampled for required assistance with activities of daily living (ADLs). The facility failed to ensure staff were provided information and were proficient with necessary care required for the residents. The facility identified four residents who required the use of a sit to stand lift for transfers. An emergency room note, dated 10/09/16, documented resident #1 had a fall with a head injury. The note documented the resident received seven sutures. The note documented the resident's [DIAGNOSES REDACTED]. The facility identified 78 residents who resided in the facility. Findings: The facility policy for falls documented the falling star program was to assist the staff in maintaining the safety of the residents who were a high risk for falls. The policy documented a star would be placed outside of a resident's door to alert staff of a resident at risk for falls. The falling star policy did not define what the number on the star represented. The facility policy for lifting and movement of residents documented the staff were responsible for direct resident care and would be trained in the use of mechanical lifting devices. The policy documented the staff would be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding the use of equipment and safe lifting techniques. The policy documented the nursing staff, in conjunction with the rehabilitation staff, would assess individual residents needs for transfer assistance and would document it in the resident's care plan. The policy documented the portable lift could be used by one nursing assistant if the resident could participate in the lifting procedures. The policy documented two nursing assistants would be required to perform the procedure if the resident could not participate in the lifting procedure. The policy documented the resident's transfer type would be posted outside of the resident's door. The policy documented the transfer type would be documented in the care plan. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A monthly resident incident log, dated June 2016, documented the resident sat up in bed unassisted and fell forward hitting her head on the floor. The incident log documented the resident sustained [REDACTED]. An incident report, dated 06/25/16, documented the resident had a fall with a head injury. The resident was transported to the hospital and received 20 staples. A doctor's order, dated 06/25/16, documented the resident needed two person assistance with transfers. An annual assessment, dated 07/12/16, documented the resident was moderately impaired for daily decision making. The assessment documented the resident required extensive assistance with activities of daily living (ADLs). The assessment documented the resident had one fall with an injury. The assessment documented the resident was at risk for pressure ulcers. The printed nurse aide care plan documented to ensure the resident was wearing appropriate footwear for all transfers. The care plan documented to keep the call light in reach for needed assistance. The care plan documented the staff would follow the facility fall protocol. The care plan documented the resident required extensive staff assistance to use the toilet. The care plan documented the resident required extensive staff assistance with transfers. A care plan, dated 10/23/16, documented the resident had impaired cognition related to [MEDICAL CONDITION]. The care plan documented the resident was at risk for falls related to gait and balance problems. The care plan documented the interventions for the fall on 10/09/16 would be to ensure the resident wore appropriate footwear for all transfers, and have physical therapy evaluate the resident's current transfer type. On 11/03/16 at 9:40 a.m., the resident was observed in her room sitting in her wheelchair. The resident was asked if her television was in working order. The resident stated it was working. The resident turned on the television with no difficulty. The resident was asked if the television had been broken recently and she stated it had not. The resident's bed was observed to be in working order. The resident was asked if she was receiving her baths. The resident shook her head up and down, yes. A quarterly assessment, dated 11/12/16, documented the resident was moderately impaired for daily decision making. The assessment documented the resident required extensive assistance with ADLs. The assessment documented the resident had one fall with an injury. The assessment documented the resident had an infection of the foot and moisture associated skin damage. On 11/15/16 at 11:10 a.m., the resident was observed in her room sitting in her wheelchair. The resident's call light was within reach. The resident appeared to be neat and clean and had no odors. The resident stated she was at senior citizens, it was Tuesday, and she did not know the month. The resident stated her teeth had not been cleaned in months. The resident's toothbrush was in a small basin sitting by her sink in her room. The resident's teeth appeared to be clean and there was no odor. The resident stated she was getting her showers. The resident was asked how she got into bed and onto the toilet. The resident stated two people would help her and they used a lift. The resident's nebulizer was on the night stand and appeared to be clean. The resident stated she needed to use the bathroom. The resident was asked if she could use her call light. The resident pushed the button on the call light. The call light was answered within five minutes. On 11/15/16 at 11:20 a.m., CNA #1 entered the resident's room and the resident told her she needed to use the bathroom. CNA #1 went into the hallway to get the lift. CNA #2 entered the resident's room. The resident was lifted and transferred to the toilet using proper technique with the sit to stand lift. CNA #1 left the room. CNA #2 told the resident she would leave the bathroom if the resident wanted privacy. The resident asked her to stay. The resident was assisted by both CNAs and the sit to stand lift back into her wheelchair. The resident was wheeled to the sink so she could wash her hands. CNA #1 was asked what the star beside the resident's name meant. The CNA stated the star meant the resident was a fall risk. The CNA was asked what the number three stood for and the CNA stated it meant the resident needed the assistance of two staff for transfers using the sit to stand lift. The CNA was asked what the honey bee stood for and the CNA stated it meant the resident could only have honey thickened liquids. On 11/15/16 at 2:15 p.m., CNA #3 was asked for the nurse aide care plan for the resident. The CNA could not find the care plan. The care plan was located at the nurses' station where the resident had previously resided. On 11/15/16 at 2:40 p.m., CNA #4 stated the resident was a fall risk. The CNA stated the resident was a two person assist with the sit to stand lift. The CNA stated the resident should never be left alone in the bathroom. The CNA stated the nurse on duty would notify them if a resident had a change in their care related to falls, or they could look in the care plan. The CNA stated they received five days of training upon hire to the facility. The CNA stated nursing staff did not follow behind them when training. On 11/16/16 at 10:25 p.m., the director of nurses (DON) was asked how the certified nurse aides (CNAs) were trained upon hire to the facility. The DON stated they did have a trainer for the CNAs but at that time they were using the buddy system. The DON stated the new hire would train with another CNA for five days and then be released to work the floor independently. The DON was asked if there was a skills check list for the CNAs to use in training. The DON stated they had used a skills check off list in the past. The DON stated she wasn't sure if they still used a skills check off list. On 11/16/16 at 2:21 p.m., the CNA stated she provided training for CNA #5. The CNA stated a tour of the hall, a verbal account of the residents in that area for needs, and a demonstration of documentation on the computer were given. The CNA stated if the CNA staff had any questions or concerns they could ask the nurse, refer to the care plan at the desk, or refer to the Kardex on the computer. The CNA never mentioned training on the falling star or the number system for resident assistance. On 11/16/15 at 2:55 p.m., CNA #5 was asked how she was trained upon hire to the facility. The CNA stated she worked a double shift on one day, a single shift the next day, and was released to work the floor to provide resident care independently. The CNA stated she had no training on the number system for lifts. The CNA stated she was moved to another area after her training. The CNA stated she had transferred the resident to the bathroom by herself, did not use the sit to stand lift, and the resident fell getting into the wheelchair. On 11/16/16 at 6:30 p.m., the DON stated she printed new reports for treatment changes every day for the care plan, PT, and wound care. The DON was asked if the resident's lo-air mattress should have been secured to the bed with straps. The DON stated lo-air mattresses needed to be secured to the bed frames. The DON was asked how often the falling star outside of the resident's room was updated. The DON stated the falling star was updated weekly. The DON was asked when the resident had become a two person assist. The DON stated the resident had been moved to a different room in the past two months and became a two person assist with a sit to stand lift about that time. The DON was asked if the resident was cognitively capable of not moving if she was instructed to sit. The DON stated she could see the resident moving and would not leave her alone with her cognition. The DON was asked if the resident was cognitively capable of being left alone in the bathroom when toileting. The DON stated it would not be safe to leave the resident alone in the bathroom.

Based on observation, interview, and record review, it was determined the facility failed to provide an environment free from accident hazards for one (#1) of three residents reviewed for accidents. The facility failed to: (a) ensure staff used assistive devices to prevent the resident from falling and sustaining an injury, and (b) ensure the resident's lo-air mattress was secured to prevent exposure to the metal frame. An emergency room note, dated 10/09/16, documented resident #1 had a fall with a head injury. The note documented the resident received seven sutures. The note documented the resident's [DIAGNOSES REDACTED]. The facility identified 87 falls had occurred in the last three months. Findings: a) The facility policy for falls documented the falling star program was to assist the staff in maintaining the safety of the resident's which were a high risk for falls. The policy documented a star would be placed outside of a resident's door to alert staff of a resident at risk for falls. The facility policy for lifting and movement of residents documented the staff were responsible for direct resident care and would be trained in the use of mechanical lifting devices. The policy documented the staff would be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding the use of equipment and safe lifting techniques. The policy documented the nursing staff, in conjunction with the rehabilitation staff, would assess individual residents needs for transfer assistance and would document it in the resident's care plan. The policy documented the portable lift could be used by one nursing assistant if the resident could participate in the lifting procedures. The policy documented two nursing assistants would be required to perform the procedure if the resident could not participate in the lifting procedure. The policy documented the resident's transfer type would be posted outside of the residents door as follows: 0=Independent, 1=one person assist with a gait belt, 2=two person assist with a gait belt, 3=sit to stand with 2 assist, and 4=hoyer/maxi lift with 2 assist. The policy documented the transfer type would be documented in the care plan. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The printed nurse aide care plan documented to ensure the resident was wearing appropriate footwear for all transfers. The care plan documented to keep the call light in reach for needed assistance. The care plan documented the staff would follow the facility fall protocol. The care plan documented the resident required extensive staff assistance to use the toilet. The care plan documented the resident required extensive staff assistance with transfers. A monthly resident incident log, dated June 2016, documented the resident sat up in bed unassisted and fell forward hitting her head on the floor. The incident log documented the resident sustained [REDACTED]. An incident report, dated 06/25/16, documented the resident had a fall with a head injury. The resident was transported to the hospital and received 20 staples. A doctor's order, dated 06/25/16, documented the resident needed two person assistance with transfers. An annual assessment, dated 07/12/16, documented the resident was moderately impaired for daily decision making. The assessment documented the resident required extensive assistance with activities of daily living (ADLs). The assessment documented the resident had one fall with an injury. The assessment documented the resident was at risk for pressure ulcers. A monthly resident incident log, dated October 2016, documented the resident had a fall with a laceration when being assisted to the toilet. The incident log documented the resident let go of the sit to stand bar and fell . An emergency room note, dated 10/09/16, documented the resident had a fall with a head injury. The note documented the resident had a contusion with a laceration, and right periorbital [DIAGNOSES REDACTED]. The note documented the laceration was on the resident's face located on the right eyebrow, and was 2.8 centimeters (cm) in length. The note documented the resident received seven sutures which was dressed with antibiotic ointment. The note documented the resident had a computerized tomography (CT) of her brain, and cervical spine, and no significant abnormalities were seen. The resident was released back to the nursing facility. The note documented the resident's [DIAGNOSES REDACTED]. The printed nurse aide care plan documented to ensure the resident was wearing appropriate footwear for all transfers. The care plan documented to keep the call light in reach for needed assistance. The care plan documented the staff would follow the facility fall protocol. The care plan documented the resident required extensive staff assistance to use the toilet. The care plan documented the resident required extensive staff assistance with transfers. A care plan, dated 10/23/16, documented the resident had impaired cognition related to Alzheimer's disease. The care plan documented the resident was at risk for falls related to gait and balance problems. The care plan did not document the assistance the resident required for transfers. On 11/03/16 at 9:40 a.m., the resident was observed in her room sitting in her wheelchair. The resident was asked if her television was in working order. The resident stated it was working. The resident turned on the television with no difficulty. The resident was asked if the television had been broken recently and she stated it had not. The resident's bed was observed to be in working order. The resident was asked if she was receiving her baths. The resident shook her head up and down, yes. A quarterly assessment, dated 11/12/16, documented the resident was moderately impaired for daily decision making. The assessment documented the resident required extensive assistance with ADLs. The assessment documented the resident had one fall with an injury. The assessment documented the resident had an infection of the foot and moisture associated skin damage. On 11/15/16 at 11:10 a.m., the resident was observed in her room sitting in her wheelchair. The resident's call light was within reach. The resident appeared to be neat and clean and had no odors. The resident stated she was at senior citizens, it was Tuesday, and she did not know the month. The resident stated her teeth had not been cleaned in months. The resident's toothbrush was in a small basin sitting by her sink in her room. The resident's teeth appeared to be clean and there was no odor. The resident stated she was getting her showers. The resident was asked how she got into bed and on the toilet. The resident stated two people would help her and they used a lift. The resident's nebulizer was on the night stand and appeared to be clean. The resident stated she needed to use the bathroom. The resident was asked if she could use her call light. The resident pushed the button on the call light. The call light was answered within five minutes. On 11/15/16 at 2:15 p.m., CNA #3 was asked for the nurse aide care plan for the resident. The CNA could not find the care plan. The care plan was located at the nurses' station where the resident had previously resided. On 11/15/16 at 2:40 p.m., CNA #4 stated the resident was a fall risk. The CNA stated the resident was a two person assist with the sit to stand lift. The CNA stated the resident should never be left alone in the bathroom. The CNA stated the nurse on duty would notify them if a resident had a change in their care related to falls, or they could look in the care plan. The CNA stated they received five days of training upon hire to the facility. The CNA stated nursing staff did not follow behind them when training. On 11/16/16 at 1:25 p.m., the care plan coordinator was asked to review the resident's care plan. The care plan coordinator stated the care plan was not updated with current interventions to prevent falls for the resident. On 11/16/16 at 2:21 p.m., the CNA stated she provided training for CNA #5. The CNA stated a tour of the hall, a verbal account of the residents in that area for needs, and a demonstration of documentation on the computer were given. The CNA stated if the CNA staff had any questions or concerns they could ask the nurse, refer to the care plan at the desk, or refer to the Kardex on the computer. The CNA never mentioned training on the falling star or the number system for resident assistance. On 11/16/15 at 2:55 p.m., CNA #5 was asked how she was trained upon hire to the facility. The CNA stated she worked a double shift on one day, a single shift the next day, and was released to work the floor to provide resident care independently. The CNA stated she had no training on the number system for lifts. The CNA stated she was moved to another area after her training. The CNA stated she had transferred the resident to the bathroom by herself, did not use the sit to stand lift, and the resident fell getting into the wheelchair. b) On 11/15/16 at 4:45 p.m., the resident's mattress was observed. The eight straps which secured the mattress to the frame were not secured to the bed frame. There was a hands width between the mattress and the edge of the bed frame. The mattress moved easily on the frame. On 11/15/16 at 5:02 p.m., the maintenance man was asked how the mattress was secured to the bed frame. The maintenance man stated it would be easier to show the surveyor. The maintenance man stated the mattress should be even with the edge of the bed frame. Upon observation of the bed and mattress the maintenance man stated the mattress was not attached to the bed and the straps should have been attached to the bed frame. On 11/16/16 at 6:30 p.m., the DON stated she printed new reports for treatment changes every day for the care plan, PT, and wound care. The DON was asked if the resident's lo-air mattress should have been secured to the bed with straps. The DON stated lo-air mattresses needed to be secured to the bed frames. The DON was asked how often the falling star outside of the resident's room was updated. The DON stated the falling star was updated weekly. The DON was asked when the resident had become a two person assist. The DON stated the resident had been moved to a different room in the past two months and became a two person assist with a sit to stand lift about that time. The DON was asked if the resident was cognitively capable of not moving if she was instructed to sit. The DON stated she could see the resident moving and would not leave her alone with her cognition. The DON was asked if the resident was cognitively capable of being left alone in the bathroom when toileting. The DON stated it would not be safe to leave the resident alone in the bathroom.

Based on observation, record reviews and interviews, it was determined the facility failed to prevent potentially hazardous chemicals from being accessible for three (#36, 61 and #172) sampled residents identified by the facility who were cognitively impaired and wandered. Findings: 1. A significant change assessment, dated 01/21/14, for resident #36 documented she was cognitively impaired and ambulated with the use of a walker. 2. A quarterly assessment, dated 02/27/14, for resident #61 documented he was severely impaired in cognitive skills for daily decision making and used a wheelchair for mobility. 3. A quarterly assessment, dated 02/27/14, for resident #172 documented she was severely impaired in cognitive skills for daily decision making and used a wheelchair for mobility. The assessments did not address the residents as wandering, but through observations and interviews, it was determined the three residents (#36, #61 and #172) did wander throughout the facility. On 04/21/2014 at 8:15 a.m., a mechanical room door across from the therapy room was observed to be unlocked and found to have chemicals within reach that were potentially hazardous. These included 'Windex', with a label which documented harmful if swallowed, 'Mild Bowl and Porcelain Cleaner', with a label which documented, "...Caustic to skin and internal tissue..." and 'Easy Off Oven Cleaner'. The material safety data sheet for the oven cleaner documented the cleaner was corrosive, caused burns to skin and eyes on contact and was harmful is swallowed. At 8:21 a.m., a mechanical room across from room 22 was unlocked. There were several bottles of window cleaner and toilet bowl cleaner on shelves in the room. The maintenance man opened the door and then left the room without locking the door. At 8:35 a.m., the director of nursing (DON) was asked if there were any wandering residents. The DON verified three residents who had dementia and wandered. She stated they were known to open doors and enter rooms. On 04/21/14 at 09:20 a.m., housekeeper #3 was asked how he ensured that dangerous chemicals were kept away from wandering or demented residents. He stated, "I don't keep anything dangerous on top of my cart, usually just hand sanitizer. The door on my cart that has other chemicals underneath is broken, but I try to keep that side of the cart close to the wall." When asked if he had told anyone about the broken door he replied, "No, my supervisor told me about it when I started working here back in January of this year. She told me they had been trying to get a new door for the cart where the chemicals are kept, but they hadn't got one yet." The broken door on the housekeeper's cart was observed to hang open slightly. The cart contained 'Mild Bowl and Porcelin Cleaner', with a label which documented, "...corrosive...could burn skin and eyes, and internal tissues if swallowed." At 9:30 a.m. housekeeper #2 was asked where she kept her housekeeping cart. She was asked how she made sure that wandering or demented residents were kept safe from accessing dangerous chemicals. She replied, "We keep this room locked up." When asked how this was accomplished, she pointed to the lock on the door and stated, "When we aren't in here we lock that door. Sometimes we forget, but it is supposed to be locked."

On 12/18/12, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to identify, assess, monitor and provide treatment when one resident (#4) experienced changes in condition with the development of a stage IV pressure ulcer. At 4:30 p.m., the Oklahoma State Department of Health was notified. The immediate jeopardy situation was verified at 5:00 p.m. At 5:15 p.m., the administrator and the ADON were notified of the IJ situation. At 7:10 p.m., an acceptable plan of removal was presented to the survey team. The facility's plan of removal was as follows: "1. All residents will have full, thorough physical assessment/evaluation to determine if any pressure areas exist. These assessments/evaluations will be initiated on 12/18/12 and will be completed on 12/19/12. 2. Should any resident be found with a pressure area, the Medical Director and their staff will be notified immediately for appropriate treatment orders. 3. RNs and LPNs will be inserviced on wound policy and how to do a proper and thorough full body physical assessment/evaluation by 12/19/12. CMAs and CNAs will be inserviced on recognizing skin irregularities and the need to immediately report the irregularity to the charge nurse. Any staff not inserviced by 12/19/12 will receive inservicing on or before their next scheduled work day. 4. Residents identified to be at risk for skin breakdown will be assessed/evaluated at least weekly, and will have interventions put in place to prevent skin breakdown. 5. The facility wound care policy will be evaluated for effectiveness, and modified as needed or recommended by the Medical Director and their staff by 12/19/12. 6. The wound Care Team will review all wounds weekly. 7. All new admissions will have a full, thorough physical assessment/evaluation upon admission. 8. The Administrator and the Director of Nursing, or their designee, will be responsible for compliance. 9. The facility will be in substantial compliance on 12/19/12." On 12/19/12 at 8:05 a.m., 11:15 a.m., 1:30 p.m., 4:00 p.m. and 5:30 p.m., staff were interviewed and were knowledgeable in assessing, monitoring and reporting any skin changes. LPNs and RNs were knowledgeable concerning complete skin assessments, notification of the physician and family of skin changes, thorough documentation of pressure ulcers/skin changes and provision of care. CNAs and CMAs were knowledgeable concerning observation of changes in skin and notification of the charge nurse of any changes. The Immediate Jeopardy was removed as of 12/19/12 at 6:00 p.m. after all staff working through 12/20/12 had been inserviced. The deficient practice remained at actual harm at a pattern. Based on record review, observation and staff interviews, it was determined the facility failed to identify and provide treatment for one (#4) of six sampled residents with pressure ulcers. Because of the facility's failure to thoroughly assess, identify and provide treatment, the resident developed a stage IV pressure ulcer, resulting in actual harm. The facility also failed to thoroughly and consistently provide weekly skin assessments for four (#3, 4, 5 and #6) of six sampled residents who were at risk for the development of pressure ulcers. The facility identified 76 of 76 residents at risk for altered skin integrity and/or the development of pressure ulcers. Findings: 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 'Braden Scale For Predicting Pressure Sore Risk' completed on 10/17/12 documented the resident was at mild risk for the development of pressure sores. The initial assessment dated [DATE] documented the resident was able to make self be understood and understood others. The assessment documented the resident's BIMS score was 15, indicating the resident was independent with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance with bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. The assessment documented the resident was continent of bowel and bladder. The assessment documented the resident was at risk of developing pressure ulcers, and had no unhealed pressure ulcers at stage 1, 2, 3 or 4. The assessment documented there were no other ulcers, wounds or skin problems and a pressure reducing device for the bed was in use. The care plan dated 10/29/12 documented the resident was at risk for skin breakdown related to (r/t) immobility associated with sacrum fracture (fx), right hip pain, chronic back pain and [MEDICAL CONDITION] joint disease (DJD) bilateral hips. The goal documented the resident would not have skin breakdown throughout the next review date. Approaches documented on the care plan included: ~Observe skin q week for s/s (signs/symptoms) of skin breakdown. Notify MD of new conditions or worsening conditions. ~Pressure reducing mattress on bed ~Encourage resident to turn and reposition q 2 hours and prn. Assist as needed. ~Keep skin clean and dry. ~Treatments per MD order. ~Perform Braden scale per protocol. ~Dietary consult as needed. ~See ADL function section of care plan. Approaches for the ADL section of the care plan included: ~PT/OT/ST per MD orders. ~Encourage resident to participate in ADLs as much as she is able. ~Resident is extensive assist with bed mobility, transfers, dressing, personal hygiene, bathing and toileting. ~Adjust level of assistance based on therapy recommendations. 'Weekly Head to Toe Skin Assessments' completed by licensed staff on 10/24/12, 10/31/12, 11/07/12, 11/14/12, 11/21/12 and 11/28/12 documented the resident's skin was clean, dry and intact. The 'Admission Nursing Evaluation' dated 10/17/12 and 'Daily Skilled Nurse's Notes' dated 10/17/12 through 12/03/12 documented the resident had no pressure ulcers or abnormal skin conditions. The 'Daily Skilled Nurse's Notes' dated 12/03/12 documented, "...out this AM (morning) for pre-op (pre-operative) appt (appointment)...Resident left facility @ (at) 12:30 (p.m.) via our van. (Family member to meet resident at hospital..." The note documented the resident had no pressure ulcer. The resident did not return to the facility after the pre-op appointment, and was admitted to the hospital on [DATE] following the pre-operative appointment. The resident's records from the hospital were reviewed. The 'History & Physical' performed by the physician's assistant on 12/03/12 at 1:59 p.m. documented, "..."Physical examination...extremities...she does have a decubitus ulcer on her buttocks...Impression...decubitus ulcer...plan...the patient will be admitted to the hospital...will also get her set up with wound care for the area on her buttocks..." The 'Initial Physical Assessment Adult-text' performed by a RN and dated 12/03/12 at 3:20 p.m. documented, "Nursing Progress Note...Pt. (patient) had decubitus ulcers between her buttocks with deep tissue injury present. The wound assessment documented the stage IV pressure ulcer, located between the buttock fold, distal to coccyx measured 4 cm in length and 3 cm in width with necrotic tissue, eschar and slough. The deep tissue injury, located to the inner aspect of left buttock, measured 1 cm in length and 1 cm in width with a 1 cm shearing skin tear present on top of the deep tissue injury. The facility did not thoroughly assess the resident's skin to identify a pressure ulcer or deep tissue injury was present at any time during the resident's stay at the facility. The facility did not provide treatment for the pressure ulcer. On 12/18/12 at 12:30 p.m., LPN #4 was interviewed. The surveyor asked the LPN how the facility ensured residents did not develop pressure ulcers. She stated residents were assessed for their individualized needs by the charge nurse upon admission and interventions were implemented to help prevent skin breakdown. She stated some interventions included assisting the resident with turning and repositioning every two hours or more often if needed, keeping skin clean and dry with the provision of incontinent care as needed, and providing gel mattresses/chair cushions. She stated complete head to to skin assessments were completed by the charge nurses on each resident weekly. She stated when any redness or irritation developed the nurse notified the physician and then provided the treatment as ordered by the physician. She stated if the skin did not improve with the treatment, the physician was notified for another treatment. She stated the appearance, size and location of any pressure areas were documented weekly by the charge nurse. On 12/18/12 at 1:45 p.m., LPN #5 was interviewed. The surveyor asked the LPN how she ensured skin assessments were accurate and thorough. The LPN stated she looked at the skin on the front and back side of each resident. She stated she looked on the surface of the skin but only examined in crevices/folds if the resident was of a large size. The surveyor asked the LPN if pressure ulcers could develop in crevices/folds of residents who were not of a large size. The LPN answered, "I guess they could." On 12/18/12 at 3:20 p.m., the physician assistant #1 was interviewed. She stated she had observed the pressure area to the buttock fold area distal to the coccyx during the resident's pre-operative appointment on 12/03/12. She stated the area contained necrotic tissue. She stated a pressure area of that size and condition would develop over the course of at least 2 weeks. On 12/18/12 at 3:40 p.m., CNA #5 was interviewed. The surveyor asked the CNA how he ensured residents did not develop skin problems related to pressure. The CNA stated residents were turned/repositioned every two hours or more often if needed. He stated if the resident was able to move about in bed independently they watched and encouraged the resident to turn every two hours. He stated skin was observed during incontinent care and bathing activities. He stated if any redness or breaks in skin were observed the charge nurse was notified. The surveyor asked the CNA if he had cared for resident #4. He stated he had cared for her and the resident had been able to turn and reposition herself in bed independently for several weeks. He stated he had not seen any areas of skin breakdown when assisting the resident with dressing, undressing or bathing. On 12/19/12 at 9:45 a.m., CNA #4 was interviewed. The CNA stated she had cared for the resident for several weeks. The CNA stated she assisted the resident with transfers. She stated the resident performed personal hygiene independently after toileting so she had not really seen the resident's buttocks. She stated she had not observed any skin issues when assisting the resident to dress or undress. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] documented the resident was severely impaired in cognitive skills for daily decision making. The resident required extensive assistance of two persons for moving and turning in bed, and for all activities of daily living. The assessment documented the resident was frequently incontinent of bowel and bladder. She was at risk for skin breakdown due to debility, incontinence, and a history of skin related issues. The record documented the resident was hosptalized on [DATE] for a possible stroke and returned to the facility on [DATE] with a stage two pressure ulcer to the left buttocks. On 10/11/12 a Braden scale for predicting pressure sore risk documented the resident was a moderate risk for development of a pressure sore. The October 2012 physician's orders [REDACTED]. The 'Weekly Head to Toe Skin Assessments' documented: 10/15/12, "...Skin W/D/I (warm/dry/intact)...decub (decubitus) to buttocks reopened...tx (treatment) in place..." 10/22/12, "...pin size opening to left buttocks noted. Tx. (treatment) in place..." 10/29/12, "...tx in place for area to buttocks...Small open area noted...No drainage..." 11/05/12 and 11/12/12, "...No new open areas..." 11/26/12, "...Tx done Rt (right) heel and coccyx area..." There was no weekly head to toe skin assessment documented for 11/19/12. There was no documentation describing: ~ stage of the wound, ~ size, depth, and any undermining or tunneling, ~ exudate, ~ pain, and ~ wound bed, wound edges and surrounding tissue. A physician's orders [REDACTED]." A "Weekly Pressure Ulcer Record" dated 11/27/12 had a diagram of a body with a circle on the coccyx area and a circle on the right heel. There was no documentation of the onset of a right heel wound. The record documented measurements of both wounds, with descriptions of the wound bed and surrounding skin color as well as treatments. The resident was again hosptalized on [DATE] through 12/14/12 for the insertion of a gastrostomy tube. A facility policy titled, "Skin Breakdown Prevention Policy and Procedure" documented, "...skin evaluations will be performed on a weekly basis..." On 12/17/12 at 12:30 p.m., LPN #3 was asked how wounds were assessed when a resident was admitted . She stated the charge nurse assessed the wound. She stated the wound was measured and then documented in the resident's record. She stated all residents with wounds were evaluated by the charge nurse on a weekly basis. On 12 17/12 at 4:20 p.m., the ADON was shown documentation of the 'Weekly Head to Toe Skin Assessments and 'Weekly Pressure Ulcer' records. She was asked if the documentation on these forms was complete as per facility policy. She stated it was not complete. On 12/18/12 at 10:15 a.m., the surveyor observed the resident's pressure ulcers with LPN #3. The wound on the resident's buttock appeared to have areas of yellow slough in the wound bed with areas of red tissue at the wound edges. The new wound on the right heel was unstageable and measured 1 cm. in length x 2 cm. width with necrotic tissue noted in areas of the wound bed. 3. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A comprehensive annual assessment dated [DATE] documented the resident required extensive assistance of one person with transfers and activities of daily living. The assessment documented the resident was frequently incontinent of bowel and bladder and had one stage two pressure ulcer. A nurse's note dated 10/28/12 at 10:45 a.m. documented, "...open area to left buttock...res has stage II, 1 x 2 cm decub (decubitus ulcer) to L (left) buttocks...N/O (new order)..." A physician's orders [REDACTED]. The monthly physician's orders [REDACTED]. The 'Weekly Head to Toe Skin Assessments' documented: 10/28/12, "...1 x 2 stage II decub to L buttocks..." 11/12/12 and 11/19/12, "...wound to coccyx with tx. (treatment)..." 11/26/12, "...wound noted to left buttock tx in place..." 12/3/12, 12/10/12, and 12/17/12, "...wound to buttock, tx in place..." There was no documentation describing: ~ stage of the wound, ~ size, depth, and any undermining or tunneling, ~ exudate, ~ pain, and ~ wound bed, wound edges and surrounding tissue. A "Weekly Pressure Ulcer Record" dated 12/13/12 had a diagram of a body with a circle on the coccyx area. There was no documentation of the onset or site/location of the wound. The record documented a wound measurement of 0.5 x 0.5 cm. size. There was no documentation of wound stage or description of the wound. On 12/17/12 at 4:00 p.m., the ADON was shown documentation of the weekly head to toe skin assessments and weekly pressure ulcer records. She was asked if the documentation on these forms was complete as per facility policy. She stated it was not complete. On 12/18/12 at 10:15 a.m., the surveyor observed the resident's wounds with LPN #2. She was asked how she would assess the resident's wound on the wound treatment sheet. She described a measurement of 1 cm. x 0.5 cm. She was asked if any other documentation should be written. She stated she would document the treatment that would be given to the resident. 4. Resident #6 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. The 'Weekly Head to Toe Skin Assessment' documented the resident's skin was clean, dry and intact on 11/13/12 and 11/20/12. A physician's telephone order dated 11/13/12 documented, "...Apply [MEDICATION NAME] to wound q 72 hrs or prn. Clean c wound cleanser at time of new dsg (dressing)...Diagnosis: [REDACTED]. There was no documentation in the resident's record of the size and appearance of the wound on 11/13/12. The 'Weekly Pressure Ulcer Record' first documented the presence of a stage 2 pressure ulcer to the coccyx on 11/21/12 measuring 0.25 cm length x 0.25 cm width x 0.1 cm depth. The wound was observed on 12/19/12 at 10:30 a.m. with LPN #3. The pressure ulcer was pinpoint in size, with no drainage. The surrounding skin was pink. The LPN stated the wound had really improved and was now almost healed. The surveyor asked the LPN how wounds were to be assessed. She stated wounds were assessed when first observed and then weekly. She stated documentation on 'Weekly Pressure Ulcer Record" should include the area involved, the measurements, appearance, treatment order and any other interventions in place for the prevention of further breakdown. The surveyor asked the LPN about the documentation of the resident's wound on 11/13/12. The LPN stated there was none.

Based on observation, record review and interview, it was determined the facility failed to accurately assess and provide interventions for one (#4) of four sampled residents whose record was reviewed for accurate medication administration. This failure resulted in the resident experiencing actual harm as evidenced by the resident's statement of being in extreme pain. This had the potential to affect 60 of 78 residents who received medication for pain. Findings: Resident #4 was admitted to the facility on [DATE] at 2:00 p.m., with [DIAGNOSES REDACTED]. The physician's 'Admission/Start-Up' orders dated 08/13/12, documented the resident was to receive [MEDICATION NAME] 7.5/325 mg (milligrams) 1 to 2 tablets every four hours as needed for pain and [MEDICATION NAME] 500 mg every four hours as needed for muscle spasms. There had been no initial MDS (Minimum Data Set) assessment completed due to the resident's admission on 08/13/12. There was no initial care plan in the resident's record. The 'Admission Nursing Evaluation', dated 08/13/12, documented the resident was alert, oriented to person, place and time, and cooperative. There was no documentation the resident was assessed for pain. A nurse's note dated 08/13/12, for the 2 p.m. to 10 p.m. shift, documented, "...states he has discomfort to lower back r/t (related to) surgery..." There was no documentation of a thorough assessment for pain. A 'Daily Skilled Nurse's Note' dated 08/14/12, for the 10 p.m. to 6 a.m. shift, documented the resident had no pain. An entry at 1:00 a.m. documented, "PRN (as needed) meds given for pain..." There was no documentation of a thorough assessment for pain. On 08/14/12 at 2:15 p.m., the surveyor asked the resident about his pain level and medications. The resident stated his pain had been severe after he was admitted to the facility and during the night. He stated he had received pain medication at noon on 08/13/12, while at the hospital before being transferred to the facility, and did not receive any other medications, including medication for the relief of pain, until 8:00 a.m. on 08/14/12. The surveyor asked the resident to rate his level of pain on a scale of 0-10 during the time he had been in the facility. The resident stated the pain level ranged from 5 to 12. He stated his pain was so bad during the night he was ready to call his family and have them come get him. He stated when the pain medication was administered at 8:00 a.m. and 12:00 p.m. on 08/14/12, effective relief was obtained and he had been able to participate in therapy as scheduled. The August 2012 MAR (Medication Administration Record) and the resident's individual narcotic record documented the resident's first dose of [MEDICATION NAME] 7.5/325 mg was administered on 08/14/12 at 8:00 a.m., and a second dose was administered at 12:00 p.m. On 08/14/12 at 2:30 p.m., the surveyor interviewed LPN #1 about the resident's pain and pain medications. The LPN stated the resident rated his pain at 4-5 upon arrival at the facility and then again requested pain medication on 08/13/12 at 7:45 p.m. The surveyor asked the LPN if she assessed the resident's pain at that time. She stated she had not. The surveyor asked the LPN when pain was to be assessed. She stated pain should be assessed any time a resident complains of pain. She stated the resident's pain should have been assessed at that time. The LPN stated she told the resident the pain medication was not yet available when he requested medication at 7:45 p.m. The LPN stated the medications were not received in the facility until 8:00 a.m. on 08/14/12. The surveyor asked the LPN about how medications were ordered and when they should be received from the pharmacy. She stated medications were usually delivered by the pharmacy at approximately 7:00 p.m. She stated there had been a problem with how the orders had been faxed to the pharmacy and the pharmacy had requested further clarification. The surveyor asked the LPN if the resident had to wait too long for pain medication and the LPN stated, "Yes." On 08/14/12 at 2:45 p.m., the surveyor asked the DON (Director of Nursing) when she would expect a resident's pain to be assessed. She stated the presence of pain should be assessed upon admission on the 'Admission Nursing Evaluation', and a thorough assessment completed if the resident was experiencing pain. She stated an assessment for pain should also be completed every shift on the 'Daily Skilled Nurse's Note'. The surveyor asked the DON about medication delivery from the pharmacy. She stated medications were to be received within four hours from the time they were ordered. She stated any time a resident needed medication sooner than the four hour time frame, they were to contact her or other administrative staff to obtain the medication from the pharmacy. On 08/14/12 at 3:00 p.m., the surveyor interviewed LPN #3 about the assessment of the resident's pain and the documentation of the administration of pain medication. The LPN initially stated he had administered pain medication as he had documented. The surveyor then told the LPN the facility did not receive the resident's medications until 8:00 a.m. on 08/14/12. The LPN then stated he was not sure of his documentation or the assessment of the resident. A facility policy 'Pain Assessment' documented, "The purpose of this procedure is to assess the resident's pain level and provide optimal comfort through a pain control plan...A comprehensive assessment will be completed as part of the initial nursing assessment...medicate the resident as the physician ordered..."