Every finding on record at Heartway at York Manor Health and Rehab

Based on record review and interview, the facility failed to maintain evidence of grievances with resolutions for 1 (#8) of 1 sampled resident sampled reviewed for grievances.The administrator identified 41 residents resided in the facility.Findings:An undated, facility grievances policy, read in part, To provide structure and a forum for residents to voice complaints, grievances and seek their resolution .Procedure: 1. The resident has the right, and the facility will promptly work to resolve the grievance with the resident. 2. Grievances may be communicated orally or in writing. The resident also has the right to file grievances anonymously. 3. The resident will receive the resolution decision in writing. A quarterly assessment, dated 08/14/25, showed a BIMS of 14 which indicated Resident #8 was cognitively intact for daily decision making. The assessment showed Resident #8 had diagnoses which included Parkinson's disease and schizophrenia. On 09/09/25 at 10:11 a.m., Resident #8 stated their flip phone was missing about a month ago. Resident #8 stated they let the administrator know and they looked for it but had not received any follow up on it yet. On 09/12/25 at 2:38 p.m., the administrator stated they did not have a grievance log to track resident grievances. The administrator stated if they did, it would be a mile long.

Based on observation, interview, and record review, the facility failed to include the actual and working hours of licensed and unlicensed staff on the daily posted staffing and failed to ensure disciplines were included on the nurse staffing data for 7 (09/08/25 through 09/14/25) of 7 days reviewed for posted nurse staffing.The DON identified 41 residents resided in the facility.Findings: On 09/15/25 at 3:18 p.m., a dry erase board was observed to show staff names, the shift, the date and the census. The dry erase board did not show the number of hours worked. The undated policy titled Nurse Staffing Information, read in part, The facility must post the following information on a daily basis.The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident are per shift: a. Registered nurses b. Licensed practical nurses or licensed vocational nurses (as defined under State Law) c. Certified nurse aides. A Daily Nursing Sign-In Sheet, dated 09/08/25, showed 19 staff worked the day shift. The sheet did not show the discipline for 17 of 19 employees. The Daily Nursing Sign-In Sheet showed eight staff worked the evening shift. The sheet did not show the discipline for five of the eight employees. The Daily Nursing Sign-In Sheet showed three staff worked the night shift. The sheet did not show the discipline for two of the three employees. A Daily Nursing Sign-In Sheet, dated 09/09/25, showed 15 staff worked the day shift. The sheet did not show the discipline for 12 of 15 employees. The Daily Nursing Sign-In Sheet showed nine staff worked the evening shift. The sheet did not show the discipline for six of the nine employees. The Daily Nursing Sign-In Sheet showed three staff worked the night shift. The sheet did not show the discipline for two of the three employees. A Daily Nursing Sign-In Sheet, dated 09/10/25, showed 15 staff worked the day shift. The sheet did not show the discipline for 12 of 15 employees. The Daily Nursing Sign-In Sheet showed eight staff worked the evening shift. The sheet did not show the discipline for six of the eight employees. The Daily Nursing Sign-In Sheet showed three staff worked the night shift. The sheet did not show the discipline for three of the three employees. A Daily Nursing Sign-In Sheet, dated 09/11/25, showed 15 staff worked the day shift. The sheet did not show the discipline for 12 of 15 employees. The Daily Nursing Sign-In Sheet showed nine staff worked the evening shift. The sheet did not show the discipline for eight of the nine employees. The Daily Nursing Sign-In Sheet showed three staff worked the night shift. The sheet did not show the discipline for three of the three employees. A Daily Nursing Sign-In Sheet, dated 09/12/25, showed 14 staff worked the day shift. The sheet did not show the discipline for 11 of 14 employees. The Daily Nursing Sign-In Sheet showed seven staff worked the evening shift. The sheet did not show the discipline for five of the seven employees. The Daily Nursing Sign-In Sheet showed three staff worked the night shift. The sheet did not show the discipline for two of the three employees. A Daily Nursing Sign-In Sheet, dated 09/13/25, showed ten staff worked the day shift. The sheet did not show the discipline for 9 of ten employees. The Daily Nursing Sign-In Sheet showed eight staff worked the evening shift. The sheet did not show the discipline for six of the eight employees. The Daily Nursing Sign-In Sheet showed three staff worked the night shift. The sheet did not show the discipline for two of the three employees. A Daily Nursing Sign-In Sheet, dated 09/14/25, showed 7 staff worked the day shift. The sheet did not show the discipline for six of seven employees. The Daily Nursing Sign-In Sheet showed eight staff worked the evening shift. The sheet did not show the discipline for six of the eight employees. The Daily Nursing Sign-In Sheet showed three staff worked the night shift. The sheet did not show the discipline for two of the three employees. On 09/15/25 at 3:20 p.m., the administrator stated they posted the daily staffing information was posted on the dry erase board and they maintained the information on the Daily Nursing Sign-In Sheets.

Based on observation and interview, the facility failed to ensure kitchen equipment was properly dried before storing, the ice machine was free of debris and build-up and cross contamination was prevented during 2 of 2 meal services observed.The DON identified 41 residents ate meals from the kitchen.Findings:On 09/08/25 at 12:44 p.m., cook #1 was observed to stack wet trays by the steam table and place wet cooking utensils in the drawers. On 09/08/25 at 12:59 p.m., the maintenance supervisor removed the front cover of the ice machine, and a black substance was observed on the back of the cover. A black and red growth were observed in the corners and underneath where the pump was held. On 09/08/25 at 12:58 p.m., the maintenance supervisor stated the ice machine was professionally cleaned by a company last week. The maintenance supervisor looked and stated it was mold. The maintenance supervisor stated they were shutting down the ice machine to clean it and contacting the company that cleaned the ice machine last week. The maintenance supervisor stated there was no documentation of when the facility cleaned the ice machine. On 09/09/25 at 11:58 a.m., DA #1 was observed wearing gloves, placed a spoon and fork on a napkin on a tray, then touched their shirt and left hip in a rubbing motion. They continued to place silverware on trays and not to wash their hands or change their gloves. On 09/09/25 at 12:01 p.m., the DM was observed to wear gloves and touch the counter, meal cards, thermometer, plates, then pulled out the tortillas from the bag, and rolled them from side to side to separate them from each other. They were not observed to change gloves or wash their hands between touching surface items and food. On 09/15/25 at 2:03 p.m., the DM stated kitchen staff wore gloves to stop cross contamination. They stated they changed their gloves and washed their hands when they left the kitchen. The DM stated they prevented the growth of mold and mildew on trays and dishes by allowing them to air dry before putting them away. They stated they were not present on 09/08/25 and could not speak to what happened on that day.

Based on record review and interview, the facility failed to implement an antibiotic stewardship program.The DON identified 41 residents resided in the facility.Findings:An undated facility Antibiotic Stewardship policy, read in part, Develop and implement protocols to optimize the treatment of infections by ensuring that residents who require an antibiotic, are prescribed the appropriate antibiotic .Develop, promote and implement a facility-wide system to monitor the use of antibiotics .Facility leadership commitment to safe and appropriate antibiotic use; Appropriate facility staff accountable for promoting and overseeing antibiotic stewardship .Implement policy(ies) or practice to improve antibiotic use; Track measures of antibiotic use and resistance to relevant staff such as prescribing clinicians and nursing staff. On 09/10/25 at 12:25 p.m., the DON stated they had not been able to locate the trending of infections. They stated the nurses documented and monitored for side effects of antibiotics in progress notes and they monitored the nurse's notes. The DON stated they would expect to find a facility map with color coding for different infections to trend infections, but they had not found that. The DON stated they were to use McGreers criteria but had not been doing it.

Based on record review and interview, the facility failed to ensure an individual was designated as the infection preventionist.The DON identified 41 residents resided in the facility.Findings: An undated staff list did not show the facility had an individual designated as an infection preventionist. On 09/08/25 at 1:44 p.m., the administrator stated they did not currently have an infection preventionist. On 09/15/25 at 3:11 p.m., the DON stated they were trying to determine who would complete training to become the infection preventionist. They stated the former DON was the previous infection preventionist.

Based on record review and interview, the facility failed to provide care for 1 (#4) of 1 sampled resident reviewed for nephrostomy care.The administrator identified one resident who had a nephrostomy in the facility.Findings:An annual assessment, dated 08/09/25, showed Resident #4 had a BIMS of 13 which indicated they were cognitive for daily decision making. The assessment showed diagnoses which included spina bifida and cerebral palsy. A review of physician orders, dated 05/20/24 through current, showed no active orders for the care of a nephrostomy for Resident #4. A care plan, revised 08/27/25, showed a focus for suprapubic catheter and colostomy, the care plan did not address the nephrostomy. Review of the July, August and September 2025 treatment record, showed the nurse to clean the area to the suprapubic catheter. The treatment records did not address care for the nephrostomy for Resident #4. On 09/15/25 at 9:38 a.m., CNA #3 stated Resident #4 had a nephrostomy and they emptied it daily. On 09/15/25 at 1:41 p.m., the DON stated Resident #4 had a colostomy, nephrostomy and suprapubic catheter. They stated staff did not change the nephrostomy they monitored, cleaned the catheter and placed a dressing around it. The DON stated an order was not entered in the system; therefore, it would not have populated on the treatment administration record. A care plan was not updated to reflect the care of the nephrostomy. They stated the staff must have assumed they were to clean the nephrostomy when they cleaned the colostomy and suprapubic catheter.

Based on record review and interview, the facility failed to provide rationales for gradual dose reductions for 4 (#8, 45, 9 and #11) of 5 sampled residents reviewed for unnecessary medications.The DON identified 27 residents resided in the facility and received psychotropic medications.Findings:3. A quarterly assessment, dated 06/11/25, showed Resident #9 had a BIMS score of six, which indicated the resident was severely impaired in cognition for daily decision making. A Note to Attending Physician/Prescriber, dated 07/12/25, showed the pharmacist had recommended a gradual dose reduction for Clonazepam (an antianxiety medication) 2mg every 12 hours as needed and Lorazepam (an antianxiety medication) 2mg every 6 hours as needed. The Note to Attending Physician/Prescriber showed the physician disagreed with the recommendation but did not show the physician had documented a clinical rationale. On 09/11/25 at 3:00 p.m., the DON stated the physician should have documented a clinical rationale for declining the gradual dose reduction for Resident #9. 4. A quarterly assessment, dated 06/15/25, showed Resident #11 had a BIMS score of 13, which indicated the resident was cognitively intact for daily decision making. A Note to Attending Physician/Prescriber, dated 08/25/25, showed the pharmacist had recommended a gradual dose reduction for celexa (an antidepressant medication) 40mg daily and trazodone (an antidepressant medication) 50mg at bedtime. The Note to Attending Physician/Prescriber showed the physician disagreed with the recommendation but did not show the physician had documented a clinical rationale. On 09/11/25 at 2:58 p.m., the DON stated the physician should have documented a clinical rationale for declining the gradual dose reduction for Resident #11. 1. A quarterly assessment, dated 08/14/25, showed a BIMS of 14 which indicated Resident #8 was cognitively intact for daily decision making. The assessment showed diagnoses which included borderline personality disorder, dementia, anxiety, depression, schizoaffective disorder and Parkinson's disease. A care plan, revised 08/29/25, showed focus' which included anti-anxiety medication. A physician's order, dated 09/11/25, showed to administer buspirone HCl Oral Tablet 10 MG (an anxiolytic.) Review of medication regimen reviews and gradual dose reductions from 08/20/24 to 08/25/25, showed a gradual dose reduction, dated 06/13/25 for Buspirone 10 mg TID. The physician marked disagree with no rationale provided. On 09/10/25 at 12:51 p.m., the DON provided a physician's note dated 06/18/25. The note showed Resident #45 had depression and anxiety as a diagnosis on the same date as the GDR was signed. The DON also provided a written letter from the physician which showed the reason the Buspar was not reduced was due to Resident #45 exhibited s/s of depression and anxiety during the visit on 06/18/25. A rationale was not provided by the end of the survey. 2. A quarterly assessment, dated 06/23/25, showed Resident #45 had a BIMS of 15 which indicated they were cognitively intact for daily decision making. The assessment showed diagnoses of anxiety, depression and schizophrenia. A physician's order, dated 08/26/24, showed to administer buspirone 10 mg (an antianxiety medication) 1 tablet by mouth two times a day related to anxiety disorder. Review of gradual dose reductions (GDR) and medication regimen reviews (MRR) from 08/20/24 to 08/01/25, showed a GDR dated 06/01/25 for Buspirone 10 mg by mouth twice a day was denied by the physician with no rationale provided. A care plan, dated 07/03/25, showed concerns which included anxiety. On 09/10/25 at 12:51 p.m., the DON stated the pharmacist sends us the recommendations and then the doctor reviewed them. The DON stated they did not know who followed up but would check. By the end of the survey an answer was not provided.

Based on observation, record review, and interview, the facility failed to ensure ordered medication was available for 2 (#45 and #11) of 10 sampled residents were reviewed for medication availability. The DON identified 41 residents received medications. Findings: 1. On 09/10/25 at 8:19 a.m., during medication administration observation, CMA #2 was not observed to administer Daliresp (an anti-inflammatory medication) 250mcg to Resident #45. A quarterly assessment, dated 06/23/25, showed Resident #45 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making. A physician order, dated 07/02/25, showed an order for Daliresp oral tablet 250mcg by mouth once daily for chronic obstructive pulmonary disease. The medication administration record, dated July 2025, did not show Daliresp had been administered. The medication administration record showed Other/See nurses notes from 07/02/25 through 07/12/25 and 07/31/25. The medication administration record showed the medication was on hold from 07/13/25 through 07/26/25. The medication administration record showed Resident #45 was hospitalized from [DATE] through 07/30/25. The medication administration record, dated August 2025, did not show Daliresp had been administered. The medication administration record showed Other/See nurses notes from 08/01/25-08/31/25. The medication administration record, dated 09/01/25 through 09/10/25, did not show Daliresp had been administered. The medication administration record showed Other/See nurses notes from 09/01/25 through 09/10/25. On 09/10/25 at 8:19 a.m., during medication administration observation, CMA #2 stated they were waiting for the pharmacy to deliver the Daliresp 250mcg. CMA #2 stated they had called the pharmacy on 09/09/25 and was told the medication required a prior authorization. On 09/10/25 at 1:09 p.m., CMA #2 stated if a medication was not available to administer, they were to contact the pharmacy and notify the charge nurse or DON. CMA #2 stated they had notified the DON the medication was not available on 09/09/25. On 09/11/25 at 4:14 p.m., the DON stated the Dalirep had not been available because the physician had not signed the prior authorization. 2. A physician order, dated 03/08/22, showed Resident #11 was ordered Abilify Maintena (an antipsychotic medication) 400mg intramuscularly one time per day on the 8th of every month. The quarterly assessment, dated 06/15/25, showed Resident #11 had a BIMS score of 13, which indicated the resident was cognitively intact for daily decision making, and had a diagnosis of bipolar disorder. The treatment administration record, dated September 2025, showed Abilify Maintena 400mg was ordered to be administered on 09/08/25. The treatment administration record showed Other/See nurses notes on 09/08/25 for the Abilify Maintena 400mg intramuscularly. An eMar Medication Administration Note, dated 09/08/25, read in part, Med [medication] not administered due to it is not in the building. Med reordered. On 09/11/25 at 2:58 p.m., the DON reviewed the electronic clinical record for Resident #11 and stated they were to receive Abilify Maintena on the 8th of every month. On 09/11/25 at 4:12 p.m., the DON stated the nurse had notified the oncoming shift they had administered the Abilify Maintena on 09/08/25. The DON stated they would notify the pharmacy and the physician. They stated they had not been made aware the medication had been unavailable on 09/08/25. On 09/15/25 at 1:51 p.m., Resident #11 stated they were supposed to receive an injection monthly for auditory hallucinations. They stated they had not experienced auditory hallucinations and had not yet received the injection for September. On 09/15/25 at 2:23 p.m., the DON stated they had put an order into the electronic clinical record to administer the Abilify Maintena 400mg intramuscularly on 10/11/25 rather than 09/11/25. They stated they would clarify the order and administer the medication.

Based on record review and interview, the facility failed to ensure a recapitulation of the resident's stay had been completed and discharge medication information had been provided for 1 (#44) of 1 sampled resident who was reviewed for discharge.The DON identified one resident had been discharged in the past 3 months.Findings: An annual assessment, dated 02/12/25, showed Resident #44 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making and was independent with most activities of daily living. A care plan, revised on 02/13/25, showed Resident #44 would like to be discharged to their own apartment. A nurse note, dated 07/11/25, showed the resident discharged from the facility with their personal belongings and medications. A discharge return not anticipated assessment, dated 07/11/25, showed the resident had a planned discharge to their home/community. The assessment did not show the facility had provided the resident/resident representative the resident's current reconciled medication list. An Interdisciplinary Discharge summary, dated [DATE], showed Resident #44 was discharged to their private residence. The discharge summary did not show a recapitulation of the resident's stay, or documentation that medication instructions had been provided. A Check Out Medication List, dated 7/11/25 showed the medication name, dosage, and the number of pills provided to Resident #44. The list did not contain the frequency of the medications or instructions for use. A Resident Transfer/Discharge Form, dated 07/11/25, showed the resident was discharged home, was alert, oriented, and ambulated independently. The form did not show a recapitulation of the resident's stay or documentation that medication instructions had been provided. On 09/11/25 at 3:45 p.m., the administrator stated the MDS coordinator completed discharge summaries which included a recapitulation of the residents stay. On 09/11/25 at 4:25 p.m., the MDS coordinator stated they had completed the discharge summary for Resident #44. They stated they had not included a recapitulation of the resident's stay on the discharge summary, or documented medication instructions had been provided. On 09/12/25 at 10:22 a.m., the DON stated Resident #44 should have been discharged with medication instructions, but they had not found documentation the information had been provided to Resident #44.

Based on record review and interview, the facility failed to ensure assessments were accurate for 1 (#16) of 12 sampled residents whose assessments were reviewed.The DON identified 41 residents resided in the facility. Findings:A nurse note, dated 06/18/25, showed Resident #16 had delusions.A nurse note, dated 06/20/25, showed Resident #16 had delusions.A quarterly assessment, dated 06/23/25, showed Resident #16 had a BIMS score of 13 which indicated the resident was cognitively intact for daily decision making, had a diagnosis of schizophrenia, and did not experience delusions during the seven-day look-back period.On 09/11/25 at 2:12 p.m., the DON stated Resident #16 experienced delusions.On 09/11/25 at 3:38 p.m., the MDS coordinator stated they reviewed nurse progress notes when they completed assessments. They stated they were unsure if the assessment was correct related to delusions for Resident #16.

Based on record review and interview, the facility failed to ensure resident representatives were notified of a change in condition for 1 (#9) of 1 sampled resident reviewed for notification of change.The DON identified 41 residents resided in the facility.Findings: An undated policy Notification of Change, read in part, The facility must immediately inform the resident, consult with the resident's physician, and notify, consistent with his/her authority, the resident representative(s) when there is.A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or A decision to transfer or discharge the resident from the facility. The guardianship paperwork, dated 02/13/25, showed Resident #9 had a guardian. A nurse note, dated 08/05/25 at 9:34 a.m., showed Resident #9 was sent to the emergency room. The note did not show the resident's guardian had been notified. A nurse note, dated 08/12/25 at 9:19 a.m., showed Resident #9 was sent to the emergency room. The note did not show the resident's guardian had been notified. A nurse note, dated 08/12/25, showed the physician had discontinued clonidine (a medication used to treat high blood pressure), started prazosin (a medication used to treat high blood pressure) 2mg twice daily, prazosin 1mg every eight hours as needed, and Aldactone (a medication used to treat high blood pressure) 25mg daily. The note did not show the resident's guardian had been notified. A nurse note, dated 08/25/25 at 8:05 p.m., showed the physician had ordered propranolol (a medication used to treat high blood pressure and anxiety) for Resident #9. The note did not show the resident's guardian had been notified. A nurse note, dated 08/27/25 at 12:38 p.m., showed the physician had increased the propranolol to 60mg every eight hours as needed for anxiety and agitation. The note did not show the resident's guardian had been notified. A nurse note, dated 08/28/25 at 7:13 p.m., showed propranolol had been decreased to 40mg every eight hours as needed. The note did not show the resident's guardian had been notified. On 09/09/25 at 1:42 p.m., Resident #9's guardian stated they were not consistently notified of changes in the resident's treatment/medication and hospitalization. On 09/15/25 at 9:26 a.m., LPN #1 stated the residents' representatives were to be notified of any change in condition. LPN #1 stated they documented notification of change in the nurse progress notes. On 09/15/25 at 10:19 a.m., the DON stated the residents' representatives were to be notified of any change in condition and they were to document the notification in a nurse progress note. On 09/15/25 at 11:48 a.m., the DON reviewed the electronic clinical record and stated it did not show Resident #9's guardian had been notified of the changes on 08/05/25, 08/12/25, 08/25/25, 08/27/25, or 08/28/25.

Based on record review and interview, the facility failed to ensure care plans were comprehensive for 2 (#16 and #4) of 12 sampled residents reviewed for comprehensive care plans.The DON identified 41 residents resided in the facility.Findings:1. On 09/09/25 at 10:03 a.m., Resident #16 was observed to speak, and their dentures did not stay in their mouth correctly. On 09/09/25 at 11:03 a.m., Resident #16's upper denture did not stay in place while talking and they repeatedly pushed the upper denture in place with their hand during the interview. An admission assessment, dated 09/23/24, showed the care area assessment triggered dental concerns due to Resident #16 being edentulous. An undated policy Comprehensive Care Plan, read in part, Each resident will have a person-centered comprehensive care plan developed and implemented to meet his/her preferences and goals and address the resident's medical, physical, mental and psychosocial needs. A significant change assessment, dated 07/08/25, showed a BIMS of 13 which indicated Resident #16 was cognitively intact for daily decision making. The assessment showed diagnoses which included cancer and schizophrenia. The care area assessment triggered dental concerns due to Resident #16 being edentulous. A care plan, revised 07/15/25, showed no concern/focus for dental. Review of provider documents for Resident #16 showed no dental documents. On 09/09/25 at 11:03 a.m., Resident #16 stated their dentures did not fit correctly. They stated they had not told the facility staff, but they know because they can see it just like you. On 09/12/25 at 11:07 a.m., CNA #1 stated Resident #16 had not been seen by a dentist to their knowledge. They stated Resident #16 had dentures and they were loose. On 09/12/25 at 11:22 a.m., the social services director stated the dentist came last month and they provided a list of people who had their insurance. The social services director stated the nurses documented when a resident was seen by the dentist. On 09/12/25 at 11:26 a.m., the DON stated dental visits were documented in progress notes by nursing. The DON stated Resident #16 would not allow the dentist to see them. They stated the MDS coordinator would know if the refusals by Resident #16 were care planned. On 09/12/25 at 12:33 p.m., the MDS coordinator stated Resident #16 refused a lot of treatments. They stated the dentist was recently in the facility and Resident #16 did not see them. The MDS coordinator stated Resident #16 was not on the list to be seen by the dentist. They stated they did not know if Resident #16 refusals were care planned. The MDS coordinator, after checking the care plan, stated the care plan did not address dental and they did not know why, but it was triggered by the care area assessment. 2. An annual assessment, dated 08/09/25, showed a BIMS of 13 which indicated Resident #4 was cognitively intact for daily decision making. The assessment showed diagnoses which included colostomy, spina bifida and cerebral palsy. An order summary report, dated September 2025, did not show an order for the care of a nephrostomy. A care plan, revised 08/27/25, showed a focus for suprapubic catheter and colostomy to promote wound healing and required total assistance. The care plan did not address the nephrostomy or nephrostomy care. Review of the July, August and September 2025 MAR, did not address the nephrostomy or nephrostomy care. On 09/15/25 at 9:38 a.m., CNA #3 stated Resident #4 had a nephrostomy and CNAs emptied the collection bag. On 09/15/25 at 1:41 p.m., the DON stated Resident #4 had a colostomy, nephrostomy and suprapubic catheter. They stated the facility did not change the nephrostomy; they monitored, cleaned and placed a dressing around it. The DON stated an order was not entered. They stated the nurses must have assumed the order for the colostomy and suprapubic catheter included the nephrostomy care as well. The DON stated the nephrostomy must have been missed on the care plan.

Based on record review and interview, the facility failed to revise and accurately revise a care plan for 2 (#9 and #4) of 2 residents sampled were reviewed for care plans.The administrator identified 41 residents resided in the facility.Findings: 1. A progress note, dated 06/05/25, showed Resident #9 was in the common area for dinner meal when they began walking toward the nurses' station. The note showed Resident #9 began running and hit the front door until it opened. The note showed staff was headed towards them during the time, however no one was able to reach Resident #9 before they made it out the door. The note showed Resident #9 was stopped by staff approximately five feet outside the building. The note showed the police department and emergency medical services arrived and Resident #9 was taken to the emergency department for evaluation due to increased anxiety. A progress note, dated 06/05/25, showed Resident #9 returned to the facility at 10:20 p.m., and began pacing about the facility walking towards doors and was on one-on-one observation with staff. A progress note, dated 06/06/25, showed Resident #9 continued pacing after they returned from the emergency department on 06/05/25. A quarterly assessment, dated 06/11/25, showed a BIMS of 6 which indicated a severe cognitive impairment for daily decision making. The assessment showed diagnoses which included schizophrenia, heart failure, anxiety and depression. The assessment showed medications taken during the look back period included antipsychotic, antianxiety, antidepressants and anticonvulsant medications. Section E of the assessment showed other behavioral symptoms not directed towards other such as pacing or elopement attempts were not exhibited during the look back period. A care plan, revised 07/01/25, showed Resident #9 was a risk for elopement with an actual incident on 02/16/25 regarding a cut to their right hand. Interventions included to document any wandering behaviors, triggers, and patterns. The care plan was not revised to include the elopement attempt on 06/05/25. On 09/15/25 at 1:41 p.m., the DON stated they did not know why the care plan was not revised. 2. An annual assessment, dated 08/09/25, showed a BIMS of 13 which indicated Resident #4 was cognitive for daily decision making. The assessment showed diagnoses which included spina bifida, cerebral palsy and a stage four pressure ulcer. The assessment showed Resident #4 was at risk for pressure ulcers and had a current pressure ulcer stage three present on admission. A physician wound note, dated 08/27/25, showed the wound as a stage three pressure injury. A care plan, revised 08/27/25, showed Resident #4 had a stage four pressure ulcer. On 09/09/25 at 9:27 a.m., Resident #4 stated they had a wound on their bottom. They stated the staff informed them the wound was getting better but Resident #4 was not sure. On 09/12/25 at 11:31 a.m., the MDS coordinator stated the face sheet showed the pressure wound was a stage four, but the wound doctor staged the wound at a stage three to the right ischium. They stated the care plan was revised 08/27/25. The MDS coordinator stated they should have gone by the wound doctor orders and assessment.

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of 5% or less. Two medication errors were observed out of 31 opportunities, which indicated a 6.25% medication error rate.The DON identified 41 residents receive medications in the facility.On 09/10/25 at 8:19 a.m., CMA #2 was observed to administer Budesonide-Fomotorol Fumarate (a corticosteroid medication for chronic obstructive pulmonary disease) 80-4.5 mcg/act 2 puffs to Resident #45. CMA #2 was not observed to encourage or instruct Resident #45 to rinse their mouth after using the inhaler. Resident #45 was not observed to receive Daliresp (a medication for chronic obstructive pulmonary disease) 250 MCG tablet by mouth.An undated policy titled Administration of Inhalers by Certified Medication Aides, read in part, Encourage mouth rinse if corticosteroid inhaler was used.A physician order, dated 11/21/24, showed Resident #45 was ordered Budesonide-Formoterol Fumarate Inhalation Aerosol 80-4.5 MCG/ACT two puffs twice daily. The order showed to rinse mouth with water after each dose.A quarterly assessment, dated 06/23/25, showed Resident #45 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making.A physician order, dated 07/02/25, showed Resident #45 was ordered Daliresp 250mcg one tablet by mouth once daily.On 09/10/25 at 1:09 p.m., CMA #2 stated the Daliresp 250mcg tablet was not available for administration to Resident #45. On 09/10/25 at 1:09 p.m., CMA #2 stated Resident #45 would become argumentative if they educated or encouraged them to rinse their mouth after using the inhaler. CMA #2 stated they notified the DON, on 09/09/25, the Daliresp was unavailable. On 09/10/25 at 1:19 p.m., the DON stated the charge nurses were to monitor the CMAs to ensure medications were provided as ordered. They stated they were unaware the Daliresp was unavailable and Resident #45 should have been encouraged to rinse their mouth after the inhaler use. On 09/11/25 at 4:25 p.m., the DON stated they would need to provide training related to the medication error rate.

Based on observation and interview, the facility failed to ensure medications were secured for 1 (treatment cart #1) of 1 treatment carts observed.The DON identified two treatment carts in the facility. Findings: On 09/09/25 at 11:32 a.m., LPN #1 was observed to enter room [ROOM NUMBER]. LPN # 1 was observed to leave the treatment cart #1 unlocked and unattended. On 09/09/25 at 11:34 a.m., LPN #1 returned to treatment cart #1 and lock it. On 09/09/25 at 11:42 a.m., LPN #1 stated they kept medications secured by locking the treatment carts when they were unattended. LPN #1 stated they had not been paying attention when they left treatment cart #1 unlocked and unattended. On 09/09/25 at 4:30 p.m., the DON stated treatment carts were to be kept locked when they were unattended to secure medications.

Based on observation, record review, and interview, the facility failed to ensure menus were followed for 1 meal of 1 meal observed.The DON identified 41 residents ate meals from the kitchen.Findings:On 09/09/25 at 12:00 p.m., soft beef tacos were observed to be served for lunch, no vegetable was served other than the lettuce and tomatoes. On 09/09/25 at 12:01 p.m., cook #1 used tongs to place lettuce, tomatoes and cheese on each plate. The serving of lettuce, tomatoes and cheese was less than three ounces. An undated facility [policy Menus, read in part, Ensure that menus are developed and prepared to meet resident choices including their nutritional, religious, cultural and ethnic needs while using established national guidelines. The facility Production Guides menu, dated 09/09/25, for the noon meal showed soft beef taco with sauce, Spanish rice, capri blend vegetables, shredded lettuce/tomato and summer fruit cup to be served. The menu showed to use the #8 scoop for the shredded lettuce and tomato. On 09/15/25 at 2:03 p.m., the DM stated the serving size for lettuce tomato and cheese was four ounces. They stated the reason they used the tongs was because the residents will not eat all that lettuce. The DM stated residents eat very little lettuce and cheese. They stated the capri vegetables were not served because they did not have any.

Based on observation, record review, and interview, the facility failed to ensure trash cans were covered in the kitchen for 1 (the trash can by the handwashing sink) of 2 trash cans observed in the kitchen.The human resources employee identified 2 trash cans in the kitchen, and the DON identified 41 residents received nourishment from the kitchen.Findings: On 09/08/25 at 12:05 p.m., the trashcan by the handwashing sink was observed to be uncovered and without a lid. On 09/09/25 at 11:18 a.m., the trashcan next to the handwashing sink was observed to be uncovered and without a lid. An undated policy titled, Disposal of Garbage/Rubbish, read in part, All containers will have tight-fitting lids or covers and will be kept covered when stored or not in continuous use. On 09/15/25 at 2:03 p.m., the DM stated they had never had a lid for the trashcan by the handwashing sink.

Based on record review and interview, the facility failed to ensure assessments were encoded and transmitted for 2 (#9 and #45) of 12 sampled residents whose assessments were reviewed.The DON identified 41 residents resided in the facility.Findings: 1. A quarterly assessment, dated 06/11/25, showed Resident #9 had a BIMS score of six, which indicated the resident was severely impaired in cognition for daily decision making. An entry assessment, dated 07/21/25, showed Resident #9 had been readmitted to the facility. A nurse note, dated 07/28/25, showed the resident was sent to the hospital.Review of the assessments in the electronic clinical record did not show a discharge assessment had been completed.An entry assessment, dated 08/04/25, showed Resident #9 had been readmitted to the facility.On 09/11/25 at 12:40 p.m., the MDS coordinator reviewed the assessments in the electronic clinical record and stated they should have completed a discharge return anticipated assessment on 07/28/25.2. A quarterly assessment, dated 06/23/25, showed Resident #45 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making. Review of the assessments in the electronic clinical record, showed the most recent assessment completed was a discharge return anticipated assessment, dated 07/26/25, and did not show Resident #45 had been readmitted to the facility. A nurse note, dated 07/30/25 at 12:58 p.m., showed Resident #45 had been readmitted to the facility. On 09/09/25 at 2:36 p.m., the MDS coordinator reviewed the electronic clinical record and stated Resident #45 had discharged from the facility on 07/26/25 and they should have completed an entry assessment upon the resident's return on 07/30/25.

Based on record review and interview, the facility failed to provide written notices of transfer to residents transferred to acute care hospitals by the facility for three (#17, 27, and #45) of three sampled residents reviewed for discharges and hospitalization s. The ADON stated nine residents had transferred to an acute care hospital in the previous three months. Findings: An undated Transfer and Discharge policy, read in part, Preparation and orientation of the resident is essential to ensure safe and orderly transfer or discharge from the facility. Sufficient preparation means that the facility informs the resident where he/she is going and takes steps under its control to ensure safe transportation. The facility will involve the resident and the resident's family/representative in selecting the new residence. The policy did not include procedures which included notification in writing prior to transfer. 1. Resident #17 had diagnoses which included Parkinson's disease and dementia. A nurse's note, dated 12/28/24 at 6:23 p.m., documented Resident #17 had been transferred to an acute care hospital following a fall. A nurse's note, dated 01/05/25 at 7:22 p.m., documented Resident #17 had been transferred to an acute care hospital for altered mental status. 2. Resident #27 had diagnoses which included diabetes and heart failure. A nurse's note, dated 12/06/24 at 7:11 a.m., documented Resident #27 had been transferred to an acute care hospital for confusion. 3. Resident #45 had diagnoses which included paranoid schizophrenia. A nurse's note, dated 10/05/24 at 9:00 a.m., documented the resident had been transferred to an acute care hospital on for verbal and physical aggression. On 01/28/25 at 10:17 a.m., the DON was asked to provide the written notices of transfer for Resident #17, 27, and #45. They stated they had never heard of a written notice of transfer until that day. On 01/28/25 at 12:22 p.m., the DON stated the facility had not been providing written notices of transfers when residents had been transferred to hospitals. They stated they had searched through the documentation of residents who had been transferred and found no notices of transfers.

Based on observation and interview, the facility failed to post nurse staffing in a prominent place accessible to residents and visitors. The administrator identified 42 residents who resided in the facility. Findings: On 01/26/25 at 8:54 a.m., a tour of the facility was conducted. No nurse staff posting was observed. On 01/27/25 at 1:40 p.m., the nurse staff posting for the facility was not observed. The DON stated they were not aware the nurse staff posting was not posted or needed to be posted.

Based on record review, observation, and interview, the facility failed to ensure residents were free from neglect for one (#1) of three residents reviewed for abuse and neglect. The facility failed to prevent a resident from having been left unattended in the shower room which resulted in a fall that caused a right fibula fracture. The deficient practice was determined to be past-noncompliance since the facility identified the situation and implemented interventions to prevent the recurrence of the situation. The Resident Census and Conditions of Residents documented 41 residents resided in the facility. Findings: An undated facility policy titled Shower/Tub Bath, documented the following: Stay with the resident throughout the bath. Never leave the resident unattended in the tub or shower. Res #1 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 09/04/22, documented the resident was cognitively intact, independent with most ADLs, and required extensive assistance with bathing. An OSDH initial incident report, Form 283, dated 10/04/22, documented Certain Injuries for Res #1. The report documented the residents had a fall in the shower room and was sent to the ER for evaluation. An in-service training report, dated 10/05/22, documented 51 staff members were educated on resident shower safety, never leaving a resident unattended in the shower, and never moving an injured resident until EMS arrives and takes over care. An OSDH final incident report, Form 283, dated 10/06/22, documented Certain Injuries for the resident. The report documented the following: On 10/03/22 at 9:30 a.m., the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident returned to the facility via EMS on 10/03/22 at 3:18 p.m., with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident stated after her shower she was getting dressed and was trying to put her bra on when she fell . Res #1 stated CNA #1 was not in the shower room with her when she was showering or when she fell . The Activities Director was in the hall at the time of resident's fall and stated CNA #1 had passed her heading into the shower room and when the CNA opened the shower room door, she told the Activities Director to get the nurse. CNA #1 self-terminated prior to the investigation being completed and she had been reported to the CNA board for neglect of a resident. On 11/03/22 at 1:12 p.m., Res #1 was observed lying in bed with a fiberglass cast to the right lower leg. The resident stated she lost her balance while trying to dress after showering which caused the fall. The resident stated the CNA had left the room prior to the fall for 1-2 minutes but returned to help immediately when she fell . On 11/03/22 at 2:15 p.m., the Activities Director stated she was a witness to the event as stated in the incident report. She stated CNA #1 walked past her in the hall, walking towards the shower room. She stated having observed CNA #1 stop at the doorway of the shower room and screamed for help. She reported having notified the nurse in charge and then observed the nurse and CNA #1 attend to Res #1 in the shower room after the fall. The Activities Director stated she was certain the CNA was not in the shower room supervising the resident when the fall occurred but the CNA should have been according to facility policy. On 11/03/22 at 4:22 p.m., the DON stated CNAs are expected to be in the room with residents at all times during a shower/bath according to policy. The DON stated the CNA should have been in the shower room with Res #1 at the time of the fall.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident was free from physical restraints imposed for the purpose of convenience for one (#1) of three residents sampled for restraints. The registered nurse on duty restrained the resident to her bed with duct tape. During an interview with the surveyor, resident #1 stated, It freaked me out! It didn't feel good at all. I have claustrophobia. The administrator (adm) identified 48 residents who resided in the facility. Findings: The facility's restraint policy documented, The long-term care facility creates and maintains an environment that fosters a restraint-free environment .The resident has the right to be free from any physical restraints imposed and psychoactive drugs administered for the purpose of discipline or convenience of staff, which are not required by the resident's medical condition. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 11/19/15, documented the resident was cognitively intact; was independent with transfers, ambulation, and walking; and had disorganized thinking and inattention. On 01/25/16 at 2:00 to 3:00 p.m., an in-service was conducted with all the facility staff. The 'In-Service Training Report' documented, .Discussed when and to who abuse is reported. Explained that phone numbers are located at nursing station if needed. Notification must be immediately made of alleged abuse. Refer to policy ASG 27 .Review on restraints. We are free of restraints. Refer to policy and nursing standards P-P page 108. If we need a restraint we must first obtain a doctor's order. Restraints are considered using bed sheets, lap buddys, seat belts, any kind of tape. We are a restraint free environment . An initial incident report, submitted on 01/26/16, to Oklahoma State Department of Health (OSDH), documented an allegation of abuse regarding an incident on 01/24/16 at approximately 11:15 a.m. The report documented registered nurse (RN) #1 had duct taped the resident to her bed. The report documented immediate action was taken and an investigation was started. A notification to the Nurse Aide/Nontechnical Service Worker Abuse Registry was also submitted with the report. It was documented the physician, family, Adult Protective Services, Local Law Enforcement, and the Nursing Board were also notified of the incident by the facility. The final incident report to OSDH, submitted 01/29/16, documented, .Our facility has zero tolerance for any type of abuse or neglect towards any of our residents. Additionally, we are a restraint free facility. Based upon admission by (nurse name deleted) to duct taping resident to the bed, as well as the statements by the resident, her roommate, and other employees, (nurse name deleted) was terminated from our facility. Employees have been in-serviced on abuse and neglect, and the reporting process. On 02/29/16 at 12:15 p.m., the resident was observed ambulating with a walker down the facility's hallway to her room. When inside the resident's room, the resident was asked to describe the events surrounding the incident when she was duct taped to her bed. The resident said she had fallen in her room and hit the back of her head. She said RN #1 had told her not to get up because she was afraid she would fall again and she was going to call Emergency Medical Services (EMS) to take her to the hospital. The resident said she kept getting up off the bed and RN #1 told her she was going to duct tape her to the bed if she didn't stay still. The resident said the nurse did it as a joke. The resident was asked how and where the tape was placed on her body. The resident stated she was lying on her side with a sheet over her body. She stated she could not remember exactly where the tape was but believed three long pieces of duct tape were placed on her body. She said one piece of tape was over her ankles, one over her knees, and one over her hips. The resident stated each piece of tape went across the bed and was affixed to the metal on the bed frame on each side. She also said her hands were taped together. The resident was asked how long she was taped to the bed. She stated about five minutes. She stated when EMS came to get her, RN #1 and EMS took the tape off. The resident was asked how it made her feel to be taped to the bed. She stated, It freaked me out! It didn't feel good at all. I have claustrophobia. The resident was asked if she was abused. The resident said she was not abused. She said she felt like RN #1 was one of the few people who really cared for her. The resident was asked if she was hurt or had any bruises from the incident. She said she was not hurt and had no bruising. The resident said the police had asked her some questions and she was not going to press charges. On 02/29/16 at 3:20 p.m., the adm was asked if the RN should have restrained the resident. She stated, Definitely not, we are a restraint free facility. She stated inservices were conducted after the incident to ensure it would never happen again. Every staff member was inserviced on 01/25/16 by 3:00 p.m. The facility staff were interviewed regarding the inservice which was given on 01/25/16 regarding restraints and abuse/neglect. The staff voiced sufficient knowledge and understanding of the facility's restraint and abuse/neglect policies.

Based on observation, interview, and record review, it was determined the facility failed to ensure the residents' received adequate supervision for the prevention of accidents for one (#1) of four sampled residents reviewed for falls. Resident #1 sustained a fracture to the left femoral neck, lacerations, hematomas and skin tears. The facility failed to: a) Thoroughly investigate the residents' falls to determine the underlying cause of the falls for the residents, b) Consistently evaluate the effectiveness of the interventions to prevent falls which had been implemented for the residents, and c) Consistently implement new interventions to prevent falls with each fall occurrence and when interventions were not effective. The facility identified 17 residents who had fallen 36 times from February 2013 through October 2013. Findings: The facility's fall policy and procedures documented each resident would be provided with the adequate supervision, appropriated assistive devices, and functional programs to prevent accidents. The policy documented: a) Each resident would receive the assessment and interventions necessary to prevent falls or minimize injuries when falls occurred. b) Each resident fall would be analyzed and trended in order to maintain a safe environment. c) Each resident who was at risk for falls would have a visual fall risk identifier on the room door to communicate to the staff the resident was at high risk for falls. d) A post incident review was to be completed after each fall and reviewed by nursing management. e) The resident's care plan was to be updated with the occurrence of each fall. The update was to include the date the fall occurred, interventions to prevent falls which were determined by the fall investigation, and the probable reasons the fall occurred. f) The certified nurses aide assignment record would be updated to communicate the new interventions to prevent falls. 1. Resident #1 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The comprehensive admission assessment, dated 01/06/13, documented the resident was severely impaired for daily decision making and required moderate assistance with the activities of daily living (ADLs). The assessment documented the resident was not steady with transfers; required a wheelchair for mobility; and received routine pain, antipsychotic, and antianxiety medications. The care plan, dated 01/09/13, documented the resident had safety needs and was at risk for falls. The care plan documented interventions to prevent falls and included: 1. the staff was to anticipate the resident's needs; 2. the staff was to be sure the resident's call light was within reach, remind the resident how to use the call light, and answer the call light promptly; 3. the staff was to educate the resident, family, and caregivers about safety reminders; 4. the staff was to encourage the resident to participate in exercise activities to promote strengthening; 5. the staff was to ensure the resident wore appropriate footwear; 6. the staff was to follow the facility fall protocol; 7. the nurse would investigate the cause of a fall; 8. the nurse was to notify therapy for an evaluation when appropriate; 9. the staff was to use a gait belt and assist the resident with all transfers; 10. the nurse was to complete a fall risk assessment every three months; and 11. the nurse was to assess the resident for low blood pressure upon standing. An incident report, dated 02/05/13 at 2:20 a.m., documented the resident complained she had fallen and her right hip and back hurt a lot. The report documented the resident was oriented to person and was anxious. The report documented the resident had a gait imbalance, had a current urinary tract infection, was incontinent, and had weakness. The report documented the physician was notified and x-rays for the hip and back were ordered. The x-ray report documented the resident did not sustain any fractures or injuries. The incident report documented the family was notified. The incident report did not document new interventions to prevent falls. The care plan, dated 02/05/13, did not document the resident had fallen on 02/05/13 at 2:20 a.m. The care plan was not updated with new interventions to prevent falls. An incident report, dated 02/05/13 at 7:30 p.m., documented the resident was found on her knees in front of the toilet in the bathroom. The report documented the resident's knees were discolored but the resident denied pain. The report documented the resident was oriented to self, confused, and anxious. The incident report documented the resident received diuretics, had a gait imbalance, impaired memory, was drowsy, incontinent, had a recent change in medication, had a recent illness, and was weak. The incident report documented the resident was ambulating without assistance and was wearing improper footwear. The report documented the physician and family were notified. The incident report documented a personal alarm was to be placed on the resident for fall prevention. The care plan, dated 02/05/13, did not document the resident had fallen on 02/05/13 at 7:30 p.m. The care plan was updated and documented the personal alarm for fall prevention. An incident report, dated 03/01/13 at 2:32 p.m., documented the resident was found sitting on the floor beside the bed, the personal alarm was on the resident, and the call light was within reach. The report documented the resident was confused, was unable to state what occurred, and had no injuries. The report documented the physician and family were notified. The report documented the resident was placed on a low bed and a fall mat was placed on the floor next to the bed. The report did not document the underlying cause of the fall. The care plan did not document the resident's fall and did not document new interventions to prevent falls. An incident report, dated 04/12/13 at 3:45 a.m., documented the resident was found sitting on the floor with a golf ball size bleeding hematoma to the right forehead and a 0.5 centimeter (cm) by 0.25 cm laceration to the left hand. The report documented first aide was performed, neurological checks were begun, and routine pain medications were held. The report documented at 5:00 a.m., a six inch by six inch discolored area of swelling was observed to the resident's right thigh. The resident was transported by EMS to the emergency room . The report documented the spouse had removed the personal alarm, attempted to assist the resident to the bathroom, and the resident fell and hit her head on the end of the bed. The report documented the physician and family were notified. The report did not document new interventions to prevent falls. The care plan did not document the resident's fall or new interventions to prevent falls. An x-ray report, dated 04/21/13, documented the resident did not have fractures to the right leg. An incident report, dated 08/13/13 at 4:30 p.m., documented the resident was in the dining room sitting in her wheelchair. The resident stood up and fell lacerating right pointer finger. The report documented the resident denied pain, first aide was performed, the physician and family were notified, and the resident was toileted. The report did not document new interventions to prevent falls. The care plan did not document the resident's fall or new interventions to prevent falls. An incident report, dated 08/26/13 at 3:42 p.m., documented the resident fell in the lobby, hit her head, landed on her left side, and complained of left sided pain but was not able to rate the pain. The report documented the resident sustained [REDACTED]. The report documented x-rays were ordered for the left leg, hip, and shoulder, and neurological checks were started. The report documented the physician and family were notified. The report did not document new interventions to prevent falls. An x-ray, dated 08/26/13, documented the resident sustained [REDACTED]. The report documented the physician and family were notified and the resident was transported to the emergency room . The care plan did not document the resident's fall or new interventions to prevent falls. An incident report, dated 09/15/13 at 6:00 p.m., documented the resident and spouse had fallen when the resident's husband removed the alarm and the resident attempted to sit on his lap. The report documented the resident complained of minimal pain to the sacrum. The report did not document interventions to prevent falls. The care plan did not document the resident's fall or new interventions to prevent falls. On 10/21/13 at 1:48 p.m., the resident was sitting in her wheelchair in the lobby area. The resident was awake, alert, clean, well groomed, and odor free. A personal alarm was in place on the resident and the resident wore geri-sleeves on both arms. On 10/21/13 at 3:45 p.m., certified nurse aide (CNA) #1 was interviewed regarding the facility fall prevention policy. The CNA stated the staff was made aware of residents who were at risk for falls by word of mouth. The CNA stated the fall interventions for a resident who was at risk were documented on the CNA kardex. The CNA stated regular resident rounds were performed to prevent falls. The CNA stated she did not know what the fall protocol consisted of. On 10/22/13 at 11:00 a.m., the resident was sitting in her wheelchair at a table in the dining room and was attempting to stand up. A personal alarm was in place on the resident. A staff member intervened and assisted the resident to sitting position. On 10/22/13 at 1:30 p.m., the assistant director of nurses (ADON) was interviewed regarding the facility's fall policy. The ADON stated fall interventions were evaluated when the interventions were implemented and were reviewed with each fall. The ADON stated tracking and trending was completed for the resident falls. The ADON stated the CNAs were consulted regarding the effectiveness of the interventions which had been implemented for each fall. The ADON stated the activities director should be involved with fall prevention and the activities for fall prevention should be addressed on the care plan. The initial interventions to prevent falls documented on the resident's care plan were discussed with the DON and ADON. The ADON and DON were asked how the resident's care plan was individualized. The ADON and DON made no comment. On 10/22/13 at 2:00 p.m., the director of nurses (DON) was interviewed regarding the facility fall policy. The ADON stated the facility managed a resident who was at high risk for falls by placing the resident on a low bed, placing a fall mat next to the bed, placing a personal alarm on the resident, and putting anti-tippers on the wheelchair. The DON stated it was difficult to individualize the fall interventions for each resident due to the residents' severe dementia. The DON stated the fall protocol was the procedure the nurses followed when a fall occurred and was not the policy for fall prevention. The DON stated a "Post Incident Review" was no longer utilized, was not completed when the resident had fallen, and the incident report was the only document filled out at the time of a fall. The DON stated she was aware the new incident reports did not have new interventions to prevent falls and the report was not sufficient enough to determine the cause of every fall. The DON stated the staff determined which interventions were implemented at the time of a fall and were determined by the characteristics of the fall. The DON stated the facility had not been able to determine the cause of the resident's falls. The DON stated the interventions to place a low bed and a fall mat did not correspond with the residents need of assistance in toileting or address the removal of the alarm by the husband. The DON also stated the interventions to remind the resident to use the call light and ask for assistance was not an effective intervention to prevent falls when a resident was severely impaired for daily decision making. The DON stated the personal alarm was effective in preventing many of the resident's falls.

On 07/19/12, an Immediate Jeopardy (IJ) situation was identified in accident hazards. The facility failed to implement measures to promote resident safety related to multiple elopements which could have resulted in injury. On 07/19/12 at 7:01 p.m., the Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ in accident hazards. On 07/19/12 at 7:05 p.m., the administrator and the DON were notified of the IJ in accident hazards related to elopement which placed the facility in an extended survey. On 07/19/12 at 7:44 p.m., the facility submitted a plan of removal of immediacy. The plan was not accepted. On 07/19/12 at 8:14 p.m., the facility submitted an acceptable plan of removal of immediacy. FACILITY PLAN OF REMOVAL OF IMMEDIACY The facility plan of removal documented: "1) A staff member will be assigned to perform one on one and will document location and activity every 15 minutes. When staff needs to be relieved another staff member will monitor and initial form. 2) Friday July 19, 2012 facility will notify family that for the resident's safety relocation is necessary and facility will start the process of placing the resident at another facility. 3) Till placement is found the facility will continue to perform one on one and document. 4) Plan of care is updated to reflect the one on one with the resident due to elopement risk. 5) All staff will be in-serviced by 4:00 p.m. Friday 20, 2012." IMMEDIACY REMOVED On 07/19/12 starting at 7:30 p.m. until 07/20/12 at 1:50 p.m., the resident was with a facility staff member. At that time the resident was discharged from the facility and transferred to another facility. The administrator and DON presented the survey team with copies of in-services, a resident care plan, and other documents related to elopement and accident hazards. Staff interviews were conducted on 07/20/12. Certified nurse aids, charge nurses, dietary staff, office staff, housekeeping, and maintenance staff were interviewed in regards to their knowledge of the in-service to ensure the staff understood the risk of resident elopement and the safety interventions implemented to prevent elopement. All staff interviewed responded appropriately. The IJ was removed effective 07/20/12 at 1:30 p.m., when the last in-service had been completed and staff interviews were conducted. The deficient practice remained at a level of actual harm at a pattern level. Based on observation, record review, and interview, it was determined the facility failed to ensure each resident received adequate supervision to promote resident safety for five (#4, #5, #7, #11, and #12) of twelve residents reviewed for accident hazards. The facility failed to: a. implement measures to prevent elopement for resident #12 who wandered from the facility onto a busy street 8 times in the previous 8 months. b. identify the cause of falls and implement preventative measures for residents #5 and #11 who had multiple falls resulting in lacerations requiring stitches. c. follow the facility policy for supervised smoking and failed to complete a thorough smoking assessment to identify and implement safe smoking interventions for residents #4, #7, and #12. The facility census and condition report identified 41 residents currently resided in the facility. Findings: The facility's lost or missing resident policy, dated 11/10/95, documented prompt actions were to be taken by the facility if a resident was lost or missing from the facility. The policy documented the facility administrator had primary responsibility for compliance with the policy. The policy documented the person who discovered the resident missing would report the fact to the charge nurse, DON, and the administrator. The policy documented an accurate record would be documented of the time the resident was reported missing; times of notification of administrator, family, police, etc.; steps taken to locate the resident; and any other pertinent information. The policy documented when a resident was returned to the facility, and the DON or the charge nurse would complete an incident report, notify the physician, the family, the police department, and hospitals. The policy documented the charge nurse would document all events and notifications in detail. A smoking policy and procedure, dated 06/12/06, documented the facility would establish a smoking schedule for the residents, a facility employee would supervise residents when smoking, and combustible items were prohibited in the residents' possession (including lighters, matches, cigarettes, cigars, pipes, loose tobacco and papers). The smoking policy and procedure, updated with an addendum on 07/30/10. The addendum documented smoking times were on the hour from the hours of 8:00 a.m. to 8:00 p.m. The addendum documented no smoking would be permitted during meal times 12:00 p.m. to 1:00 p.m. and 5:00 p.m. to 6:00 p.m. The addendum documented cigarettes would be handed out on the hour. The policy did not document residents would be assessed for safety with use of tobacco products and combustibles. 1a. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The clinical record documented the resident was admitted to the facility from a residential care facility due to the resident's increasing need for medical support. The admission assessment, dated 10/31/12, documented the resident was moderately impaired with daily decision making, ambulated independently, and had a behavior of wandering. The assessment documented the behavior of wandering placed the resident at significant risk of getting to a potentially dangerous place outside of the facility. The assessment documented the resident used tobacco. An undated elopement risk assessment documented the resident was cognitively impaired with poor decision-making skills. The assessment documented the resident had expressed a desire to leave the facility and go home. The assessment documented the resident was known to be an elopement risk. The assessment documented the resident had denied experiencing any pain. The assessment documented the exit doors had alarms. The assessment did not document interventions to prevent the resident from wandering away from the facility. The assessment did not document interventions were included in the resident's plan of care. The assessment was not dated or signed by facility staff. No documentation of an initial care plan was available in the resident's clinical record. On 07/19/12 at 6:00 p.m., assistant director of nurses(ADON) was asked if an initial care plan was completed for the resident. The ADON stated the first care plan completed for the resident was on 04/21/12. An interdisciplinary progress note, dated 10/30/11 at 8 p.m., documented the facility staff reported the resident was missing from the facility. The progress note documented the facility and immediate campus was searched. The progress note documented the resident was found on the opposite side of a high motor vehicle traffic street and south of the facility. No documentation of an initial care plan was available in the resident's clinical record. On 07/19/12 at 6:00 p.m., assistant director of nurses(ADON) was asked if an initial care plan was completed for the resident. The ADON stated the first care plan completed for the resident was on 04/21/12. An interdisciplinary progress note, dated 11/14/11 at 8:55 a.m., documented the resident had left the facility while exit doors were being repaired. The progress note documented the facility staff found the resident as he stepped to walk into the street with high motor vehicle traffic. An incident report was completed. The incident was not reported to the appropriate agency. An interdisciplinary progress note, dated 12/17/12 at 3:30 a.m., documented the resident had left the facility unsupervised and staff had observed the resident south of the facility. The progress note documented the resident had a desire to go home. An incident report for this elopement was not found in the resident's clinical record. No documentation of an initial care plan was available in the resident's clinical record. On 07/19/12 at 6:00 p.m., assistant director of nurses(ADON) was asked if an initial care plan was completed for the resident. The ADON stated the first care plan completed for the resident was on 04/21/12. An interdisciplinary progress note, dated 01/08/12 at 10:30 a.m., documented a staff member had seen the resident walking west approximately eight blocks from the facility. The note documented the resident had walked across a street with high motor vehicle traffic. On 01/08/12, the facility had completed an incident report and documented the incident was reported to the appropriate agency. No documentation of an initial care plan was available in the resident's clinical record. On 07/19/12 at 6:00 p.m., assistant director of nurses(ADON) was asked if an initial care plan was completed for the resident. The ADON stated the first care plan completed for the resident was on 04/21/12. An interdisciplinary progress note, dated 02/07/12 at 3:30 p.m., documented the resident was returned to the facility by a deputy sheriff. The note documented the deputy had found the resident walking south of the facility beside the street with high motor vehicle traffic. On 02/08/12, an incident report documented the measures to prevent recurrence were to place the resident on one hour watch. No documentation of an initial care plan was available in the resident's clinical record. On 07/19/12 at 6:00 p.m., assistant director of nurses(ADON) was asked if an initial care plan was completed for the resident. The ADON stated the first care plan completed for the resident was on 04/21/12. An interdisciplinary progress note, dated 03/28/12 at 4:00 p.m., documented the resident left the facility behind a delivery man. The note documented the resident walked to the south parking lot and was attempting to cross the street with high motor vehicle. An incident report for this elopement was not found in the resident's clinical record. No documentation of an initial care plan was available in the resident's clinical record. On 07/19/12 at 6:00 p.m., assistant director of nurses(ADON) was asked if an initial care plan was completed for the resident. The ADON stated the first care plan completed for the resident was on 04/21/12. An interdisciplinary progress note, dated 4/11/12 at 11:26 a.m., documented the resident was found outside the facility and had attempted to leave through the unsecured courtyard gate. No documentation of an initial care plan was available in the resident's clinical record. On 07/19/12 at 6:00 p.m., assistant director of nurses(ADON) was asked if an initial care plan was completed for the resident. The ADON stated the first care plan completed for the resident was on 04/21/12. A care plan, dated 04/21/12, did not document the resident's risk for elopement or the resident's history of elopements. The care plan did not document interventions to prevent elopement. An interdisciplinary progress note, dated 05/10/12 at 5:30 p.m., documented the resident had left the facility through the back door and walked around the back of the facility through the unsecured courtyard gate. An incident report for this elopement was not found in the resident's clinical record. The care plan, dated 04/21/12, was not updated to include the resident's elopements or interventions to prevent recurrence. An interdisciplinary progress note, dated 05/18/12 at 11:45 a.m., documented the resident was missing from the facility. The progress note documented the resident was found by the administrator fifteen minutes later one block north and two blocks east of the facility. An incident report was completed and the physician and the family were notified. The facility's intervention to prevent recurrence was to visually check the resident every 30 minutes for four hours, then every four hours for 20 hours, and then to resume every two hour checks. The care plan, dated 04/21/12, was not updated to include the resident's elopements or interventions to prevent recurrence. On initial tour on 07/16/12 at 1:45 p.m., four of the six facility exit doors were observed to have a key pad device to unlock the doors with codes. Two doors (the exit door to the resident smoking area and the door near the laundry room) had no key pad devices with codes. The doors had a single button to be pushed at the same time the door's exit handle was pressed. No doors were observed to have a security device to signal staff if a resident at risk for elopement was going out the doors unsupervised. On 07/17/12 at 12:45 p.m., the facility's fenced yard was observed. The area had two gates. One gate led to the north side of the facility to the parking lot and the street. The other gate lead to the south side of the facility with a parking lot and two streets. Both gates gave access to the street with high motor vehicle traffic. On 07/17/12 at 12:50 p.m., the DON was asked how many residents were at risk for elopement. The DON stated only one, resident #12. On 07/16/12, 07/17/12, and 07/18/12, resident #12 was observed to exit through the smoke break area door to the fenced yard area without staff supervision. The resident was observed to push the exit button and the door handle without difficulty and go through the door. On 07/19/12 at 5:50 p.m., dietary aide #1 was asked if resident #12 had ever eloped from the facility. The dietary aide stated the resident had not eloped. On 07/19/12 at 5:40 p.m., the day shift charge nurse was asked if resident #12 had ever eloped. The charge nurse stated the resident usually left after going outside, around the building, and through a gate to the street. On 07/19/12 at 6:00 p.m., the assistant director of nurses (ADON) was asked what type of measures were put into place to prevent elopement. The ADON stated visual checks every 15 minutes would be done when the resident was returned to the facility. The ADON stated she did not know how long the checks would be done. The ADON stated there had been a discussion with the administrator about a month before concerning the possibility of an alarm system for residents who wander. On 07/19/12 at 6:06 p.m., the activity director (AD) was asked what type of activities were provided for resident #12. The AD stated the resident liked to smoke with his peers, play bingo, play shape games, play cards, play ball toss, and talk. On 07/19/12 at 6:10 p.m., the DON was asked what had the facility put into place to prevent resident #12 from eloping. The DON stated close supervision and all staff were aware the resident might elope. The DON stated the resident was more apt to elope if he had increased anxiety. The DON stated the resident had increased pacing if anxious and the staff knew to "watch closer." The DON stated the resident usually eloped out through the smoking area and through the courtyard gates. The DON stated the facility had chains wrapped around the gate to give the illusion of being locked. The DON was asked if it had kept the resident from eloping. The DON stated the resident had not left in a long time. The DON was asked when had the resident last eloped. The DON stated she would have to look at the incident reports. The DON returned and stated she had 5 incident reports of elopement, the last time being on 05/18/12. SMOKING HAZARD-RESIDENT #12 1b. The admission assessment, dated 10/31/12, documented the resident was moderately impaired with daily decision making, ambulated independently, and had a behavior of wandering. The assessment documented the behavior of wandering placed the resident at significant risk of getting to a potentially dangerous place outside of the facility. The assessment documented the resident used tobacco. No documentation of an initial care plan was available in the resident's clinical record. On 07/19/12 at 6:00 p.m., assistant director of nurses(ADON) was asked if an initial care plan was completed for the resident. The ADON stated the first care plan completed for the resident was on 04/21/12. The care plan did not reflect the resident's use of tobacco products. On 07/17/12 at 8:55 a.m., the LPN #1 was asked when smoking assessments were completed. The LPN stated the assessments were now being done on the computer and only residents admitted after April 2012 had a smoking assessment completed on admission. All other residents would have a smoking assessment completed when a quarterly assessment was to be done. On 07/17/12 at 12:45 p.m., the DON stated the facility policy and procedure did not include an assessment to be completed on residents who smoked to determine safety. The DON stated all residents were supervised as they smoked. On 07/17/12 at 2:20 p.m., the laundry aide was asked if resident #12's clothing had any burn holes. The laundry aide stated the resident's clothing had burn holes. Throughout survey on 07/16/12, 07/17/12, 07/18/12, 07/19/12 and the morning of 07/20/12, the resident was observed smoking cigarettes in the designated smoking area of the facility. 2. Resident #5 was admitted to the facility on [DATE]. The medical record documented the resident had [DIAGNOSES REDACTED]. A fall risk assessment dated , November 2011, documented the resident was at a high risk for falls. An incident report, dated 01/16/12, documented the resident was found on the floor. The report documented the resident had lacerations above and below the right eye. The report documented the interventions to prevent recurrence were to have the resident's bed in low position and a mat on the floor beside the bed. A 90 day assessment, dated 04/05/12, documented the resident was moderately cognitively impaired for decision making, had no behaviors, and required extensive assistance with transfers and ambulation. The post incident review, dated 01/16/12, documented the resident's care plan needed to be updated or written as a result of this incident. The care plan, dated 01/04/12, did not document the resident's fall and interventions to prevent recurrence. An incident report, dated 04/15/12, documented the resident was found lying on the floor on the right side with the wheelchair between the resident and the door. The report documented the resident had a laceration on the bridge of the nose, a laceration below the nose, and a laceration to the right inside of the mouth. The report documented the resident was transported to the emergency room for evaluation. The report did not document interventions to prevent recurrence. The care plan, dated 01/04/12, was not updated to include the resident's fall and interventions to prevent recurrence. The post incident review, dated 04/15/12, documented the resident's care plan needed to be updated or written as a result of this incident. An incident report, dated 06/01/12, documented the resident fell from bed and received a laceration to the right hand middle finger. The resident was sent to the emergency room for evaluation and returned to the facility with six sutures to fingertip of right hand middle finger. The incident report documented the resident had impaired memory and decision making, and was visually impaired. The report documented the interventions to prevent recurrence were to check frequently and move the wheelchair out of the room. The care plan, dated 01/04/12, was not updated to include the resident's fall and interventions to prevent recurrence. The post incident review, dated 06/01/12, documented the resident's care plan needed to be updated or written as a result of this incident. 07/17/12 at 12:45 p.m., the ADON was asked what interventions were implemented to prevent falls. The ADON stated the interventions were documented on the incident reports and the care plans and there were no other interventions. On 07/18/12 at 3:30 p.m., the resident was observed in a wheel chair in hallway. On 07/19/12 at 9:30 a.m., the resident was observed in a wheel chair in the lobby. The resident self propelled the wheel chair. 3. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 01/20/12, documented the resident had no impairment with daily decision making. The assessment documented the resident used tobacco products. The resident's care plan, dated 01/31/12, documented the resident smoked as an activity. The care plan did not document interventions to promote safe smoking for the resident. On 07/17/12 at 8:45 a.m., the DON was asked if the facility completed safe smoking assessments for the resident. The DON stated a safe smoking assessment had not been completed. The DON stated an assessment for safe smoking was to be completed on admission and only updated if there was a change to the resident's condition. On 07/17/12 at 8:55 a.m., licensed practical nurse (LPN) #1 was asked when smoking assessments were completed. The LPN stated the assessments were being done on the computer and only those residents admitted after April 2012 had a smoking assessment completed on admission. All other residents would have a smoking assessment completed when a quarterly assessment was completed. On 07/17/12 at 12:45 p.m., the DON stated the facility policy and procedure did not include an assessment to be completed for residents who smoked to determine safety. The DON stated all residents were supervised as they smoked. The facility did not have a smoking assessment documented for the resident. On 07/17/12 at 12:55 p.m., resident #7 was observed in the lobby area waiting for the smoke break to begin. The resident was wearing a knit type collared pull over shirt with a pocket at the left breast area. The pocket was observed to have a pack of cigarettes. The resident had a 1-inch diameter burn hole to the lower right front of the shirt. The LPN #2 was standing next to the resident. LPN #2 asked the resident about the cigarette pack which had four cigarettes. The resident could not recall how the cigarettes were obtained. On 07/17/12 at 12:57 p.m., the social service director (SSD) was asked if the burn hole in the resident's shirt was new. The SSD examined the burn hole and stated the hole was new. LPN #2 examined the resident and obtained vital signs. The SSD asked the resident when the burn hole occurred. The resident stated, "I don't know how it got there." On 07/17/12 at 1:00 p.m., LPN #1 was asked how many residents smoked cigarettes. The LPN stated 14 residents smoked. On 07/17/12 at 1:05 p.m., the administrator was asked what time the residents smoked. The administrator stated every hour except during meals at 12 noon and at 5:00 p.m. The administrator was asked who was assigned to supervise the residents at the smoke breaks. The administrator stated the receptionist, activities, medical records, social services, any staff available. On 07/17/12 at 1:35 p.m., the SSD with the surveyor present observed the resident's clothing. One shirt and one pair of sweat type pants were observed to have burn holes. On 07/17/12 at 2:30 p.m., the facility twelve month history of incident and accident reports were reviewed. No incidents or accidents involving the smoking of cigarettes were documented. On 07/19/12 at 11:20 a.m., the laundry aide was interviewed. The laundry aide stated four residents had burn holes in their clothing. On 07/19/12 at 1:00 p.m., the administrator stated the facility had only recently started doing supervised smoking. 4. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 06/15/12, documented the resident had vision problems, had functional limitation to one side of the body, utilized psychotropic medication for behaviors, depression, insomnia, and used tobacco. The assessment documented the resident was alert and oriented and was able to make daily decision. A care plan, dated 06/18/12, had no documentation of the resident risk for injury with smoking. The care plan documented the resident smoked with peers in the designated area. On 07/16/12 at 6:00 p.m., the resident was observed to ambulate with a quad cane out to the patio area. The resident was smoking a cigarette. On 07/17/12 at 8:45 a.m., the DON was asked if the facility did safe smoking assessments for the resident. The DON stated a safe smoking assessment had not been done. The DON stated an assessment for safe smoking was done on admission and only updated if there was a change the resident's condition. On 07/17/12 at 12:45 p.m., the DON stated the facility policy and procedure did not include an assessment to be completed on residents who smoked to determine safety. The DON stated all residents were supervised as they smoked. On 07/17/12 at 2:20 p.m., the laundry aide was asked if resident #4's clothing had any burn holes. The laundry aide stated the resident's clothing had no burn holes. 5. Resident #11's original admitted to the facility was 03/19/09. The resident's readmitted was 02/24/12. The medical record documented the resident had [DIAGNOSES REDACTED]. The resident was not in the facility at the time of the survey. A fall risk assessment, dated December 2011, documented the resident was a high risk for falls. A 60 day assessment, dated 01/21/12, documented the resident was moderately cognitively impaired for decision making, required limited assist with transfers, and required extensive assist with ambulation. An incident report, dated 02/25/12, documented the resident fell and was found on the floor underneath his wheel chair looking for his glasses. The resident received an abrasion to his right knee. The report documented the resident was impaired for memory and decision making, had delirium indicators present, was physically impaired, and was visually impaired. The report documented the interventions to prevent recurrence were to have the resident's glasses repaired to stay on his face and to instruct the resident to ask for help. A post incident review, dated 02/27/12 (for the 02/25/12 incident), documented the resident's care plan needed to be updated or written as a result of this incident. No documentation of an initial care plan was available in the resident's clinical record. On 07/19/12 at 6:00 p.m., assistant director of nurses(ADON) was asked if an initial care plan was completed for the resident. The ADON stated the first care plan completed for the resident was on 03/23/12. An incident report, dated 02/26/12, documented the resident fell forward from his wheel chair and hit his forehead on the floor. The report documented the resident stated his forehead hurt and he had an abrasion to the right side of his forehead. The report documented the interventions to prevent recurrence were to hold the 8:00 p.m. medications trazodone, thorazine, ativan, and a medication review by psychiatrist and the primary physician. The incident final report, dated 02/27/12, documented the resident was a high fall risk. A post incident review, dated 02/27/12, (for the 02/26/12 incident) documented the resident's care plan needed to be updated or written as a result of this incident. No documentation of an initial care plan was available in the resident's clinical record. On 07/19/12 at 6:00 p.m., assistant director of nurses(ADON) was asked if an initial care plan was completed for the resident. The ADON stated the first care plan completed for the resident was on 03/23/12. An incident report, dated 02/28/12, documented the resident fell from his wheel chair onto the dining room floor. The report documented the resident had no apparent injury. The report documented the resident had impaired memory and decision making, was physically impaired, was visually impaired, was restless, and was constantly moving his wheel chair. The report documented the interventions to prevent recurrence were to encourage the resident to call for help when needed and to avoid propelling his wheel chair in congested areas to prevent wheel chair collisions with furniture and/or people to prevent the resident from being propelled from the wheel chair to the floor. The incident final report, dated 02/29/12 (for the 02/28/12 incident), documented the resident had poor safety awareness and a history of falls. No documentation of an initial care plan was available in the resident's clinical record. On 07/19/12 at 6:00 p.m., assistant director of nurses(ADON) was asked if an initial care plan was completed for the resident. The ADON stated the first care plan completed for the resident was on 03/23/12. An incident report, dated 03/02/12, documented the resident slid off his bed and received an abrasion on his mid-back. The report documented the interventions to prevent recurrence were the staff was instructed to frequently ask the resident if he needs help transferring and encourage the resident to wait for the staff to assist him with transfers. The post incident review, dated 03/02/12, documented the resident had a decline in cognitive skills, and poor safety awareness. No documentation of an initial care plan was available in the resident's clinical record. On 07/19/12 at 6:00 p.m., assistant director of nurses(ADON) was asked if an initial care plan was completed for the resident. The ADON stated the first care plan completed for the resident was on 03/23/12. An incident report, dated 03/03/12, documented the resident was in the dining room, attempted to stand, and fell to the floor on his left shoulder. The report documented the interventions to prevent recurrence were to remind the resident to ask for assistance. A post incident review, dated 03/03/12, documented the resident had a decline in cognitive skills and poor safety awareness. The review documented the resident's care plan needed to be updated as a result of this incident. No documentation of an initial care plan was available in the resident's clinical record. On 07/19/12 at 6:00 p.m., assistant director of nurses(ADON) was asked if an initial care plan was completed for the resident. The ADON stated the first care plan completed for the resident was on 03/23/12. An incident report, dated 03/09/12, documented the resident had been assisted to bed and his glasses were placed on the dresser. The report documented the resident was found on the floor in his room with his pants and briefs pulled down and feces on the floor. The report documented the resident had two lacerations above his left eye brow. The report documented the resident had impaired memory, had impaired decision making, was physically impaired, and had visual impairment. The report documented the interventions to prevent recurrence were to place a padded mat on the floor at the bedside, allow the resident to wear his glasses to bed, and to toilet the resident before he goes to bed. The resident was sent to the emergency room for evaluation. A nurse's note, dated 03/09/12, documented the resident returned from the emergency room with three sutures in the lacerations. A post incident review, dated 03/09/12, documented the resident's care plan needed to be updated as a result of this incident. A care plan, dated 03/14/12, did not document the resident's fall. The care plan documented the nurse would complete a fall risk assessment at least quarterly and every time the resident had a fall to attempt to provide the resident the safest care possible. An incident report, dated 03/18/12, documented the resident was seated in his wheel chair in the lobby eating lunch, leaned forward, and fel

On 07/19/12, an Immediate Jeopardy (IJ) situation was identified in accident hazards. The facility failed to implement measures to promote resident safety related to multiple elopements which could have resulted in injury. On 07/19/12 at 7:01 p.m., the Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ in accident hazards. On 07/19/12 at 7:05 p.m., the administrator and the DON were notified of the IJ in accident hazards related to elopement which placed the facility in an extended survey. On 07/19/12 at 7:44 p.m., the facility submitted a plan of removal of immediacy. The plan was not accepted. On 07/19/12 at 8:14 p.m., the facility submitted an acceptable plan of removal of immediacy. FACILITY PLAN OF REMOVAL OF IMMEDIACY The facility plan of removal documented: "1) A staff member will be assigned to perform one on one and will document location and activity every 15 minutes. When staff needs to be relieved another staff member will monitor and initial form. 2) Friday July 19, 2012 facility will notify family that for the resident's safety relocation is necessary and facility will start the process of placing the resident at another facility. 3) Till placement is found the facility will continue to perform one on one and document. 4) Plan of care is updated to reflect the one on one with the resident due to elopement risk. 5) All staff will be in-serviced by 4:00 p.m. Friday 20, 2012." IMMEDIACY REMOVED On 07/19/12 starting at 7:30 p.m. until 07/20/12 at 1:50 p.m., the resident was with a facility staff member. At that time the resident was discharged from the facility and transferred to another facility. The administrator and DON presented the survey team with copies of in-services, a resident care plan, and other documents related to elopement and accident hazards. Staff interviews were conducted on 07/20/12. Certified nurse aids, charge nurses, dietary staff, office staff, housekeeping, and maintenance staff were interviewed in regards to their knowledge of the in-service to ensure the staff understood the risk of resident elopement and the safety interventions implemented to prevent elopement. All staff interviewed responded appropriately. The IJ was removed effective 07/20/12 at 1:30 p.m., when the last in-service had been completed and staff interviews were conducted. The deficient practice remained at a level of actual harm at a pattern level. Based on observation, record review, and interview, it was determined the facility administration did not function effectively and efficiently to ensure each resident received adequate supervision to promote resident safety for five (#4, #5, #7, #11, and #12) of twelve residents reviewed for accident hazards. The facility failed to: a. implement measures to prevent elopement for resident #12 who wandered from the facility onto a busy street 8 times in the previous 8 months. b. identify the cause of falls and implement preventative measures for residents #5 and #11 who had multiple falls resulting in lacerations requiring stitches. c. follow the facility policy for supervised smoking and failed to complete a thorough smoking assessment to identify and implement safe smoking interventions for residents #4, #7, and #12. The facility census and condition report identified 41 residents currently resided in the facility. Findings: The facility's lost or missing resident policy, dated 11/10/95, documented prompt actions were to be taken by the facility if a resident was lost or missing from the facility. The policy documented the facility administrator had primary responsibility for compliance with the policy. The policy documented the person who discovered the resident missing would report the fact to the charge nurse, DON, and the administrator. The policy documented an accurate record would be documented of the time the resident was reported missing; times of notification of administrator, family, police, etc.; steps taken to locate the resident; and any other pertinent information. The policy documented when a resident was returned to the facility, and the DON or the charge nurse would complete an incident report, notify the physician, the family, the police department, and hospitals. The policy documented the charge nurse would document all events and notifications in detail. A smoking policy and procedure, dated 06/12/06, documented the facility would establish a smoking schedule for the residents, a facility employee would supervise residents when smoking, and combustible items were prohibited in the residents' possession (including lighters, matches, cigarettes, cigars, pipes, loose tobacco and papers). The smoking policy and procedure, updated with an addendum on 07/30/10. The addendum documented smoking times were on the hour from the hours of 8:00 a.m. to 8:00 p.m. The addendum documented no smoking would be permitted during meal times 12:00 p.m. to 1:00 p.m. and 5:00 p.m. to 6:00 p.m. The addendum documented cigarettes would be handed out on the hour. The policy did not document residents would be assessed for safety with use of tobacco products and combustibles. 1a. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The clinical record documented the resident was admitted to the facility from a residential care facility due to the resident's increasing need for medical support. The admission assessment, dated 10/31/12, documented the resident was moderately impaired with daily decision making, ambulated independently, and had a behavior of wandering. The assessment documented the behavior of wandering placed the resident at significant risk of getting to a potentially dangerous place outside of the facility. The assessment documented the resident used tobacco. An undated elopement risk assessment documented the resident was cognitively impaired with poor decision-making skills. The assessment documented the resident had expressed a desire to leave the facility and go home. The assessment documented the resident was known to be an elopement risk. The assessment documented the resident had denied experiencing any pain. The assessment documented the exit doors had alarms. The assessment did not document interventions to prevent the resident from wandering away from the facility. The assessment did not document interventions were included in the resident's plan of care. The assessment was not dated or signed by facility staff. No documentation of an initial care plan was available in the resident's clinical record. On 07/19/12 at 6:00 p.m., assistant director of nurses(ADON) was asked if an initial care plan was completed for the resident. The ADON stated the first care plan completed for the resident was on 04/21/12. An interdisciplinary progress note, dated 10/30/11 at 8 p.m., documented the facility staff reported the resident was missing from the facility. The progress note documented the facility and immediate campus was searched. The progress note documented the resident was found on the opposite side of a high motor vehicle traffic street and south of the facility. No documentation of an initial care plan was available in the resident's clinical record. On 07/19/12 at 6:00 p.m., assistant director of nurses(ADON) was asked if an initial care plan was completed for the resident. The ADON stated the first care plan completed for the resident was on 04/21/12. An interdisciplinary progress note, dated 11/14/11 at 8:55 a.m., documented the resident had left the facility while exit doors were being repaired. The progress note documented the facility staff found the resident as he stepped to walk into the street with high motor vehicle traffic. An incident report was completed. The incident was not reported to the appropriate agency. An interdisciplinary progress note, dated 12/17/12 at 3:30 a.m., documented the resident had left the facility unsupervised and staff had observed the resident south of the facility. The progress note documented the resident had a desire to go home. An incident report for this elopement was not found in the resident's clinical record. No documentation of an initial care plan was available in the resident's clinical record. On 07/19/12 at 6:00 p.m., assistant director of nurses(ADON) was asked if an initial care plan was completed for the resident. The ADON stated the first care plan completed for the resident was on 04/21/12. An interdisciplinary progress note, dated 01/08/12 at 10:30 a.m., documented a staff member had seen the resident walking west approximately eight blocks from the facility. The note documented the resident had walked across a street with high motor vehicle traffic. On 01/08/12, the facility had completed an incident report and documented the incident was reported to the appropriate agency. No documentation of an initial care plan was available in the resident's clinical record. On 07/19/12 at 6:00 p.m., assistant director of nurses(ADON) was asked if an initial care plan was completed for the resident. The ADON stated the first care plan completed for the resident was on 04/21/12. An interdisciplinary progress note, dated 02/07/12 at 3:30 p.m., documented the resident was returned to the facility by a deputy sheriff. The note documented the deputy had found the resident walking south of the facility beside the street with high motor vehicle traffic. On 02/08/12, an incident report documented the measures to prevent recurrence were to place the resident on one hour watch. No documentation of an initial care plan was available in the resident's clinical record. On 07/19/12 at 6:00 p.m., assistant director of nurses(ADON) was asked if an initial care plan was completed for the resident. The ADON stated the first care plan completed for the resident was on 04/21/12. An interdisciplinary progress note, dated 03/28/12 at 4:00 p.m., documented the resident left the facility behind a delivery man. The note documented the resident walked to the south parking lot and was attempting to cross the street with high motor vehicle. An incident report for this elopement was not found in the resident's clinical record. No documentation of an initial care plan was available in the resident's clinical record. On 07/19/12 at 6:00 p.m., assistant director of nurses(ADON) was asked if an initial care plan was completed for the resident. The ADON stated the first care plan completed for the resident was on 04/21/12. An interdisciplinary progress note, dated 4/11/12 at 11:26 a.m., documented the resident was found outside the facility and had attempted to leave through the unsecured courtyard gate. No documentation of an initial care plan was available in the resident's clinical record. On 07/19/12 at 6:00 p.m., assistant director of nurses(ADON) was asked if an initial care plan was completed for the resident. The ADON stated the first care plan completed for the resident was on 04/21/12. A care plan, dated 04/21/12, did not document the resident's risk for elopement or the resident's history of elopements. The care plan did not document interventions to prevent elopement. An interdisciplinary progress note, dated 05/10/12 at 5:30 p.m., documented the resident had left the facility through the back door and walked around the back of the facility through the unsecured courtyard gate. An incident report for this elopement was not found in the resident's clinical record. The care plan, dated 04/21/12, was not updated to include the resident's elopements or interventions to prevent recurrence. An interdisciplinary progress note, dated 05/18/12 at 11:45 a.m., documented the resident was missing from the facility. The progress note documented the resident was found by the administrator fifteen minutes later one block north and two blocks east of the facility. An incident report was completed and the physician and the family were notified. The facility's intervention to prevent recurrence was to visually check the resident every 30 minutes for four hours, then every four hours for 20 hours, and then to resume every two hour checks. The care plan, dated 04/21/12, was not updated to include the resident's elopements or interventions to prevent recurrence. On initial tour on 07/16/12 at 1:45 p.m., four of the six facility exit doors were observed to have a key pad device to unlock the doors with codes. Two doors (the exit door to the resident smoking area and the door near the laundry room) had no key pad devices with codes. The doors had a single button to be pushed at the same time the door's exit handle was pressed. No doors were observed to have a security device to signal staff if a resident at risk for elopement was going out the doors unsupervised. On 07/17/12 at 12:45 p.m., the facility's fenced yard was observed. The area had two gates. One gate led to the north side of the facility to the parking lot and the street. The other gate lead to the south side of the facility with a parking lot and two streets. Both gates gave access to the street with high motor vehicle traffic. On 07/17/12 at 12:50 p.m., the DON was asked how many residents were at risk for elopement. The DON stated only one, resident #12. On 07/16/12, 07/17/12, and 07/18/12, resident #12 was observed to exit through the smoke break area door to the fenced yard area without staff supervision. The resident was observed to push the exit button and the door handle without difficulty and go through the door. On 07/19/12 at 5:50 p.m., dietary aide #1 was asked if resident #12 had ever eloped from the facility. The dietary aide stated the resident had not eloped. On 07/19/12 at 5:40 p.m., the day shift charge nurse was asked if resident #12 had ever eloped. The charge nurse stated the resident usually left after going outside, around the building, and through a gate to the street. On 07/19/12 at 6:00 p.m., the assistant director of nurses (ADON) was asked what type of measures were put into place to prevent elopement. The ADON stated visual checks every 15 minutes would be done when the resident was returned to the facility. The ADON stated she did not know how long the checks would be done. The ADON stated there had been a discussion with the administrator about a month before concerning the possibility of an alarm system for residents who wander. On 07/19/12 at 6:06 p.m., the activity director (AD) was asked what type of activities were provided for resident #12. The AD stated the resident liked to smoke with his peers, play bingo, play shape games, play cards, play ball toss, and talk. On 07/19/12 at 6:10 p.m., the DON was asked what had the facility put into place to prevent resident #12 from eloping. The DON stated close supervision and all staff were aware the resident might elope. The DON stated the resident was more apt to elope if he had increased anxiety. The DON stated the resident had increased pacing if anxious and the staff knew to "watch closer." The DON stated the resident usually eloped out through the smoking area and through the courtyard gates. The DON stated the facility had chains wrapped around the gate to give the illusion of being locked. The DON was asked if it had kept the resident from eloping. The DON stated the resident had not left in a long time. The DON was asked when had the resident last eloped. The DON stated she would have to look at the incident reports. The DON returned and stated she had 5 incident reports of elopement, the last time being on 05/18/12. SMOKING HAZARD-RESIDENT #12 1b. The admission assessment, dated 10/31/12, documented the resident was moderately impaired with daily decision making, ambulated independently, and had a behavior of wandering. The assessment documented the behavior of wandering placed the resident at significant risk of getting to a potentially dangerous place outside of the facility. The assessment documented the resident used tobacco. No documentation of an initial care plan was available in the resident's clinical record. On 07/19/12 at 6:00 p.m., assistant director of nurses(ADON) was asked if an initial care plan was completed for the resident. The ADON stated the first care plan completed for the resident was on 04/21/12. The care plan did not reflect the resident's use of tobacco products. On 07/17/12 at 8:55 a.m., the LPN #1 was asked when smoking assessments were completed. The LPN stated the assessments were now being done on the computer and only residents admitted after April 2012 had a smoking assessment completed on admission. All other residents would have a smoking assessment completed when a quarterly assessment was to be done. On 07/17/12 at 12:45 p.m., the DON stated the facility policy and procedure did not include an assessment to be completed on residents who smoked to determine safety. The DON stated all residents were supervised as they smoked. On 07/17/12 at 2:20 p.m., the laundry aide was asked if resident #12's clothing had any burn holes. The laundry aide stated the resident's clothing had burn holes. Throughout survey on 07/16/12, 07/17/12, 07/18/12, 07/19/12 and the morning of 07/20/12, the resident was observed smoking cigarettes in the designated smoking area of the facility. 2. Resident #5 was admitted to the facility on [DATE]. The medical record documented the resident had [DIAGNOSES REDACTED]. A fall risk assessment dated , November 2011, documented the resident was at a high risk for falls. An incident report, dated 01/16/12, documented the resident was found on the floor. The report documented the resident had lacerations above and below the right eye. The report documented the interventions to prevent recurrence were to have the resident's bed in low position and a mat on the floor beside the bed. A 90 day assessment, dated 04/05/12, documented the resident was moderately cognitively impaired for decision making, had no behaviors, and required extensive assistance with transfers and ambulation. The post incident review, dated 01/16/12, documented the resident's care plan needed to be updated or written as a result of this incident. The care plan, dated 01/04/12, did not document the resident's fall and interventions to prevent recurrence. An incident report, dated 04/15/12, documented the resident was found lying on the floor on the right side with the wheelchair between the resident and the door. The report documented the resident had a laceration on the bridge of the nose, a laceration below the nose, and a laceration to the right inside of the mouth. The report documented the resident was transported to the emergency room for evaluation. The report did not document interventions to prevent recurrence. The care plan, dated 01/04/12, was not updated to include the resident's fall and interventions to prevent recurrence. The post incident review, dated 04/15/12, documented the resident's care plan needed to be updated or written as a result of this incident. An incident report, dated 06/01/12, documented the resident fell from bed and received a laceration to the right hand middle finger. The resident was sent to the emergency room for evaluation and returned to the facility with six sutures to fingertip of right hand middle finger. The incident report documented the resident had impaired memory and decision making, and was visually impaired. The report documented the interventions to prevent recurrence were to check frequently and move the wheelchair out of the room. The care plan, dated 01/04/12, was not updated to include the resident's fall and interventions to prevent recurrence. The post incident review, dated 06/01/12, documented the resident's care plan needed to be updated or written as a result of this incident. 07/17/12 at 12:45 p.m., the ADON was asked what interventions were implemented to prevent falls. The ADON stated the interventions were documented on the incident reports and the care plans and there were no other interventions. On 07/18/12 at 3:30 p.m., the resident was observed in a wheel chair in hallway. On 07/19/12 at 9:30 a.m., the resident was observed in a wheel chair in the lobby. The resident self propelled the wheel chair. 3. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 01/20/12, documented the resident had no impairment with daily decision making. The assessment documented the resident used tobacco products. The resident's care plan, dated 01/31/12, documented the resident smoked as an activity. The care plan did not document interventions to promote safe smoking for the resident. On 07/17/12 at 8:45 a.m., the DON was asked if the facility completed safe smoking assessments for the resident. The DON stated a safe smoking assessment had not been completed. The DON stated an assessment for safe smoking was to be completed on admission and only updated if there was a change to the resident's condition. On 07/17/12 at 8:55 a.m., licensed practical nurse (LPN) #1 was asked when smoking assessments were completed. The LPN stated the assessments were being done on the computer and only those residents admitted after April 2012 had a smoking assessment completed on admission. All other residents would have a smoking assessment completed when a quarterly assessment was completed. On 07/17/12 at 12:45 p.m., the DON stated the facility policy and procedure did not include an assessment to be completed for residents who smoked to determine safety. The DON stated all residents were supervised as they smoked. The facility did not have a smoking assessment documented for the resident. On 07/17/12 at 12:55 p.m., resident #7 was observed in the lobby area waiting for the smoke break to begin. The resident was wearing a knit type collared pull over shirt with a pocket at the left breast area. The pocket was observed to have a pack of cigarettes. The resident had a 1-inch diameter burn hole to the lower right front of the shirt. The LPN #2 was standing next to the resident. LPN #2 asked the resident about the cigarette pack which had four cigarettes. The resident could not recall how the cigarettes were obtained. On 07/17/12 at 12:57 p.m., the social service director (SSD) was asked if the burn hole in the resident's shirt was new. The SSD examined the burn hole and stated the hole was new. LPN #2 examined the resident and obtained vital signs. The SSD asked the resident when the burn hole occurred. The resident stated, "I don't know how it got there." On 07/17/12 at 1:00 p.m., LPN #1 was asked how many residents smoked cigarettes. The LPN stated 14 residents smoked. On 07/17/12 at 1:05 p.m., the administrator was asked what time the residents smoked. The administrator stated every hour except during meals at 12 noon and at 5:00 p.m. The administrator was asked who was assigned to supervise the residents at the smoke breaks. The administrator stated the receptionist, activities, medical records, social services, any staff available. On 07/17/12 at 1:35 p.m., the SSD with the surveyor present observed the resident's clothing. One shirt and one pair of sweat type pants were observed to have burn holes. On 07/17/12 at 2:30 p.m., the facility twelve month history of incident and accident reports were reviewed. No incidents or accidents involving the smoking of cigarettes were documented. On 07/19/12 at 11:20 a.m., the laundry aide was interviewed. The laundry aide stated four residents had burn holes in their clothing. On 07/19/12 at 1:00 p.m., the administrator stated the facility had only recently started doing supervised smoking. 4. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 06/15/12, documented the resident had vision problems, had functional limitation to one side of the body, utilized [MEDICAL CONDITION] medication for behaviors, depression, [MEDICAL CONDITION], and used tobacco. The assessment documented the resident was alert and oriented and was able to make daily decision. A care plan, dated 06/18/12, had no documentation of the resident risk for injury with smoking. The care plan documented the resident smoked with peers in the designated area. On 07/16/12 at 6:00 p.m., the resident was observed to ambulate with a quad cane out to the patio area. The resident was smoking a cigarette. On 07/17/12 at 8:45 a.m., the DON was asked if the facility did safe smoking assessments for the resident. The DON stated a safe smoking assessment had not been done. The DON stated an assessment for safe smoking was done on admission and only updated if there was a change the resident's condition. On 07/17/12 at 12:45 p.m., the DON stated the facility policy and procedure did not include an assessment to be completed on residents who smoked to determine safety. The DON stated all residents were supervised as they smoked. On 07/17/12 at 2:20 p.m., the laundry aide was asked if resident #4's clothing had any burn holes. The laundry aide stated the resident's clothing had no burn holes. 5. Resident #11's original admitted to the facility was 03/19/09. The resident's readmitted was 02/24/12. The medical record documented the resident had [DIAGNOSES REDACTED]. The resident was not in the facility at the time of the survey. A fall risk assessment, dated December 2011, documented the resident was a high risk for falls. A 60 day assessment, dated 01/21/12, documented the resident was moderately cognitively impaired for decision making, required limited assist with transfers, and required extensive assist with ambulation. An incident report, dated 02/25/12, documented the resident fell and was found on the floor underneath his wheel chair looking for his glasses. The resident received an abrasion to his right knee. The report documented the resident was impaired for memory and decision making, had [MEDICAL CONDITION] indicators present, was physically impaired, and was visually impaired. The report documented the interventions to prevent recurrence were to have the resident's glasses repaired to stay on his face and to instruct the resident to ask for help. A post incident review, dated 02/27/12 (for the 02/25/12 incident), documented the resident's care plan needed to be updated or written as a result of this incident. No documentation of an initial care plan was available in the resident's clinical record. On 07/19/12 at 6:00 p.m., assistant director of nurses(ADON) was asked if an initial care plan was completed for the resident. The ADON stated the first care plan completed for the resident was on 03/23/12. An incident report, dated 02/26/12, documented the resident fell forward from his wheel chair and hit his forehead on the floor. The report documented the resident stated his forehead hurt and he had an abrasion to the right side of his forehead. The report documented the interventions to prevent recurrence were to hold the 8:00 p.m. medications [MEDICATION NAME], and a medication review by psychiatrist and the primary physician. The incident final report, dated 02/27/12, documented the resident was a high fall risk. A post incident review, dated 02/27/12, (for the 02/26/12 incident) documented the resident's care plan needed to be updated or written as a result of this incident. No documentation of an initial care plan was available in the resident's clinical record. On 07/19/12 at 6:00 p.m., assistant director of nurses(ADON) was asked if an initial care plan was completed for the resident. The ADON stated the first care plan completed for the resident was on 03/23/12. An incident report, dated 02/28/12, documented the resident fell from his wheel chair onto the dining room floor. The report documented the resident had no apparent injury. The report documented the resident had impaired memory and decision making, was physically impaired, was visually impaired, was restless, and was constantly moving his wheel chair. The report documented the interventions to prevent recurrence were to encourage the resident to call for help when needed and to avoid propelling his wheel chair in congested areas to prevent wheel chair collisions with furniture and/or people to prevent the resident from being propelled from the wheel chair to the floor. The incident final report, dated 02/29/12 (for the 02/28/12 incident), documented the resident had poor safety awareness and a history of falls. No documentation of an initial care plan was available in the resident's clinical record. On 07/19/12 at 6:00 p.m., assistant director of nurses(ADON) was asked if an initial care plan was completed for the resident. The ADON stated the first care plan completed for the resident was on 03/23/12. An incident report, dated 03/02/12, documented the resident slid off his bed and received an abrasion on his mid-back. The report documented the interventions to prevent recurrence were the staff was instructed to frequently ask the resident if he needs help transferring and encourage the resident to wait for the staff to assist him with transfers. The post incident review, dated 03/02/12, documented the resident had a decline in cognitive skills, and poor safety awareness. No documentation of an initial care plan was available in the resident's clinical record. On 07/19/12 at 6:00 p.m., assistant director of nurses(ADON) was asked if an initial care plan was completed for the resident. The ADON stated the first care plan completed for the resident was on 03/23/12. An incident report, dated 03/03/12, documented the resident was in the dining room, attempted to stand, and fell to the floor on his left shoulder. The report documented the interventions to prevent recurrence were to remind the resident to ask for assistance. A post incident review, dated 03/03/12, documented the resident had a decline in cognitive skills and poor safety awareness. The review documented the resident's care plan needed to be updated as a result of this incident. No documentation of an initial care plan was available in the resident's clinical record. On 07/19/12 at 6:00 p.m., assistant director of nurses(ADON) was asked if an initial care plan was completed for the resident. The ADON stated the first care plan completed for the resident was on 03/23/12. An incident report, dated 03/09/12, documented the resident had been assisted to bed and his glasses were placed on the dresser. The report documented the resident was found on the floor in his room with his pants and briefs pulled down and feces on the floor. The report documented the resident had two lacerations above his left eye brow. The report documented the resident had impaired memory, had impaired decision making, was physically impaired, and had visual impairment. The report documented the interventions to prevent recurrence were to place a padded mat on the floor at the bedside, allow the resident to wear his glasses to bed, and to toilet the resident before he goes to bed. The resident was sent to the emergency room for evaluation. A nurse's note, dated 03/09/12, documented the resident returned from the emergency room with three sutures in the lacerations. A post incident review, dated 03/09/12, documented the resident's care plan needed to be updated as a result of this incident. A care plan, dated 03/14/12, did not document the resident's fall. The care plan documented the nurse would complete a fall risk assessment at least quarterly and every time the resident had a fall to attempt to provide the resident the safest care possible. An incident report, dated 03/18/12, documented the resident was seated in his wheel c