Every finding on record at Wagoner Health & Rehab

Based on observation and interview, the facility failed to provide meals at a palatable temperature for 3 (#4, 6, and #7) of 3 sampled residents reviewed for meal palatability.The infection preventionist identified 48 residents received meals from the kitchen. Findings:On 02/23/26 at 12:50 p.m., a test tray was sampled for temperature and palatability. The fried potatoes were undercooked and lukewarm, the turnip greens were lukewarm, the cornbread was cold and dry.1. An annual assessment for Res #4, dated 11/21/25, showed the resident had a BIMS score of 15 which indicated intact cognition.On 02/23/26 at 8:30 a.m., Res #4 stated when they ate in their room the food was always cold. Res #4 stated the food did not taste good.2. A quarterly assessment for Res #6, dated 01/10/26, showed the resident had a BIMS score of 15 which indicated intact cognition.On 02/23/26 at 8:55 a.m., Res #6 stated the food was cold by the time it was delivered to their room. Res #6 stated the food had tasted bad for a long time.On 02/24/26 at 7:50 a.m., Res #6 stated the potatoes they had for lunch the day before were undercooked, crunchy, and the meal was cold.3. A quarterly assessment for Res #7, dated 12/11/25, showed the resident had a BIMS score of 15 which indicated intact cognition.On 02/24/26 at 1:10 p.m., Res #7 stated they ate all meals in their room, and the food was almost always cold by the time it arrived.On 02/25/26 at 10:00 a.m., the DM stated they were working to get the trays out to the residents quicker and ensure the food was warm and palatable.

Based on observation, record review, and interview, the facility failed to ensure 2 (dietary aide #1 and the DM) of 2 dietary staff washed their hands immediately upon entry to the kitchen.The infection preventionist identified 48 residents received meals from the kitchen. Findings:On 02/23/26 at 11:55 a.m., dietary aide #1 was observed to enter the kitchen and begin working without washing their hands.On 02/23/26 at 11:59 a.m., dietary aide #1 was observed to enter the kitchen and begin working without washing their hands.On 02/23/26 at 12:00 p.m., the DM was observed to enter the kitchen and begin working without washing their hands.On 02/23/26 at 12:04 p.m., dietary aide #1 was observed to enter the kitchen and begin working without washing their hands.On 02/23/26 at 12:07 p.m., dietary aide #1 was observed to enter the kitchen and begin working without washing their hands.An undated policy titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices showed staff were required to wash their hands when entering the kitchen.On 02/24/26 at 8:00 a.m., the DM stated when someone entered the kitchen, they were to wash their hands.

Based on record review and interview, the facility failed to ensure the wasting of narcotic medications was witnessed by 2 staff members for 1 (#5) of 3 sampled residents reviewed for medication administration.The infection preventionist identified 48 residents received medication in the facility. Findings: An undated Discarding and Destroying Medications policy showed documenting the destruction of narcotics required the signatures of at least two witnesses.An admission record for Res #5, dated 08/20/24, showed the resident had diagnoses which included emphysema and heart failure.A physician's order for Res #5, dated 12/06/25, showed the resident was to receive oxycodone 10 mg (a narcotic pain medication) by mouth every six hours.A Controlled Drug Receipt/Record/Disposition Form, dated 02/2026, showed on 02/13/26 at 6:00 a.m. one 10 mg oxycodone tablet was wasted. The form only included one signature.On 02/24/26 at 11:15 a.m., LPN #1 stated if they needed to waste a narcotic medication a nurse had to witness and sign off with the other employee.On 02/24/26 at 3:25 p.m., the infection preventionist stated two staff members had to sign off if a narcotic medication was wasted.

Based on observation, record review, and interview, the facility failed to ensure EBP was utilized during PEG tube care for 1 (#7) of 7 sampled residents reviewed for infection control.The infection preventionist identified 23 residents were on EBP. Findings:On 02/23/26 at 9:20 a.m., LPN #1 was observed during PEG tube care for Res #7. LPN #1 was not observed to wear a gown. A sign was observed on the resident's door that showed Res #7 was on EBP.A facility Enhanced Barrier Precautions policy, dated 04/29/24, read in part, EBP requires donning of gown and gloves during high-contact resident/guest care activities.EBP is indicated for resident/guests with any of the following when contact precautions do not apply.Wounds or an indwelling medical device.Indwelling medical devices examples include central lines, urinary catheters, feeding tubes and tracheostomies.A care plan focus for Res #7, initiated 05/09/25, showed the resident was at risk of infection due to the presence of a PEG tube and EBP was to be utilized when providing care.On 02/23/26 at 9:25 a.m., LPN #1 stated they should have worn a gown while proving PEG tube care for Res #7.On 02/24/26 at 3:35 p.m., the infection preventionist stated gowns were to be utilized when care was provided to a resident on EBP.

Based on record review and interview, the facility failed to revise the care plan after a fall for 3 (#1, 2, and #3) of 4 sampled residents reviewed for fall interventions.The DON identified 19 falls in the last six months.Findings:A policy titled Falls - Clinical Protocol, revised April 2025, read in part, For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall.the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling and also reconsider the current interventions.1. An undated medical diagnosis list showed Res #1 had diagnoses which included congestive heart failure and multifocal motor neuropathy.A care plan, dated 01/01/25, showed Res #1 had potential for injury related to falls. The care plan showed Res #1 had fallen on 01/01/25, 03/31/25, and 06/14/25 with fall prevention interventions documented.A facility incident report, dated 08/10/25, showed Res #1 had a non-injury fall while transferring from the bed without assistance. The care plan did not document an intervention for the 08/10/25 fall.A discharge report, dated 09/15/25, showed Res #1 discharged from the facility on 08/29/25. 2. An undated medical diagnosis list showed Res #2 had diagnoses which included atrial fibrillation and a history of falling.A care plan, dated 02/24/25, showed Res #2 was at risk for falls with fall prevention interventions documented. The care plan showed the resident had not fallen.A facility incident report, dated 05/26/25, showed Res #2 had a fall with major injury while ambulating in the facility.The care plan did not document an intervention for the 05/26/25 fall.On 09/15/25 at 1:49 p.m., Res #2 stated they were able to ambulate independently but lost their balance sometimes. Res #2 stated they had fallen while ambulating a few months ago and hurt their shoulder. 3. An undated medical diagnosis list showed Res #3 had diagnoses which included dementia and Alzheimer's disease.A care plan, dated 02/23/25, showed Res #3 had potential for injury related to falls. The care plan showed Res #3 had fallen on 02/23/25, 03/07/25, 06/07/25, and 08/12/25 with fall prevention interventions documented.A facility incident report, dated 09/04/25, showed Res #3 had a fall with minor injury while transferring from the bed without assistance.The care plan did not document an intervention for the 09/04/25 fall. On 09/16/25 at 1:45 p.m., Res #3 stated they could not remember any falls or injuries resulting from falls. On 09/16/25 at 3:00 p.m., the DON stated Res #1, 2, and #3's care plans should have been revised to reflect a new fall prevention intervention after each fall.

Based on observation, record review, and interview, the facility failed to ensure scoops were not left in bulk containers and the handwashing sink had hot water. The corporate nurse manager reported 46 residents received meals from the kitchen. Findings: On 04/07/25 at 7:27 a.m., an initial tour of the kitchen was conducted. A scoop was observed in a bulk container of flour and the handwashing sink did not have hot water. An undated facility policy titled Food Receiving and Storage, read in part, Foods shall be received and stored in a manner that complies with safe food handling practices. On 04/09/25 at 10:15 a.m., the dietary manager stated that scoops should not be left in bulk containers, and that the handwashing sink should be repaired.

Based on record review and interview, the facility failed to ensure competencies were completed yearly and upon hire for 5 (LPN #1, LPN #2, CNA #1, CNA #2, and CNA #3) of 5 employees reviewed for competencies. Human Resources reported seven LPNs and 21 CNAs were employed by the facility. Findings: 1. LPN #1 had a hire date of 02/27/25. On 04/09/25 at 4:30 p.m., LPN #1's employment file was reviewed, it did not show a competency/skills check had been completed upon hire. 2. LPN #2 had a hire date of 09/18/19. On 04/09/25 at 4:35 p.m., LPN #2's employment was reviewed, it did not show a competency/skills check had been completed upon hire. 3. CNA #1 had a hire date of 11/11/24. On 04/09/25 at 4:40 p.m., CNA #1's employment file was reviewed, it did not show a competency/skills check had been completed upon hire. 4. CNA #2 had a hire date of 02/04/25. On 04/09/25 at 4:45 P.m., CNA #2's employment filewas reviewed, it did not show a competency/skills check had been completed upon hire. 5. CNA #3 had a hire date of 08/25/24. On 04/09/25 at 4:50 p.m., CNA #3's employment filewas reviewed, it did not show a competency/skills check had been completed upon hire. On 04/09/25 at 5:26 p.m., the business office manager stated they did not have skills checks/competencies. On 04/10/25 at 11:09 a.m., the DON stated that competencies should be completed upon hire and annually. They also stated they had not completed competencies in over a year.

Based on observation, record review, and interview, the facility failed to: a. ensure enhanced barrier precautions were utilized for residents with wounds for 1 (#32) of 1 sampled resident who was reviewed for wound care; b. ensure infection control was maintained and enhanced barrier precautions were utilized during urinary catheter care for 2 (#17 and #46) of two sampled residents who were reviewed for urinary catheter; and c. ensure clean laundry was covered when transported to resident rooms. The DON identified four residents with wounds, 4 residents with urinary catheters, and 45 residents whose laundry was processed by the facility. Findings: 1. On 04/08/25 at 2:43 p.m., LPN #2 was observed to provide wound care for Resident #32. LPN #2 was not observed to utilize a gown during wound care. Signage regarding enhanced barrier precautions was not observed near the resident's room. A policy titled, Enhanced Barrier Precautions, dated August 2022, read in part, EBP's employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply .Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include .wound care .Signs MAY BE posted in the door or wall outside the resident room indicating the type of precautions and PPE [personal protective equipment] required. A quarterly assessment, dated 03/03/25, showed Resident #32 had a stage four pressure ulcer, and had a BIMS summary score of four, which indicated the resident was severely impaired in cognition for daily decision making. On 04/08/25 2:50 p.m., LPN #2 stated wound care for Resident #32 only required gloves. On 04/09/25 at 1:27 p.m., the IP stated staff should implement EBP when providing wound care for Resident #32. On 04/09/25 at 1:35 p.m., the DON stated staff were to implement EBP when they provided wound care. They stated the only way staff would know a resident was on EBP was if they knew Resident #32 had a wound. They stated they did not utilize signage to indicate EBP. 2. On 04/08/25 at 10:18 a.m., CNA #2 was observed to don three gloves on each hand and CNA #1 was observed to don two gloves on each hand and assist the resident with positioning. CNA #2 was not observed to change gloves during catheter care. Signage regarding enhanced barrier precautions was not observed near the resident's room. A policy titled, Enhanced Barrier Precautions, dated August 2022, read in parts, EBP's employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply .Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include .device care .urinary catheter .Signs MAY BE posted in the door or wall outside the resident room indicating the type of precautions and PPE required. An admission assessment, dated 12/26/24, showed Resident #46 had a diagnosis of unspecified abnormal findings in urine, had an indwelling urinary catheter, and a BIMS summary score of 15, which indicated the resident was cognitively intact for daily decision making. On 04/08/25 at 11:31 a.m., CNA #2 stated they wore three pairs of gloves during catheter care because they had watched a video online that informed them to utilize three pairs of gloves at one time. They stated they were supposed to discard the outer glove when it had become soiled, but they had forgotten. On 04/09/25 at 7:47 a.m., CNA #2 stated the nurse usually informed the CNAs if a resident was on any type of precautions which required PPE other than gloves. On 04/09/25 at 1:23 p.m., the IP stated staff were to utilize one pair of gloves at a time. The IP stated residents with urinary catheters were to be placed on EBP. The IP stated they communicated with staff if a resident was on EBP. On 04/09/25 at 1:35 p.m., the DON stated they had inserviced staff about utilizing gowns and gloves when they provided catheter care. They stated staff knew to utilize EBP if they observed the resident had a urinary catheter. The DON stated staff were to change gloves and sanitize anytime they went from soiled to a clean task when providing care. The DON stated staff should never wear more than one pair of gloves at a time during the provision of care. 42171 3. On 04/08/25 at 09:45 a.m., LPN #1 was observed flushing Resident #17's catheter. She was observed to don gloves and position the resident, then they doffed the gloves and did not perform hand hygiene. LPN #1 then proceeded to the hallway to obtain supplies, upon returning to the room, LPN #1 donned a pair of gloves without performing hand hygiene. LPN #1 then flushed the resident's catheter, went to the bathroom to retrieve paper towels and returned to the resident. LPN #1 then doffed the gloves and exited the room without performing hand hygiene. LPN #1 was not wearing a gown while flushing Resident #17's catheter. On 04/08/25 at 11:07 a.m., CNA #3 and CNA #4 were observed providing catheter care to Resident #17. They were not wearing gowns. A physician order, dated 11/13/24, showed an order to provide catheter care every shift. A quarterly assessment, dated 01/07/25, showed Resident #17 had a BIMS score (a test for cognitive function) of 15. Which was indicative of independence for daily decision making. The assessment also showed Resident #17 had an indwelling urinary catheter. A physician order, dated 02/28/25, showed an order for the catheter to be flushed every Monday, Wednesday, Friday and as needed. On 04/08/25 at 9:55 a.m., LPN #1 stated they should perform hand hygiene when changing gloves and should change gloves when moving from dirty to clean, they also stated gowns should be worn when providing direct care to residents with a catheter. 4. On 04/07/25 at 9:06 a.m., Laundry #1 was observed transporting clean clothes uncovered. On 04/07/25 at 11:35 a.m., Laundry #1 was observed transporting clean clothes uncovered. On 04/08/25 at 8:46 a.m., Laundry #1 was observed transporting clean clothes uncovered. On 04/10/25 at 9:55 a.m., Laundry # 1 stated they did not know clean linens were supposed to be covered. On 04/10/25 at 11:45 p.m., the infection preventionist stated clean clothes should be covered while transporting them.

Based on record review and interview, the facility failed to ensure menus were reviewed and approved by the dietician. The corporate nurse manager reported 46 residents received food from the kitchen. Findings: An undated policy titled Menus, read in part, Menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy.The dietician reviews and approves all menus. A dietary menu, dated 04/02/25- 04/09/25, was reviewed. There was no documentation the menu had been approved by the dietician. On 04/09/25 at 10:15 a.m., the dietary manager stated they thought the menus were approved by the dietician and they would look for documentation. No documentation was provided. On 04/10/25 at 10:26 a.m., the social services director stated the menu had not been approved by the dietician.

Based on record review and interview, the facility failed to ensure psychotropic medications were monitored for side effects for 5 (#7, 17, 20, 32, and #41) of 5 sampled residents who were reviewed for unnecessary medications. The DON identified 19 residents received psychotropic medications. Findings: 1. A physician order, dated 10/28/24, showed an order for fluoxetine (an antidepressant medication) 20 mg every day for mood disorder with depressive features. A physician order, dated 12/10/24, showed an order for lorazepam (an antianxiety medication) 2 mg/ml give 0.25 ml at bedtime for anxiety. A quarterly assessment, dated 02/24/25, showed Resident #7 a diagnosis of anxiety, recurrent depressive disorder, mood disorder with depressive features, and schizoaffective disorder, had a BIMS summary score of two, which indicated the resident was severely impaired in cognition for daily decision making, had received an antipsychotic medication, antianxiety medication, and an antidepressant medication. A care plan, revised 02/27/25, read in parts, I use psychotropic medications .Monitor for side effects and effectiveness Q-SHIFT .Monitor/document/report PRN any adverse reaction of PSYCHOTROPIC medications .I have depression .Monitor/document for side effects and effectiveness .I have a dx of anxiety .Monitor/document for side effects and effectiveness. A physician order, dated 04/04/25, showed an order for quetiapine (an antipsychotic medication) 50 mg twice daily. A Side Effect Monitoring flowsheet, dated March 2025, read in part, BLANKS INDICATE NO SIDE EFFECTS OBSERVED. The flowsheet did not show any documentation side effects had been monitored from 03/01/25 through 03/31/25. A Side Effect Monitoring flowsheet, dated April 2025, read in part, BLANKS INDICATE NO SIDE EFFECTS OBSERVED. The flowsheet did not show any documentation side effects had been monitored from 04/01/25 through 04/08/25. 2. A physician order, dated 10/26/24, showed an order for divalproex sodium extended release (an anticonvulsant medication) 250 mg every day for bipolar disorder. A quarterly assessment, dated 03/03/25, showed Resident #32 had a diagnosis of depression and bipolar disorder, and a BIMS summary score of four, which indicated the resident was severely impaired in cognition for daily decision making. A care plan, revised on 03/18/25, read in parts, I use psychotropic medications [related to] Bipolar, depression, anxiety, skin picking disorder etc .Monitor for side effects and effectiveness Q-SHIFT. A physician order, dated 03/21/25, showed the order for divalproex sodium extended release was changed to divalproex sprinkles 250 mg every day for bipolar disorder. A Side Effect Monitoring flowsheet, dated March 2025, read in part, BLANKS INDICATE NO SIDE EFFECTS OBSERVED. The flowsheet did not show any documentation side effects had been monitored from 03/01/25 through 03/31/25. A Side Effect Monitoring flowsheet, dated April 2025, read in part, BLANKS INDICATE NO SIDE EFFECTS OBSERVED. The flowsheet did not show any documentation side effects had been monitored from 04/01/25 through 04/08/25. 3. A treatment administration record, dated 04/25, showed Resident #17 had diagnoses which included bipolar disorder and depression. A physician order, dated 12/31/24, showed an order for citalopram (an antidepressant medication) 40 mg daily at bedtime for other specified persistent mood disorder. A quarterly assessment, dated 01/07/25, showed Resident #17 had a BIMS score of 15 which was indicative of independence for daily decision making. The assessment showed Resident #17 had received an antidepressant medication. A care plan, revised 02/22/25, read in part, I am on psychotropic medications .Monitor for side effects and effectiveness Q-SHIFT. A Side effect Monitoring flowsheet, dated March 2025, read in part, BLANKS INDICATE NO SIDE EFFECTS OBSERVED. The flowsheet did not show any documentation side effects had been monitored from 03/01/25 through 03/31/25. A Side effect Monitoring flowsheet, dated April 2025, read in part, BLANKS INDICATE NO SIDE EFFECTS OBSERVED. The flowsheet did not show any documentation side effects had been monitored from 04/01/25 through 04/08/25. 4. A treatment administration record, dated 04/25, showed Resident #20 had a diagnosis of major depressive disorder. A care plan, revised 02/23/25, read in part, I am on antidepressant medication .Monitor/document for side effects and effectiveness Q-SHIFT. A quarterly assessment, dated 03/01/25, showed Resident #20 had a BIMS score (a test for cognitive function) of 12 which was indicative of moderate impairment for daily decision making. The assessment also showed Resident #20 had received an antidepressant medication. A physician order, dated 03/06/25, showed an order for fluoxetine (an antidepressant medication) 10 mg daily for depression. A Side effect Monitoring flowsheet, dated March 2025, read in part, BLANKS INDICATE NO SIDE EFFECTS OBSERVED. The flowsheet did not show any documentation side effects had been monitored from 03/01/25 through 03/31/25. A Side effect Monitoring flowsheet, dated April 2025, read in part, BLANKS INDICATE NO SIDE EFFECTS OBSERVED. The flowsheet did not show any documentation side effects had been monitored from 04/01/25 through 04/08/25. 5. A treatment administration record, dated 04/25, showed Resident #41 had diagnoses which included depression, bipolar disorder and anxiety disorder. A physician order, dated 10/13/24, showed an order for amitriptyline (an antidepressant medication) 25 mg daily at bedtime for depression. A physician order, dated 11/11/24, showed an order for buspirone (an antianxiety medication) 10 mg three times a day for anxiety. A quarterly assessment, dated 12/15/24, showed Resident #41 had a BIMS score of 14 which was indicative of no impairment for daily decision making. The assessment showed Resident #41 had received an antidepressant medication and an antipsychotic medication. A physician order, dated 02/26/25, showed an order for quetiapine fumarate (an antipsychotic medication) 25 mg daily for bipolar disorder. A care plan, revised 02/22/25, read in part, I am on psychotropic medications .Monitor for side effects and effectiveness Q-SHIFT. A Side effect Monitoring flowsheet, dated March 2025, read in part, BLANKS INDICATE NO SIDE EFFECTS OBSERVED. The flowsheet did not show any documentation side effects had been monitored from 03/01/25 through 03/31/25. A Side effect Monitoring flowsheet, dated April 2025, read in part, BLANKS INDICATE NO SIDE EFFECTS OBSERVED. The flowsheet did not show any documentation side effects had been monitored from 04/01/25 through 04/08/25. On 04/10/25 at 10:02 a.m., LPN #2 stated side effect monitoring was in the behavior book and they did not chart unless side effects were observed. LPN #2 also stated the care plan showed they should be documenting side effect monitoring every shift and they were not documenting every shift. On 04/10/25 at 11:04 a.m., the DON stated they did not document side effect monitoring unless a side effect was noted. They also stated they were not documenting side effect monitoring every shift like the care plan requires.

Based on observation, record review, and interview, the facility failed to ensure comprehensive care plans were developed for 2 (#21 and #41) of 12 sampled residents whose care plans were reviewed. The administrator identified 46 residents resided in the facility. Findings: 1. On 04/07/25 at 9:03 a.m., Resident #21 was observed in bed with a half bed rail, on the left side of the bed, in the up position. On 04/09/25 at 10:55 a.m., Resident #21 was observed in bed with a half bed rail, on the left side of the bed, in the up position. A policy titled Proper Use of Side Rails, dated December 2024, read in part, The use of side rails as an assistive devise will be addressed in the resident care plan. A quarterly assessment, dated 03/13/25, showed Resident #21 had a diagnosis of Alzheimer's disease, a BIMS summary score of three, which indicated the resident was severely impaired in cognition for daily decision making. A care plan, revised 03/18/25, did not show Resident #21 utilized a half side rail on the left side for bed mobility. On 04/09/25 at 1:56 p.m., the MDS coordinator stated Resident #21 utilized the half bed rail for bed mobility. They reviewed care plan and stated they had not developed a care plan related to the use of the half bed rail. 2. On 04/08/25 at 4:36 p.m., Resident #41 was observed in bed with an oxygen nasal cannula in place. On 04/09/25 at 10:56 a.m., Resident #41 was observed in bed with an oxygen nasal cannula in place. A quarterly assessment, dated 12/25/24, showed Resident #41 had a diagnosis of congestive heart failure, was dependent on staff for toileting, personal hygiene, and showering, and required partial/moderate assistance from staff for dressing, and had a BIMS summary score of 14, which indicated the resident was intact in cognition for daily decision making. A care plan, revised 02/12/25, did not show the amount of assistance Resident #41 required for activities of daily living or the resident utilized supplemental oxygen. On 04/09/25 at 1:51 p.m., the MDS coordinator stated they had not developed a care plan to address the supplemental oxygen use for Resident #41. They stated they were not aware the resident routinely utilized supplemental oxygen. On 04/09/25 at 2:00 p.m., the MDS coordinator reviewed the care plan for Resident #41 and stated they must have missed developing a care plan for Resident #41's activities of daily living needs. 42171

Based on record review and interview, the facility failed to ensure admission assessments were accurate for 1 (#2) of 12 sampled residents whose assessments were reviewed. The administrator identified 46 residents resided in the facility. Findings: An admission assessment, dated 03/07/25, showed Resident #2, had a diagnosis of atrial fibrillation, had received an anticoagulant medication while a resident, during the look back period, and had a BIMS score of 15. The medication administration record and treatment administration record, dated March 2025, did not show the resident had received an anticoagulant medication. On 04/09/25 at 1:52 p.m., the MDS coordinator stated they had coded the assessment inaccurately and should not have coded the resident had received an anticoagulant.

Based on observation, record review, and interview, the facility failed to ensure assessments were completed and consents were obtained for the use of bed rails for 1 (#21) of 1 sampled resident who was reviewed for bed rails. The nurse manager identified two residents who utilized bed rails. Findings: On 04/07/25 at 9:03 a.m., Resident #21 was observed in bed with a half bed rail, on the left side, in the up position. On 04/09/25 at 10:55 a.m., Resident #21 was observed in bed with a half bed rail, on the left side, in the up position. The Evaluation for Use of Side Rails form, dated 10/04/23, did not show the resident was assessed for entrapment with the use of the bed rail or alternatives to the use of the bed rail before they were implemented. The annual assessment, dated 12/11/24, documented Resident #21 had a diagnosis of Alzheimer's disease, and the BIMS score was six, which indicated the resident was severely impaired in cognition for daily decision making. A policy titled, Proper Use of Side Rails, dated December 2024, read in part, When used for mobility or transfer, an assessment will include a review of the resident's .Risk of entrapment from the use of side rails .Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol .Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. Review of the resident's chart did not show a consent for the use of the half bed rail. On 04/09/25 at 1:44 p.m., LPN #2 stated Resident #21 utilized the half bed rail to assist with bed mobility and transfers. They stated the DON assessed residents for the use of bed rails. On 04/09/25 at 2:11 p.m., the DON stated Resident #21 utilized the half bed rail on the left side of the bed for positioning. On 04/09/25 at 3:06 p.m., the DON stated the only documentation they completed for the use of bed rails was an assessment. They reviewed the resident's chart and stated they would check in medical records. On 04/09/25 at 5:27 p.m., the DON stated the only assessment that had been conducted for the use of bed rails for Resident #21 had been completed in October 2023. They stated they did not have a consent for the use of the bed rail or an assessment which indicated alternatives to the bed rail had been assessed. On 04/10/25 at 10:39 a.m., the DON stated residents were to be assessed annually for the use of bed rails and a consent should have been obtained.

Based on observation, record review, and interview, the facility failed to ensure treatment carts were secured for 3 (North hall treatment cart, [NAME] hall treatment cart, and the overflow treatment cart) of 5 medication/treatment carts observed. The DON identified five medication/treatment carts in the facility. Findings: On 04/07/25 at 7:32 a.m., the North hall treatment cart and the overflow treatment cart was observed by the nurses station to be unlocked and unattended. On 04/07/25 at 7:34 a.m., the treatment carts were observed to be locked in the front living room area, by the nurses station. On 04/08/25 at 9:25 a.m., the [NAME] hall treatment cart and the overflow treatment cart was observed to be by the nurses station, unlocked, and unattended. On 04/08/25 at 12:38 p.m., the overflow treatment cart was observed to be unlocked and unattended by the nurses station. On 04/09/25 at 10:53 a.m., the North hall treatment cart was observed to be unlocked and unattended. On 04/09/25 at 10:54 a.m., LPN #2 was observed to exit a resident's room, lock the cart, and push it down the hall. On 04/08/25 at 9:25 a.m., the DON stated they were supposed to keep medication/treatment carts locked when unattended. A policy titled, Storage of Medication, dated 07/21/24, read in part, Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) contained drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. On 04/08/25 at 9:29 a.m., LPN #1 stated the treatment carts were to be kept locked but they had forgotten to lock them 'out of habit.' On 04/08/25 at 12:44 p.m., LPN #2 stated they had accessed the overflow treatment cart and should have locked it. On 04/10/25 at 11:11 a.m., the DON stated the staff were to lock the medication/treatment carts when they were unattended. The DON stated, I know you have seen them unlocked and unattended three or four times.

Based on observation and interview, the facility failed to provide palatable meals for 4 (#2, #17, #20, and #46) of 18 residents interviewed regarding food palatability. The corporate nurse manager reported 46 residents received food from the kitchen. Findings: On 04/07/25 at 1:02 p.m., a test tray was sampled for palatability. The Dorito casserole was lukewarm and not well seasoned. The mixed vegetables were soggy, bland, and lukewarm. On 04/08/25 at 12:33 p.m., a test tray was sampled for palatability. The Spanish rice was warm and bland, and the banana cake was dry and without icing. 1. An admission assessment, dated 03/07/25, showed Resident #2 had a BIMS score (a test for cognitive functioning) of 15 which was indicative of independence for daily decision making. On 04/07/25 at 10:03 a.m., Resident #2 stated when they eat meals in their room the hot foods are not hot, and the cold foods are not cold. 2. A quarterly assessment, dated 01/07/25, showed Resident #17 had a BIMS score (a test for cognitive functioning) of 15 which was indicative of independence for daily decision making. On 04/07/25 at 9:16 a.m., Resident #17 stated they only eat breakfast from the kitchen because lunch and dinner were not good. 3. A quarterly assessment, dated 03/06/25, showed Resident #20 had a BIMS score (a test for cognitive functioning) of 12 which was indicative of moderate impairment for daily decision making. On 04/07/25 at 10:25 a.m., Resident #20 stated they ate most meals in their room, and they were usually not hot when they were served. They also stated the food was bland. 4. An admission assessment, dated 12/26/24, showed Resident #17 had a BIMS score (a test for cognitive functioning) of 15 which was indicative of independence for daily decision making. On 04/07/25 at 10:17 a.m., Resident #46 stated the food was not good. On 04/09/25 at 10:15 a.m., the DM was made aware of the observations. They stated they tried to serve the hall cart as quickly as possible to ensure they were warm, they also stated the banana cake should have been served with icing. 42171

Based on observation, record review, and interview, the facility failed to ensure beds/bed rails were monitored for safety for 1 (#21) of 1 sampled resident who was reviewed for bed rails. The nurse manager identified two residents who utilized bed rails. Findings: On 04/07/25 at 9:03 a.m., Resident #21 was observed in bed with a half bed rail in the up position on the left side. The bed rail was observed to be loose when moved side to side and back and forth. On 04/09/25 at 10:55 a.m., Resident #21 was observed in bed with a half bed rail in the up position on the left side. The bed rail was observed to be loose when moved side to side and back and forth. A policy titled, Bed Safety, dated June 2024, read in part, Inspection by maintenance staff of all beds and related equipment as part of regular bed safety program to identify risks and problems including potential entrapment risks. The annual assessment, dated 12/11/24, documented Resident #21 had a diagnosis of Alzheimer's disease, and had a BIMS score was six, which indicated the resident was severely impaired in cognition for daily decision making. On 04/07/25 at 9:03 a.m., Resident #21 stated, It's wiggly when they were asked about their bed rail. On 04/09/25 at 3:53 p.m., the maintenance supervisor stated they did not monitor bed rails once they had installed them. They stated if the staff reported the bed rails were loose they tightened them. The maintenance supervisor stated they had recently installed the bed rail for Resident #21. The maintenance supervisor observed the bed rail and stated, Oh wow, this is really loose, someone must have loosened that. On 04/10/25 at 10:59 a.m., the administrator stated the CNAs documented in the maintenance log if they noticed bed rails were loose. They stated they did not know why maintenance were not inspecting beds/bed rails for safety, including entrapment.

Based on observation and interview, the facility failed to ensure the call light system was functioning in one of six occupied rooms resident rooms reviewed for call light functionality. The administrator reported the census was 53. Findings: A facility policy, reviewed 07/24, titled Maintenance Service read in part, .Functions of maintenance personnel include, but are not limited to .Maintaining the paging and nurse call system in good working order . On 10/08/24 at 10:05 am, LPN #1 stated when the call light was activated a light should illuminate in the hallway by the resident's door. At 10:10 am, CNA #1 stated when they observed that the light in front of a resident's door was illuminated that indicated the resident needed assistance. At 11:50 am, the call system in room [ROOM NUMBER] was activated, no light was illuminated in the hallway or at the nurse's desk. LPN #2 stated the call light for room [ROOM NUMBER] was not functioning. At 1:30 am, the maintenance supervisor stated they tested the call lights on a weekly basis, but they did not document the tests.

Based on observation and interview the facility failed to ensure the kitchen was maintained to promote food safety and sanitation. The administrator identified 55 residents residing in the facility. Findings: On 12/21/23 at 9:10 a.m., a tour of the kitchen and dining area were conducted. The following observation was made: There were no dates on four partially used gallons of milk in refrigerator #1. On 12/21/23 at 9:20 a.m., the dietary manager stated the four gallons of milk should have open dates on them. The dietary manager removed the milk from the refrigerator.

Based on record review and interview the facility failed to ensure section the care plan decision column of the care area assessment section [section V] was completed on an annual assessment for one (#3) of two sampled resident reviewed for care plans. A facility Census List, dated 12/21/23, documented there were 55 residents living at the facility. Findings: A Comprehensive Assessment and the Care Area Process policy, dated 2001 and revised 2023, read in part, .Comprehensive assessment will be conducted to assist in the developing person-centered care plans . Resident #3 had diagnoses which included schizophrenia and recurrent depressive disorder. An annual assessment, dated 08/17/23, documented in the behaviors section [section E] the resident had rejected care one to three times during the look back period. The care planning decision column of section V [the section of the assessment were an interdisciplinary team (IDT) from the facility meet and decide wether to care plan any triggered care areas] was blank. On 12/27/23 at 1052 a.m. the MDS Coordinator stated they had found no documentation Resident #3 had attended a care plan meeting following the last annual assessment. On 12/28/23 at 9:43 a.m., the MDS Coordinator stated the care areas psychotropic medications, psychosocial, and behaviors had triggered on the assessment but they had missed care planning them. They stated section V should have been completed and those areas care planned. They stated the assessment was incomplete. They stated the IDT had not met as required following the completion of the assessment to discuss the resident care plan. They stated there was no system in place they were aware of to trigger an IDT meeting to occur following an comprehensive assessment. At 10:00 a.m. the Administrator stated they would need to put a system in place to ensure the assessment process was thorough.

Based on record review and interview the facility failed to create a comprehensive care plan for one (#3) of two sampled resident reviewed for care plans. A facility Census List, dated 12/21/23, documented there were 55 residents living at the facility. Findings: A Care Plan, Comprehensive Person Centered policy, dated 2001 and revised 2023, read in part, .The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person centered care plan for each resident . Resident #3 had diagnoses which included schizophrenia and recurrent depressive disorder. On 12/21/23 at 11:31 a.m., Resident #3 stated they had not attended a care plan meeting at the facility. On 12/27/23 at 1052 a.m. the MDS Coordinator stated they had found no documentation Resident #3 had attended a care plan meeting. On 12/28/23 at 9:43 a.m., the MDS Coordinator stated the care areas psychotropic medications, psychosocial, and behaviors had triggered on the last annual assessment, dated 08/17/23, but they had missed care planning them. They stated section V of the assessment should have been completed and those areas care planned. They stated the IDT had not met as required following the completion of the assessment to discuss the resident's care plan so the current care plan was not comprehensive. At 9:56 a.m., the SSD stated the IDT team did not meet following Resident #3's annual assessment. They stated they depended on the MDS coordinator or someone from nursing to alert her of the need for an IDT meeting. At 10:00 a.m. the Administrator stated they would need to put a system in place to ensure the IDT meet following the comprehensive assessments. 12/29/23 at 10:41 a.m., the DON stated their expectation is for each care plan to be comprehensive and complete. They stated they have a full time person now to keep track of the care plans.

Based on observation interview and record review, it was determined the facility failed to provide supervision to prevent injury for one (#3) of one sampled residents reviewed who wandered. The facility identified three residents who wandered. Findings: A policy titled, Safety and Supervision of Residents, dated (MONTH) 2007, documented, .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities .Resident-oriented approach to safety . Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident and the MDS . Implementing interventions to reduce accident risks and hazards shall include the following: communicating specific interventions to all relevant staff; assigning responsibility for carrying out interventions; providing training, as necessary; ensuring that interventions are implemented; and documenting interventions . Monitoring the effectiveness of interventions shall include the following: ensuring that interventions are implemented correctly and consistently; evaluating the effectiveness of interventions; modifying or replacing interventions as needed; and evaluating the effectiveness of new or revised interventions . Resident Risks and Environmental Hazards Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include: Unsafe wandering; Poison control . 1. Resident #3 was admitted with [DIAGNOSES REDACTED]. A care plan, dated 09/28/17, documented, .(name withheld) is at risk for falls, mood and behavior changes, adverse reactions to his medications and changes in his appetite related to use of mood altering medications .Goal .(name withheld) will be monitored and interventions applied through review date .Approaches .give all antidepressants per physician orders [REDACTED].report to physician any negative outcomes associated with use of drug .administer medication as prescribed by the physician (see current MAR & physician orders [REDACTED]. A nurse's note, dated 12/17/17 at 9:00 p.m., documented, .up and about facility in w/c . A nurse's note, dated 02/01/18 at 2:40 p.m., documented, .Res was in another res room et staff seen other res hitting this res in the face et head. Res has 1 laceration between his eyebrows et 1/2 laceration under R eye et 0.4 cm laceration on L ear. Res also has a nose bleed. Ice pack applied to face .res to ED .laceration between eyes was glued back together . A state reported incident form, dated 02/01/18, documented, .(name withheld) went into (name withheld) room and started moving things around and (name withheld) pushed him out of the room and started hitting him in the face. Because (name withheld) is deaf he doesn't hear (name withheld) yelling at him to get out of his room and (name withheld) gets frustrated at (name withheld). (name withheld) was sent to the emergency room to be assessed for his injuries. If he returns to the facility tonight the staff will watch him to keep the two apart until other arrangements can be made . A clinical review was conducted, no documentation was found to show the resident had been monitored after his return from the emergency department. A nurse's note, dated 02/14/18 at (sic), documented, .Res was found outside in court yard . A quarterly assessment, dated 03/19/18, documented the resident's cognition was limited to sometimes making self understood and sometimes understanding, highly impaired hearing, and wandered daily. On 04/11/18 at 12:18 p.m., the DON was asked to provide the care plan for the resident. She presented a notebook. She was asked if the book contained the care plans for all the residents. She stated, This is what we have. A Resident Plan of care form, dated 04/16/18, documented an interdisciplinary review of the care plan had been conducted. No updates were found documented in the care plan regarding the resident's wandering behavior. On 04/17/18 at 2:34 p.m., LPN #1 was asked if the resident was known to wander. She stated yes, he would go into other resident rooms, attempt to go through doors to assisted living areas, or outside and set off those door alarms. She was asked when the resident went into other resident's rooms had he done anything to the residents. She stated yes, he enters other resident's rooms and will move things around but he does not have any aggressive behavior. She was asked had the resident ever had any confrontations causing him injury. She stated the resident had wandered into one resident's room and physical force was used causing him injury. She was asked had anything been done to keep him from wandering. She stated it was his right to wander, and mesh stop signs were utilized on some rooms to prevent him from entering. She was asked if the stop signs were effective. She stated the stop signs do not stop him. On 04/18/18 at 9:40 a.m., the Administrator and DON were asked to provide documentation the resident was supervised following the incident. The administrator stated the facility had documentation of monitoring the day after the incident but when she went to get it the ADON had told her the documentation required completion. The administrator stated documentation could not be found now. She stated she should had taken the documentation then and put it with the chart. On 04/18/18 at 10:36 a.m., RN #1 was asked if there was any documentation regarding the resident's activity prior to being injured. She stated the documentation regarding that was what the ADON had and unable to locate at this time. On 04/18/18 at 11:24 a.m., the resident was observed in the maintenance office. A female resident was in the common area screaming at him to get out and he did not belong in that room. The resident was able to remove himself from the room and proceed across the common area to a resident's room. At 11:26 a.m., the same female resident was observed pulling the resident in his wheelchair out of a resident's room. The female resident identified the room as her room. She stated, That sucker gets in my room and I don't like it. The female resident was observed yelling for staff, and then went down the center hall and lead a CNA back to the area and informed her the resident had been in her room. At 11:45 a.m., the maintenance door was observed closed and unlocked. Observations in the office noted fingernail polish remover on the desk, aerosol air freshener, a spray bottle of vinegar and water, a spray bottle of bathroom cleaner with a small amount of liquid in the bottle, various tools, and a can of paint. On 04/18/18 at 12:00 p.m., CNA # 2 was asked what interventions were used for a resident who wandered. She stated she had been instructed to keep an eye on the resident and redirect. She was asked if the mesh stop signs were an effective intervention to keep the resident from entering other residents' rooms. She stated she did not think the stop signs were a deterrent for the resident. She stated the resident could open doors and move the stop signs. On 04/18/18 at 12:45 p.m., RN #2 was asked if the resident wandering into other residents' rooms was considered a behavior. She stated he does not do that very often. She stated the resident would wander down the hall, but it was not a behavior as he was not aggressive. She stated we keep a close eye on him and she did not know of any resident who had complained about him being in their room for the last two months. She was asked had she been notified of resident #3 being in the maintenance office alone and a female resident's room today. She stated no. On 04/18/18 at 1:05 p.m., the DON was asked if wandering was considered a behavior. She stated yes. She was asked if the resident wandered. She stated, We all know to watch out for him. She was asked after the resident had been injured were new interventions developed to ensure his safety. She stated the facility used Velcro stop signs for the two rooms the resident entered frequently. She was asked if the stop signs were effective. She stated she had not seen him enter those rooms, but he could have and she not know it. On 04/18/18 at 1:49 a.m., the administrator was informed of the resident's recent incident of being in the maintenance office and entered a female resident's rooms. She stated, They did not have anyone to watch him all the time.

On 03/02/15, an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to have an effective quality assessment and assurance program in place to identify problems and develop and implement plans of action to correct quality deficiencies. The facility's quality assessment and assurance committee failed to implement interventions to aid in the prevention of falls for four residents who had experienced falls. The Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 5:10 p.m., the administrator, the director of nurses, the assistant director of nurses, and the corporate RN consultant were informed of the IJ regarding their quality assessment and assurance committee and that a plan of removal was required. At 5:45 p.m., an acceptable plan of removal was received from the administrator. The plan of removal documented, "March 2nd, 2015... 5:20pm All QA committee staff has been notified for mandatory QA meeting for today. 5:30pm QA meeting in-service to address new QA meeting procedure to identify at risk residents including but not limited to falls. To make sure individual interventions are put in place, care planned, and all staff involved will know their role on how to care for these at risk residents. QA issues and interventions will be monitored by the DON and Administrator for follow through and effectiveness. Held by Corporate Nurse and Administrator. 6:30pm All QA committee staff will be in-serviced. Dr. (name deleted) was still seeing his patients at 5:30pm at his office." The inservice/meeting information was attached to the plan of removal. On 03/03/15 at 10:33 a.m., the DON was asked for all the information addressed in the QA committee meeting regarding the plan of removal. At 10:51 a.m., the administrator stated, "The QA meeting and the inservice were all done together. We didn't do the individual interventions. Just that we have an ineffective QA. We need to have another meeting. We didn't address the resident's identified in the IJ. We went over (Resident #3-name deleted) plan to get her off the one on one." The administrator was notified of the need for an addendum to the plan of removal. At 1:00 p.m., the administrator provided an acceptable addendum. The addendum documented, "March 3rd, 2015... 11:25am Identified residents that are high risk of falls from Morse fall assessment. 1:00pm Hold QA meeting on the four residents discuss the individualized interventions, how they will be care planned and implemented. All staff involved will know their role on how to care for these at risk residents. All committee members will be informed of this by 2:00pm. Staff will take information to Dr. (name deleted) office to review meeting notes and sign QA attendance sheet. 2:30pm Care planning and implementation of interventions will be done and in place by approximately 2:30pm for the four residents." The inservice/meeting information was attached to the plan of removal. On 03/03/15 at 4:00 p.m., the DON provided documentation to show the plan of removal and addendum had been implemented as described. Documentation was provided ensuring all committee members had been inserviced on falls and fall interventions documented. Staff were interviewed on 03/03/15 in regards to their knowledge of the fall inservice; to ensure their understanding of all aspects of the plan of removal. The IJ was removed effective 03/03/15 at 3:55 p.m. when all components of the plan of removal and addendum had been completed. The deficient practice remained at actual harm at a pattern. Based on observation, record review, and interviews, it was determined the facility failed to have an effective quality assessment and assurance program in place to identify problems and develop and implement plans of action to correct quality deficiencies, which would in turn ensure the nursing staff provided nursing and related services to enable residents to achieve and maintain their highest practicable well-being. The facility's quality assessment and assurance committee failed to provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for four (#3, #8, #9, and #13) of eight sampled residents who had experienced falls. This had the likelihood to affect all 21 residents who were identified by the facility as high risk for falls. Findings: A facility policy titled Quality Assurance Plan, documented, "Purpose The purpose of Quality Assurance Program is to provide a comprehensive program designed to provide patient resident care that is optimal within available resources and is consistent with the achievable goals for this facility. The objectives of our program are to: ~ Establish, maintain, support and document evidence of an ongoing Quality Assurance Program that includes effective mechanisms for monitoring and evaluating patient care and for appropriate response to findings... ~ Assist individual departments in continuously improving care by identifying opportunities to improve care and problems through the use of monitoring and evaluation activities..." 1. The facility failed to: Provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for four (#3, #8, #9, and #13) of eight sampled residents who had experienced falls. ~Resident #3 experienced 16 falls in four months. The resident sustained [REDACTED]. The resident also received skin tears and experienced back pain. This resulted in an Immediate Jeopardy situation. ~Resident #13 experienced 14 falls in four months. The resident sustained [REDACTED]. ~Resident #8 experienced 11 falls in four months. The resident sustained [REDACTED]. ~Resident #9 experienced five falls in one month. The resident sustained [REDACTED]. The facility identified 21 residents who were at high risk for falls. Refer to F-323. 2. On 02/25/15 at 10:13 a.m., the DON, the ADON and the MDS/care plan coordinator were asked if they had a QA committee. The DON stated, "Yes." They were asked how often the QA committee met. The DON stated, "We meet quarterly or when needed." They were asked what methods they used to identify problems that were addressed in the QA meetings. The DON stated, "Morning nurses' meetings, incident reports, and we look for a root cause of the problem." 3. On 03/02/15 at 3:09 p.m., the administrator and the DON were asked when the last QA meeting had been conducted. The administrator stated the last meeting was on 12/08/14. They were asked if they had addressed falls and fall interventions in the last meeting. The administrator stated, "No." The administrator was asked if falls and fall interventions had been addressed in the QA meeting prior to the December meeting. He stated, "No." The administrator and the DON were asked if their QA was effective. The administrator stated, "No."

On 02/27/15, an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to implement interventions to aid in the prevention falls. Resident #3 had experienced 16 falls from 10/13/14 through 02/23/15. The resident sustained [REDACTED]. The Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 10:42 a.m., the administrator, the director of nurses, the assistant director of nurses, and the corporate RN consultant were informed of the IJ regarding falls and that a plan of removal was required. They were informed this placed the facility in an extended survey. At 12:34 p.m., an acceptable plan of removal was received from the administrator. The plan of removal documented: "...February 27th, 2015 10:50AM Resident placed 1:1 with staff at all times until notice from Administrator of long term interventions. 1:1 duration approximately 4 days. Staff must keep resident within vision at all times. Staff will document every hour on resident activity/location. The charge nurse will assign a staff member each shift. 11:05AM All employees were called for immediate, mandatory in-service on falls/prevention. Not a single employee will commence to work until in-serviced on falls/prevention. In-service will be conducted first by the Corporate Consultant with the DON and ADON present, then the in-services will be conducted by the DON and ADON until completed. 11:11AM Physician notified of IJ on resident for falls. 11:40AM In-service will start on employees. All employees will be in-serviced by 2:00pm February 28th, 2015." The inservice information was attached to the plan of removal. Staff were interviewed on 03/02/15 in regards to their knowledge of the fall inservice; to ensure their understanding of all aspects of the plan of removal. At 10:26 a.m., CNA #8 was asked if she had attended a mandatory inservice. The CNA stated, "Yes." The CNA was asked what was discussed in the inservice. The CNA stated they discussed the residents had experienced a lot of falls. They discussed fall mats, alarms, activities, keep the residents busy, and to answer call lights quickly. On 03/03/15 at 4:55 p.m., it was determined an addendum to the plan of removal was required after CNA #8 failed to toilet resident #8 before she was placed in bed and failed to attach the bed alarm after the resident was placed in bed. This resulted in a fall when the resident attempted to get out of a wet bed. At 4:55 p.m., the administrator, the DON, and the ADON were notified of the need for an addendum to the plan of removal. At 5:43 p.m., the administrator provided an acceptable addendum. The addendum documented: "March 3rd, 2015... 5:05pm DON and Administrator discussed the severity and consequences that staff will face if they do not follow high risk fall resident interventions. Not following these interventions will result in immediate termination. 5:20pm All employees were called for immediate, mandatory in-service on fall/prevention and consequences of not following fall interventions. In services will be provided by DON and ADON 5:40pm in-service will start on employees. All employees will be in serviced by 11:30 pm on 3-3-15 Not a single employee will commence to work until in-serviced on fall/prevention and the severity of not following interventions. Not following interventions will result in immediate termination." The inservice information was attached to the addendum plan of removal. On 03/04/15 at 10:00 a.m., the DON provided documentation to show the plan of removal and addendum had been implemented as described. Documentation was provided ensuring all staff had been inserviced on falls and fall interventions. Staff were interviewed on 03/04/15 in regards to their knowledge of the fall inservice; to ensure their understanding of all aspects of the plan of removal. The IJ was removed effective 03/03/15 at 10:00 p.m. when all components of the plan of removal and addendum had been completed. The deficient practice remained at actual harm at a pattern. Based on observation, interview, and record review, it was determined the facility failed to: A. Provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for four (#3, #8, #9, and #13) of eight sampled residents who had experienced falls. ~Resident #3 experienced 16 falls in four months. The resident sustained [REDACTED]. The resident also received skin tears and experienced back pain. ~Resident #13 experienced 14 falls in four months. The resident sustained [REDACTED]. ~Resident #8 experienced 11 falls in four months. The resident sustained [REDACTED]. ~Resident #9 experienced five falls in one month. The resident sustained [REDACTED]. The facility identified 21 residents who were at high risk for falls. B. Ensure hot water temperatures were not an accident hazard in three (room #3, room #6, and room #10) of eight rooms on the South Hall. The facility identified six residents who resided on the South Hall who were able to turn on the hot water. Findings: A fall risk assessment policy documented, "...Fall risk assessment will be completed upon admission, quarterly and following a fall or significant change of condition afecting (sic) balance to identify and assess residents at risk for fall... ~ Any resident identified as high risk will have fall prevention approaches initiated and documented on the care plan. ~ Those residents assessed as high risk for falls will be referred to the interdisciplinary team for futher (sic) evaluation." The facility's maintenance policy documented, "...any elevation in temperature over 115 F to be reported to administrator..." 1. Resident #3 had [DIAGNOSES REDACTED]. A fall care plan, updated 07/09/14, documented, "Focus: ...high risk for falls r/t Confusion, Gait/balance problems & History of falls...Goal: ...will be free of falls...will be free of minor injury...will not sustain serious injury...Interventions: Ensure that resident is wearing appropriate footwear with non skid soles...Falling Star (of any color) intervention...frequent visual checks......Educated on the importance of locking wheels when not mobile. Ask for assistance & wait for it to come...Bowel & bladder program...obtain UA...Activities to provide 1 on 1 activities TID each day to help as diversional." A kardex care plan, dated 09/09/14, documented, "Accidents - Fall Risk...Personal & Bed alarm...fall mats...(high) fall risk...forgetful..." A quarterly assessment, dated 10/08/14, documented the resident had a BIMS of six. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance with transfers, was occasionally incontinent, and had not experienced any falls. A wandering risk scale, dated 10/08/14, documented the resident scored a nine. This score indicated the resident was at risk to wander. A Morse fall scale, dated 10/08/14, documented the resident scored a 95. This score indicated the resident was at high risk for falling. An incident report, dated 10/13/14, documented, "...pt. observed on floor between night stand and bed laying on her back...Immediate Action Taken: (Blank)..." There were no fall interventions addressed or implemented to prevent further falls. An incident report, dated 10/16/14, documented, "res sitting on buttocks on fall mat next to bed...stated was checking on the baby and slid oob...Immediate Action Taken: assessment and neuro check..." There were no new fall interventions addressed or implemented to prevent further falls. An incident report, dated 10/24/14 02:56 (2:56 a.m.), documented, "body alarm going off res found laying in floor left side of head bleeding neuro check wnl...sent res to hosp for eval...stated she was getting up...Immediate Action Taken: assessment and sent to hosp...Injuries Observed at Time of Incident: Laceration...Top of Scalp...fall mat..." There were no new fall interventions addressed or implemented to prevent further falls. A final state reported incident report, dated 10/24/14, documented, "Body alarm going off...resident found laying in the floor...left side of head bleeding...transport to hospital for evaluation...resident returned to facility with 3 staples to her scalp...Neuro check protocol was initiated...fall mat in place..." There were no new fall interventions addressed or implemented to prevent further falls. An incident report, dated 10/25/14, documented, "...Resident in upright sitting position on the floor of her bathroom door. No apparent injury...fall alarm in use...I slid out of my chair...Immediate Action Taken: Head to toe assessment...Staples intact to right side of residents head from previous fall. Neuro checks wnl..." There were no new fall interventions addressed or implemented to prevent further falls. A final state reported incident report, dated 10/27/14, documented, "At 0150 (1:50 a.m.) staff heard bed and body alarm going off...resident was found laying on the fall mat. Left side of head bleeding. 2cm laceration noted to scalp on head, bleeding and underlying hematoma...Neuro check...c/o pain at laceration site...stated "I fell out of bed again"...transport to hospital for evaluation...returned to facility with 3 staples to her scalp...bedside dresser removed from room for prevention of injury...furniture in room as (sic) been rearranged for safety..." A fall care plan, updated 10/28/14, documented, "Focus: ...high risk for falls r/t Confusion, Gait/balance problems & History of falls...Goal: ...will be free of falls...will be free of minor injury...will not sustain serious injury...Interventions: ...continue interventions on the at-risk plan...neuro checks...Pharmacy consult to evaluate medications..." A nurse's note, dated 10/29/14, documented, "...6 staples remain...to left side of scalp..." An incident report, dated 11/03/14, documented, "Called to hallway stat...res sitting on the ground with w/c directly behind her personal alarm going off...neuro assessment wnl...c/o back pain...stated I fell and...my back hurts...Immediate Action Taken: prn tramadol given...No injuries observed...Hurts a little more..." There were no new fall interventions addressed or implemented to prevent further falls. An incident report, dated 12/04/14, documented, "...res slid out of wheel chair onto her bottom personal alarm sounding...Immediate Action Taken: assessment v/s...No injuries observed..." There were no new fall interventions addressed or implemented to prevent further falls. An incident report, dated 12/16/14, documented, "...called into hallway stat res on the floor sitting on her right hip noted s/t to L knee...Immediate Action Taken: assessment v/s...Injury Observed...Skin tear...left knee..." There were no new fall interventions addressed or implemented to prevent further falls. An incident report, dated 12/26/14, documented, "Res was trying to transfer to the toilet without assistance and sat down in floor in front of her w/c...was in sitting position with feet against toilet and her head against seat of w/c. No injuries noted, Alarm attached and working...I was going to the bathroom...Immediate Action Taken: ...Neuro checks..." A fall care plan, updated 12/26/14, documented, "Focus: ...high risk for falls r/t Confusion, Gait/balance problems & History of falls...Goal: ...will be free of falls...will be free of minor injury...will not sustain serious injury...Interventions: ...Fall mats by bed...Med review as needed...obtain lab/x ray as needed..." A kardex care plan, dated 12/30/14, documented, "Accidents - Fall Risk...Chair alarm...Bed alarm...fall mats...very confused & forgetful..." An incident report, dated 01/01/15, documented, "...CNA was assisting roommate, saw res sit up and fall onto mat next to bed...bleeding from right hand...Immediate Action Taken: Assessed body for injury...skin tear to right index finger...sm area of middle finger...applied steristrips...alarm attached to res and safety mat in place...Res does not remember to use call light..." There were no new fall interventions addressed or implemented to prevent further falls. A state reported incident report, dated 01/02/15, documented, "Incident Location: Restroom...Received a final x-ray report regarding resident...states impacted fracture of the distal radius with mild to moderate dorsal angulation. X-ray obtained due to resident's complaints of pain in left arm...Last fall...was on 12-26-14 she was transferring to toilet without assistance...heard personal alarm sounding in bathroom and resident calling for help...was found sitting on floor in front of wheelchair facing the toilet...She is unaware of her personal safety and relies on staff for all care..." An incident report, dated 01/04/15, documented, "...resident noted in an upright sitting position on her bedside mat...Ask resident if she fell , she stated no, I sat down...arm splint in place r/t previous fx of distal arm...Neuro checks...Fall alarm in use...Immediate Action Taken: Head to toe assessment...No injuries observed..." There were no new fall interventions addressed or implemented to prevent further falls. An annual assessment, dated 01/08/15, documented the resident had a BIMS score of zero. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance with transfers, was frequently incontinent, had experienced two non-injury falls, two falls with injury, and one major injury fall, had sustained skin tears, and had received an antianxiety medication in the past seven days. A Morse fall scale, dated 01/16/15, documented the resident scored a 55. This score indicated the resident was at high risk for falling. A wandering risk scale, dated 01/16/15, documented the resident scored a 13. This score indicated the resident was at high risk to wander. An incident report, dated 01/22/15, documented, "...on floor in another residents room...res was sitting on floor in front of bed...Immediate Action Taken: res was assessed...neuro checks...Injuries Observed...Right trochanter (hip)..." There were no new fall interventions addressed or implemented to prevent further falls. An incident report, dated 02/01/15, documented, "...resident sliding out of wheelchair on south hall. No apparent injury...Chair alarm in use...Immediate Action Taken: vs, assisted back into wheelchair, alarm in place, assessment of possible cushion in chair contributing to resident sliding out of her chair..." An incident report, dated 02/06/15, documented, "...called into resident room r/t resident lying on mat beside bed resident stated, "I was trying to go tinkle." Immediate Action Taken: resident assessed...resident helped up...neuro check started..." There were no new fall interventions addressed or implemented to prevent further falls. An incident report, dated 02/10/15, documented, "...called to resident because resident had fell . resident was sitting on bottom next to nurse station door...Immediate Action Taken: resident assessed...resident helped up..." There were no new fall interventions addressed or implemented to prevent further falls. An incident report, dated 02/23/15, documented, "...called to resident due to resident entering another resident room. this nurse moved resident out of the other resident room. resident slid out of chair and hit her bottom after entering hallway...Immediate Action Taken: resident assessed...no injuries observed..." There were no new fall interventions addressed or implemented to prevent further falls. On 02/26/15 at 10:53 a.m., the resident was observed in bed. The resident's upper half of her body was on the bed and her legs were hanging off the bed on the floor mat. No staff were visible. At 11:28 a.m., the resident was observed in bed. The resident's upper half of her body was on the bed and her legs were hanging off the bed on the floor mat. No staff were visible. At 2:20 p.m., the resident was observed in her wheelchair. There was no cushion observed in the wheelchair. The resident was observed propelling in her wheelchair toward her room. A CNA was standing inside the resident's room talking with the resident's roommate. The resident continued further down the hallway to the closed unit. No staff were visible. At 2:43 p.m., the resident propelled herself back to the lobby. No activities were offered or provided. The resident was observed throughout the day at random times. No activities were offered or provided to the resident. On 02/27/15 at 11:59 a.m., the corporate RN consultant was asked if the facility had a falling star program. She stated, "They don't have the falling star program here." On 03/02/15 at 2:48 p.m., the DON was asked if the facility had a falling star program. She stated, "Yes. It wasn't very good. It was preventing injuries not preventing falls." The DON, the ADON, the administrator, and the corporate RN consultant were asked what the falling star interventions were that was documented on the care plan. The corporate RN consultant stated, "A list of things to prevent falls and what to use. More education needs to take place on that." They were asked who reviewed the incident reports. The DON stated that she was the one who reviewed the reports. The administrator stated, "We do a morning nurses' meeting everyday and look at falls and write the interventions down." They were asked after a resident experienced a fall where are the new fall interventions documented to prevent further falls. The DON stated, "Suppose to be on the care plan." The DON, the ADON, the administrator, and the corporate RN consultant were informed of the 16 falls the resident had experienced in four months and the injuries that had been sustained. They were asked why there were no new interventions addressed to prevent further falls. The DON stated, "They weren't documented." The DON was asked how fall interventions had been communicated to the staff. She stated, "In the ADL books there is a kardex the staff look at." They were asked if they had done a root cause analysis after each fall to determine an intervention to prevent falls. They stated, "No." At 3:22 p.m., the care plan coordinator was asked why the fall care plan had not been updated with new interventions to prevent falls. She stated, "I don't know. We talk about interventions sometimes in the nurses' meetings." She was asked if the fall interventions should have been addressed on the care plan. She stated, "Yes." The DON was asked who monitored the care plans to ensure they were being updated. She stated, "I will be now." On 03/03/15 at 3:46 p.m., the care plan coordinator was asked if they had documentation where the medications were reviewed regarding falls. She stated, "No." 2. Resident #13 was admitted to the facility with [DIAGNOSES REDACTED]. A fall care plan, dated 06/25/14, documented, "Focus: ...at risk for falls r/t history for falls, & at times a weak gait. Goal: The resident will not sustain serious injury through the review date. Interventions: Encourage resident to participate in activities Falling that promote exercise, physical activity for strengthening and improved mobility...star...program...Make sure lighting is good & floor is clutter free...non skid socks...Anticipate and meet the resident's needs...frequent visual checks...offer fluids/snacks...Check for placement of safety alarms & to check the environment to make sure her surroundings are safe for her. Clip & pressure alarm" A quarterly assessment, dated 09/03/14, documented the resident had a BIMS score of six. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance and two person assist with transfers and ambulation, was not steady during transitions and walking, and had experienced two no injury falls. A fall care plan, updated 09/09/14, documented, "On floor on mats, states she was looking for her little girl. Sustained small scratch on her ear. She was unable to state how" The care plan was not updated with any new interventions to prevent further falls. A fall care plan, updated 09/21/14, documented, "Lying on mats by bed, no injuries noted &alarm in place & sounding" The care plan was not updated with any new interventions to prevent further falls. A second update to the fall care plan, dated 09/21/14, documented, "...lying in hall by room, states she did not fall" The care plan was not updated with any new interventions to prevent further falls. A fall care plan, updated 09/24/14, documented, "Sitting on fall may (sic) next to bed...often does this trying to get up" The care plan was not updated with any new interventions to prevent further falls. An incident report, dated 10/02/14, documented, "...res observed crawling up hallway...appears to have crawled oob fall mat next to bed noted. body alawm (sic) in place. no injury noted able to move all extreme (sic) wnl for res. alert and able to make needs known...Immediate action taken: ...assessment..." There were no immediate interventions listed to prevent further falls. A fall care plan, updated 10/02/14, documented, "Fall without injury. At this time in her life...is unaware of her own need for safety & is easiy (sic) distracted/confused" The fall care plan was not updated with any new interventions to prevent further falls. An incident report, dated 11/11/14, documented, "...this nurse sitting at nurse station res stood up out of w/c and slowly fell to her knees before I could make it to her personal alarm intact sounding off did not hit head...Immediate action taken: ...checked v/s assisted res back into w/c Ativan given prior to fall..." An incident report, dated 11/14/14, documented, "res observed on knees and hands in floor on fall mat appeared to be have crawled oob. no apparent injury...denies hitting head...able to move all extreme (sic) wnl. no c/o pain or discomfort...immediate action taken...assessment complete..." There were no immediate interventions listed to prevent further falls. A fall care plan, updated 11/14/14, documented, "...crawling on hands + knees - denies hitting head..." An incident report, dated 11/19/14, documented, "...Called into kitchen stat res laying on the floor on her right side. w/c directly behind her with her personal alarm sounding...Immediate action taken: ...assessment v/s notified physician and family..." There were no immediate interventions listed to prevent further falls. A fall care plan, updated 11/19/14, documented, "...keep room well lit. Do not leave unattended p meals." An incident report, dated 11/20/14, documented, "...called into res room stat res laying on the floor on her back next to her bed personal alarm sounding off w/c by door...Immediate action taken: assessment obtain vs notified family and physician prn ativan given..." There were no immediate interventions listed to prevent further falls. A fall care plan, updated 11/20/14, documented, "...Lying on floor, on back next to her bed c personal alarm sounding...Intervention: personal/bed alarm c proper placement...physician contacted for med review. Frequent visual checks." There was no documentation found to show a medication review had been completed or how often the frequent visual checks were to be done. An incident report, dated 11/22/14 at 4:01 a.m., documented, "called to res room by cna body alarm and bed alarm going off res laying on back on fall mat next to bed...call was within reach...no apparent injury noted. Neuro checks cont from previous fall. Immediate action taken: ...assessment complete..." There were no immediate interventions listed to prevent further falls. The fall care plan was not updated with any new interventions to prevent further falls. An incident report, dated 11/22/14 at 2:21 p.m., documented, "...Resident observed on her bedside mat bed alarm sounding, no apparent injury...Head toe assessment completed, no bruising, hematomas or lacerations noted. Alarm in place..." There were no immediate interventions listed to prevent further falls. The fall care plan was not updated with any new interventions to prevent further falls. An incident report, dated 11/23/14, documented, "...Resident observed on the floor in the front lobby by her highback wheelchair. No apparent injury noted...Immediate action taken: Head to toe assessment completed...Chair alarm placed. Instructed all employees chair alarm to be in place at all while resident up..." There were no new interventions listed to prevent further falls. An incident report, dated 11/24/14, documented, "called to res room stat bed alarm and personal alarm sounding res on hands and knees on her fall mat next to bed...Immediate action taken: assessment...No injuries..." There were no immediate interventions listed to prevent further falls. A fall care plan, updated 11/24/14, documented, "...Neuro checks per facility protocol..." An incident report, dated 12/01/14, documented, "...called into dinning (sic) room stat res laying on floor in front of w/c by the exit door of dinning (sic) room...Immediate action taken: ...assessment...No injuries observed..." There were no immediate interventions listed to prevent further falls. The fall care plan was not updated with any new interventions to prevent further falls. An annual assessment, dated 12/05/14, documented the resident had a short/long term memory problem and was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance and two person assist with transfers, did not ambulate, used a wheelchair for locomotion, was not steady during transfers, and had not experienced any falls. An incident report, dated 12/30/14, documented, "...This nurse was at nurses station, res alarm sounding as res began to rise from her scoop chair. Before this nurse could reach res she sat down on floor in front of her chair. Res did not hit her head or sustain any type of injury...Immediate action taken: ...Staff assisted res back into chair and reattached alarm...Offered toileting, snack..." The fall care plan was not updated with any new interventions to prevent further falls. An incident report, dated 01/29/15, documented, "...was called into resident room...resident knees were on the mat beside her bed and her top half was bent over the bed...Immediate action taken: ...resident assessed, vs taken, resident helped up..." There were no immediate interventions listed to prevent further falls. The fall care plan was not updated with any new interventions to prevent further falls. A reportable incident, dated 02/02/15, documented, "...Staff noted purple hematoma to and under left eyebrow. No swelling noted. Unable to ascertain how bruising occurred...High risk for falls...Upon investigation it is noted that the resident had a fall on 01-29-15 and could have been the reason for the bruising to face. Resident will continue on neurochecks per facility protocol. Continue with personal clip alarm and fall mat in place. Frequent visual checks in place with toileting. Resident is assisted with all adl's..." An incident report, dated 02/02/15, documented, "resident found on mat by bed resident was on her hands and knees...Immediate action taken: resident assessed, vs taken...No injuries observed..." There were no immediate interventions listed to prevent further falls. The fall care plan was not updated with any new interventions to prevent further falls. An incident report, dated 02/28/15, documented, "Called to residents room, resident noted on bedside mat on her knees. No apparent injury noted...Immediate action taken: ...assessment...resident assisted into geri chair, chair alarm was in use and working properly..." There were no immediate interventions listed to prevent further falls. The fall care plan was not updated with any new interventions to prevent further falls. The resident was observed at random times during each day of the survey. She was observed to be in the lobby area in the broda scoop chair with a personal alarm. On 03/03/15 at 3:30 p.m., the MDS/care plan coordinator was asked why the assessment completed on 12/05/14 did not reflect the resident had experienced falls since the previous assessment. She stated, "It was just an error on my part." She was asked if the medication review had been done. She stated, "I don't know if it was done." She was asked why the care plan had not been updated with new interventions to prevent further falls. She stated she thought she had updated the care plans and did paper care plans and electronic care plans. The MDS/care plan coordinator was shown both the paper and the electronic care plans and informed of the interventions not being updated after the occurrence of falls with new interventions. She stated, "I had absolutely no training on (electronic computer system) on the care plans. I've been learning and clicking on things to update and haven't got around to hers yet." On 03/05/15 at 1130 a.m., the DON was told of the resident's falls and asked why no new interventions had been developed or the interventions in place had not been implemented to prevent further falls. She stated, "We talked about ideas. She's restless and we didn't get them on the care plan apparently." The DON was asked if the medication review had been completed. She stated we did make medication changes on her but there was not any documentation of a medication review. She stated, "We are working on interventions that work for her." 3. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. A fall care plan, updated 07/22/14, documented, "Focus:..is at risk for falls r/t confusion & unsteady balance/gait, completely unaware of safety needs & forgetful... Goal: The resident will be free of falls through the review date...The resident will be free of minor injury through the review date... Interventions:..Be sure The resident's call light is within reach and encourage the resident to use use it...Encourage the resident to participate in activities...Ensure the resident is wearing appropriate footwear with non-skid soles when...

On 4/15/13, an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to provide supervision to prevent accident/hazards for a resident who was identified at high risk for elopement. The resident had a history of [REDACTED]. At 6:36 p.m., The Oklahoma State Department of Health (OSDH) was called and verified the existence of the Immediate Jeopardy situation. At 6:43 p.m., the administrator and the DON were informed of the Immediate Jeopardy regarding elopement and that a plan of removal would be required. They were also informed that this placed the facility in a partial extended survey. At 8:13 p.m., an acceptable plan of removal was received from the DON and the administrator. The plan documented, "Plan of Removal April 15, 2013 7:10pm One on one with resident at all times until notice from Administrator of change. Staff will document every hour, staff must keep resident Within vision at all times. Charge nurse will chart every hour on resident also. Administrator, DON, or ADON will review documentation daily. The charge nurse will assign a staff to resident one on one every shift. 7:20 p.m. All employees were called for immediate, mandatory In-service. Not a single employee will commence to work until in-serviced about facility policy on Elopement/Wandering Resident. 8:15 p.m. In-service started All employees in-service will be completed by 1:30pm On April 16,2013. Administration will re-locate resident in a room closer to Nurses station. Administration is looking into a GPS like device for residents safety." The IJ was removed on 04/16/13 at 2:40 p.m. when all components of the plan of removal had been completed. The deficient practice remained at a pattern level of actual harm. Based on observation, interview, and record review, it was determined the facility failed to: ~ provide supervision to prevent residents from elopement for one (#1) of five sampled residents, who were at risk for elopement or who had exit seeking behaviors. Resident #1 had a history of [REDACTED]. This resulted in an Immediate Jeopardy situation. The facility identified three residents were identified at risk for elopement, exit seeking, and wandering. ~ provide supervision to prevent falls for one (#4) of five sampled residents who had experienced falls. The resident sustained [REDACTED]. The facility identified 29 residents who were at risk for falls. Findings: 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A social service progress note, dated 03/27/12, documented, "...has been talk to about going out with his sister and she takes him to the park and drops him off for awhile and picks him back up..." A social service progress note, dated 04/25/12, documented, "...and his sister have been consoled (sic) with about her taking...to the park and leaving him..." A comprehensive assessment, dated 05/17/12, documented the resident had a BIMS score of 15 which indicated the resident was cognitively intact. The resident had no behaviors and wandered four to six days, but less than daily. A care plan, dated 05/17/12, documented, "...Problem: ...is at risk for leaving facility without notifing (sic) staff...Goal: ...will not wander from facility unattended...Allow to wander freely within facility...explain...(to) family the importance of signing out...staff to visualize res. location q 1hour... Problem: ...demonstrates decreased cognition, he is forgetful...monitor...safety hazards and remove potential hazards as needed. Protect...from possible physical injury...Encourage...participation in ADL's and assist as needed, especially during altered concept of reality, delusions, and/or hallucinations..." A social service progress note, dated 06/25/12, documented, "...sister counseled with about taking him out and dropping him off at the park and her not signing him out..." A social service progress note, dated 07/30/12, documented, "...talked with his sister about taking him out in this hot weather letting him walk around the park or any where, told her that it was a heat advisory and no one need (sic) to be out walking around in this heat, I told her until the weather was a lot cooler he needed to stay in out of the heat." A social service progress note, dated 08/03/12, documented "...went looking for him at 2:15 p.m., sister was here and took him out..." An incident report, dated 08/10/12, documented, "...Missing Resident...Description of incident: resident left facility without supervision. A citizen...called facility and reported whereabouts. Resident left facility and went to a nearby bar...He was not harmed he was gone approximately one hour..." The care plan had not been updated to address the resident had left the facility unsupervised, without the staffs' knowledge of his whereabouts, the resident had a [DIAGNOSES REDACTED]. There were no new interventions addressed for the prevention of further elopements. Nurses' notes for August 2012 were requested but the DON stated she couldn't find them. A social service progress note, dated 10/12, documented, "...had a talk about being out in the cold...outside with no coat on...sister taking him out without signing him out..." A risk of elopement/wandering assessment, dated 11/05/12, documented the resident did not have a history of leaving the facility without supervision and did not leave the facility without informing staff. The assessment documented that the resident was not at risk for elopement/wandering at this time. The assessment failed to address the resident had left the facility unsupervised, without the staffs' knowledge of his whereabouts, and the resident was a high risk for elopement. A quarterly assessment, dated 11/06/12, documented the resident had a BIMS score of 15 which indicated the resident was cognitively intact. The resident had delusions and wandered daily. A social service progress note, dated 11/12, documented, "...sister still taking him out without a coat or signing him out..." A quarterly assessment, dated 01/28/13, documented the resident had a BIMS score of 15 which indicated the resident has cognitive skills for daily decision making. The resident had no behaviors and wandered daily. A risk of elopement/wandering assessment, dated 02/05/13, documented the resident did not have a history of leaving the facility without supervision and did not leave the facility without informing staff. The assessment did not address the resident's high risk for elopement, the family's noncompliance with signing the resident out of the facility, and the family leaving the resident unattended in various locations. A nurse's note, dated 04/07/13, documented, "CNA noticed res outside walking near road - states he walked north after he spotted her. This nurse went to get him - he was in next block walking away from facility - Came back to facility s resistance. States he had gone out the West door 'just to get some fresh air' - I asked res to please stay indoors during noc hrs for his safety...CNA states she noticed him OOB @ initial bedcheck & thought he was in BR. Will do at least hourly checks @ nite to account for presence in facility..." An incident report dated 04/07/13, documented, "...Missing Resident...Description of incident: Resident was seen at 2240 (10:40 p.m.) by employee walking down the road near the facility (was in the next block heading away from facility). Charge nurse asked resident to return to the facility-resident did so without resistance. Resident states he "was getting fresh air"...Corrective measures implemented to prevent recurrence: ...was educated on the risk of ambulating away from the facility without supervision. Staff entrance to facilty (sic) is next to residents room and upon investigation it was reported...had been seen exiting building from that door...Resident is currently on Q1hour observation by staff related to elopement. Resident stated he did not realize he was not on facility (name deleted) property..." A nurse's note, dated 04/08/13, documented, "pt went out the W-back door @ lunch & came around the front c bread for the birds...he is not to be between the buildings..DON aware of his going out the back & between the buildings..." The care plan had not been updated to address the resident had left the facility unsupervised, without the staffs' knowledge of his whereabouts, he would exit through the west back door next to his room, and going between buildings. The care plan failed to address the residents' family were non-compliant with signing the resident in and out of the facility and would leave the resident unattended in various locations in town. There were no new interventions addressed for the prevention of further elopements. A risk of elopement/wandering assessment, dated 04/09/13, documented the resident did not have a history of leaving the facility without supervision and did not leave the facility without informing staff. The assessment also documented the resident was at risk for elopement/wandering, as evidenced by: "resd was wandering outside of facility." A nurse's note, dated 04/10/13 at 10:00 p.m., documented, "Res has been inside all day & walking the halls. Res looks outside & informs staff its still raining..." A nurse's note, dated 04/12/13 at 8:00 a.m., documented, "CMA noted res going out side door by his room...able to redirect res back into bldg..." The resident's hourly elopement checks revealed the following: 04/12/13 - 3 p.m. to 11 p.m. shift, no documentation, 04/13/13 - 3 p.m. to 11 p.m. shift, no documentation, and 04/14/13 - 3 p.m. to 11 p.m. shift - 11 p.m. to 5 a.m. shifts, no documentation. On 04/15/13 at 10:50 a.m., the resident was observed in his room sleeping in bed with the television on. The resident's room was located next to the employee exit door. Staff were observed entering and exiting the west back door. The loud alarm sounded each time the door was opened and no staff were observed to monitor the resident to ensure he had not exited the facility. At 1:00 p.m., the resident was observed in his bed asleep. At 3:17 p.m., the resident was observed in his room sleeping in his bed. At 3:50 p.m., CNA #1 was asked if the resident would be up anytime before her shift ended. She stated, "After dinner, he walks around facility a couple of times and then goes to bed." She was asked if the resident had a history of [REDACTED]." She was asked if she knew about the incident that had occurred on 04/07/13. She stated, "No." She was informed the resident had left the facility and was a block away. She was asked if she should have been told about the incident. She stated, "Yes." She was asked how often she checked on him. She stated, "Every two hours usually." She was asked if she had been instructed to do more frequent checks. She stated, "No. Not on him." At 4:20 p.m., CNA #2 was asked if the resident roamed at night. She stated, "Yes." She was asked if the resident would leave the building. She stated, "Yes, he will walk around building and come back in. She was asked if she was aware he was seen a block away from the facility on 04/07/13. She stated, "I didn't know anything about that." She was asked if he ever walked off facility. She stated, "Not that I know. He'll sneak out the back door on the west hall and nobody knows." She was asked how often she performed checks on him. She stated, "He's an hourly check." She was asked why he wanted to leave. She stated, "He just wants to walk. If he's outside for our hourly check we go outside to find him." She was asked if she knew about the incident that had occurred on 04/07/13. She stated, "No, I didn't." At 5:12 p.m., the social service director was asked if the resident had left the facility without telling anyone. She stated, "Yes." She was asked if she was aware he had left the facility and was found a block away. She stated, "No, I wasn't aware." She was asked if she thought she should have been informed. She stated, "Yes, I should have been." She was asked if the family dropped him off and left him in various locations. She stated, "Football field. We have told her she can't do that, he is elderly. Last year it was during the heat, I have picked him up at the park." She was asked if any interventions had been implemented. She stated, "Doing one hour checks on him. I don't know when they started it. Making sure he is signed in and out." She was asked if he usually slept all day. She stated, "Yes, sleeps all day and roams at night." At 5:25 p.m., the resident was observed sitting in the dining room. At 6:00 p.m., the DON was asked if the resident had a history of [REDACTED]." She was asked about the incident that had occurred on 04/07/13. She stated, "He was found a block away. Staff saw him as they were coming to work. We explained not safe at night time. He thought he was still on the property." She was asked if she had conducted a training inservice after this incident. She stated, "I will check and see. We have talked to all staff and he is on hourly checks." She was asked when she had implemented the hourly checks. She stated, "I believe that night. I don't remember the date." She was asked, if family signed him in and out. She stated, "At times she does not. We have spoken to her about the importance and the resident too." She was asked if he had eloped from the facility before. She stated, "There has been another incident." She stated she thought he may have eloped in May. She was asked where he had been found. She stated, "I believe he went to a local bar and grill." A nurse's note, dated 04/15/13 at 7:00 p.m., documented, "Sleeping soundly on top of bed." At 7:00 p.m., the resident was not observed in his room. The maintenance supervisor stated, "He's outside." CNA #2 stated, "He's outside walking. He went out that back door." The maintenance supervisor opened the door and turned off the alarm. He called the resident to come in. I introduced myself to the resident. He asked my name and I repeated my name for him. He was asked if he liked to walk. The resident stated, "Yes I do." He was asked where he liked to walk. He stated, "Different places." He was asked if he ever walked after dark. He stated, "I do on Sundays." He was asked if it was just Sundays. He stated, "Yes there's nothing on T.V." The resident asked my name again. I repeated my name. He was asked if staff checked on him when he walked after dark. He stated, "They checked on me one time when I was out at 10:00 p.m." The resident again asked me my name and I repeated my name again. On 04/16/13 at 9:45 a.m., the resident was observed sitting up on the bed talking with the housekeeping supervisor. The resident had walked out into hall and asked me my name again. I repeated my name. The resident asked, "You aren't the one I talked to last night?" I stated that I was. He asked my name again. I repeated my name and he stated, "That is an easy name. I don't know why I can't remember that." At 3:40 p.m., the DON was asked if she found any training or inservice that had been conducted after the 04/07/13 incident. She stated, "No I didn't." She was asked if she found out the date she had implemented the hourly checks. She stated she thought it was April 12th. At 3:43 p.m., the MDS/care plan coordinator was asked why the family's noncompliance with signing the resident out and leaving the resident at the park and various locations had not been addressed on the care plan. She stated, "I don't know." She was asked why there were no new interventions addressed when the resident had eloped from the facility at night and was a block away. She stated, "I don't know." She was asked if a BIMS of 15 was accurate when the care plan addressed a decrease in cognition and forgetfulness. She stated, "He does well on the BIMS and then he is distracted and forgets what he is doing. I think he has those BIMS questions memorized." 2. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. A social service note, dated 10/2012, documented, "...moves about the facility in a wheelchair...can get very upset at times wanting to go home or looking for her son." A quarterly assessment, dated 12/07/12, documented the resident had a BIMS score of 6, which indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment also documented the resident did not exhibit wandering behavior, required limited assistance to transfer, did not ambulate, and was self sufficient once up in wheelchair. A nurse's note, dated 12/26/12, documented, "Res anxious...wanting son called - forgets where she is..." A social service note, dated 12/2012, documented, "...was upset about her son not coming to see her a few times this month, he is here 3 or more times a week she forgets that hes (sic) been here." A social service note, dated 01/2013, documented, "...sometimes she forgets her son has been here and she getts (sic) very upset tries (sic) to leave, startes (sic) cursing about everything, takes a while to redirect her but it can be done." A social service note, dated 02/2013, documented, "...got upset because she thinks her son hasn't been here but he was here early that day by 2:30 pm she was really upset cursing and shaking the front door wanting out. Talking to her about something else for awhile will redirect her." A risk of elopement/wandering assessment, dated 02/28/13, documented the resident was cognitively impaired with poor decision skills. The remaining portion of the assessment was left blank. The assessment did not address the resident's behavior of shaking the door and wanting to leave the facility after her son had visited. A comprehensive assessment, dated 03/01/13, documented the resident had a BIMS score of 6, which indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment also documented the resident did not exhibit wandering behavior, required limited assistance to transfer, did not ambulate, and was self sufficient once up in wheelchair. The assessment did not address the resident's behavior of shaking the door and wanting to leave the facility after her son had visited. A care plan, dated 03/01/13, documented, "Problem: Resident limited in socialization abilities and activity participation D/T impaired cognition and short attention span...Goal: Resident will attend activities of choice and continue to interact with the staff and other residents on daily basis...Approach: ...Provide verbal cues/reminders of nexxt (sic) activity...Allow time for slowed thinking process...Do not show impatience/annoyance with memory gaps...Offer simple, concrete choices...Maintain consistent routine as much as possible in care giving and activities... Offer fluids and frequent snacks as permitted by diet. Observe oral intake...Plan frequent periods of rest or quiet time... Problem: Resident verbalizes and /or demonstrates feeling of anxiety/depression...searching for family...Goal:...Resident will verbalize and /or demonstrate decreased anxiety levels...participating in activities, interacting with staff...Approach:...Encourage to verbalize feelings. Give positive feedback...Provide 1:1 visits when anxious...Consult with physician to identify/correct any treatable cause for anxiety/depression...Offer diversional activities...attempt to identify sources of anxiety and help to resolve where appropriate...Encourage coping mechanisms...talking, walking, crying...Monitor for S/SX of depression: decreased interest/pleasure in most activities, wt. loss/gain, insomnia/hypersomnia, fatigue, feelings of worthlessness, decreased concentration...Notify MD..." A nurse's medication note, dated 03/23/13 at 2:00 p.m., documented the resident received, "Ativan 0.5 (one) PO...Reason: anxiety...Result: helps." A nurse's note, dated 03/23/13, documented, "...Resident very agitated today, Ativan prn and little help." A fall report, dated 03/23/13 at 4:50 p.m., documented, "...visitor let resident outside...Plan of interventions to prevent falls in the future...Encourage resident to stay in TV lobby area...Resident found outside on the ground in (L) lying position. View of camera shows visitor coming in let resident out the front door. Resident c/o (L) hip pain...Portable x-ray could not R/O (L) hip fracture - Resident transported to (name deleted hospital) for further evaluation. Dr. (name deleted) aware...Steps taken to prevent recurrence...frequent observation by staff...encourage resident to stay in TV lobby area...What were staff doing at time of fall?...Assisting other residents." A state reportable incident report, dated 03/23/13, documented the resident was transferred to another hospital for repair of a fractured left hip. A social service note, dated 03/25/13, documented, "... went outside on front porch fell out of chair, fractured her hip...she fell on [DATE]." On 04/15/13 at 3:55 p.m., CNA #1 was asked about the incident that had occurred when the resident exited the facility. She stated, "We had pulled her back from the front door I don't know how many times and went to set up the dining room and a visitor came in and told us the resident was outside on the ground." She stated, "We went out and (CNA#2) went and got the nurse and I stayed with her." She stated that RN#1 and CNA#2 came outside and the nurse assessed the resident and they helped her into the wheelchair and brought her to her room. She stated it was cold and raining at the time and the resident wanted to get up and come back inside. She stated the resident went out to the hospital later that evening. She was asked why the resident kept going to the door. She stated she wanted her son and wanted to leave the facility. She stated, "She was confused and mad at her son and kept trying to get out and was going to walk home. She would go up to the door and shake the door." She stated we had put her in the main lobby and told the charge nurse and I think she had the CNA give her some Ativan to calm her down. She was asked if the resident had continued to go to the door and try to leave why had she not been observed more closely. She stated, we had to go set up the dining room and tried to bring her with us but she got more aggitated and the nurse was supposed to watch her. She was asked where the nurse was at that time. She stated, she was at the nurses' station but had went down the hall to do blood sugars. She was asked if the resident was left alone in the lobby area. She stated, "Yes." At 4:15 p.m., CNA #2 was asked about the incident that had occurred when the resident exited the facility. She stated, "She was more aggitated all week and mad at her son. I pulled her away from the door once and the charge nurse pulled her away from the door twice." She was asked if any staff had stayed with the resident. She stated, "No. We were in the dining room and the nurse went down the hall." She stated, "I heard a scramble down the hall and a family member came in the dining room and said a resident was down outside." She stated that she and CNA #1 went outside to the resident, who was down in the grass. She stated CNA #1 stayed with the resident and she got the nurse. At 5:25 p.m., the social service director was asked about the resident's behaviors before she exited the facility on 03/23/13. She stated the resident had been shaking the door and became more aggitated on different days before the day she exited the facility. She stated she would go up to the door and shake it and want to get out. She stated she could hear her shake the door from her office and she had moved her away from the door and redirected her several times before that day. She asked if she had reported that to anyone. She stated, "Yes, I told the charge nurse and we reported it the DON." At 5:55 p.m., RN #1 was asked about the incident. She stated the resident had been trying to exit the building and she left her around the nurses' station area because she needed to do her insulins on other residents and the CNAs had to go set up the dining room for dinner. She was asked why the resident was left alone if she was in an anxious state and wanted to leave. She stated, "It was dinner time and I had things to do and the girls (CNAs) had the dining room to set up." Did you ask any other staff to stay with the resident and monitor her. She stated, "No." She was asked if she had called the family or physician regarding the resident's behavior of going to the door and trying to exit the facility. She stated, "No." She was asked why she had not called anyone or had staff monitor the resident. She stated the resident's behavior wasn't that unusual for her, she wanted to go home and other various places and the family had been there that day. On 04/16/13 at 3:40 p.m., the administrator, DON, and care plan coordinator were asked why the care plan had not been updated with interventions to address the resident's behavior after the son visited and implement the interventions put in place to assist the resident to cope after her son visited. The administrator stated they knew she would get upset when her son left and they had the care plan and risk management meetings but she was not aware of the social service notes regarding the resident's behavior. She stated the social service director rarely was able to attend the meetings because she was out of the facility taking residents to the the doctor or doing other duties. The DON stated, "I don't have an answer for that." The care plan coordinator stated, "I don't either."

Based on observation, record review, and interview, it was determined the facility failed to ensure avoidable pressure sores did not develop for one (#2) of five sampled residents reviewed for pressure sores. The facility failed to: a) identify risk factors, b) consistently assess the condition of the resident's skin after a history of resolved pressure sores, and c) implement measures to prevent recurrence of pressure sores for resident #2 who had a history of [REDACTED]. The facility identified four residents who currently had pressure sores. Findings: The facility policy for wound prevention and management documented prevention/relief interventions included to relieve pressure areas by utilizing appropriate pressure relieving devices and techniques. The policy documented for residents who met the criteria of being high risk for developing pressure sores aggressive preventive care would be provided and a high risk care plan would be initiated and interventions would be implemented. 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 12/19/11, documented the resident's cognition was intact and did not have memory problems. The assessment documented the resident required assistance with bed mobility and transfers. The assessment documented the resident had functional limitations in range of motion in the lower extremities. The assessment documented the resident was at risk for development of pressure ulcers and had two stage II pressure sores that had been present at the time of the previous assessment. The care plan, dated 12/30/11, documented the resident had a stage II pressure ulcer on the left buttock. The intervention for the use of an anti-pressure device mattress on the bed was marked through. The interventions included treatment as ordered and monitor for effectiveness, instruct/encourage/assist the resident to reposition at least every two hours and as needed, keep skin clean/dry and linens wrinkle free, monitor progress and report to the physician. A comment dated 01/04/12 documented the pressure sore had healed and [MEDICATION NAME] was used daily. The care plan did not address risk factors that could increase the resident's risk for the development of pressure sores. A pressure risk assessment, dated 01/01/12, documented the resident was not at high risk for developing pressure sores. A quarterly assessment, dated 03/14/12, documented the resident's cognition was intact and did not have memory problems. The assessment documented the resident required assistance with bed mobility and transfers. The assessment documented the resident had functional limitations in range of motion in the lower extremities. The assessment documented the resident was at risk for development of pressure sores but did not have pressure sores at the time of the assessment. The assessment documented the resident was on a turning and repositioning program and was monitored for nutrition and hydration for wound healing. The care plan conference form, dated 03/23/12, documented there were no issues with the resident's skin. The care plan did not include interventions to prevent the further development of pressure sores related to pressure relieving devices for the chair. A pressure risk assessment, dated 04/12, documented the resident was not at high risk for developing pressure sores. A weekly pressure ulcer progress report, dated 04/20/12, documented the resident had a stage III pressure sore on the left coccyx which measured 1.2 centimeters (cm) x 0.5 cm x 0.2 cm and had scant drainage present. The section for preventive measures was blank. The section for pressure relieving pads was blank. The facility was asked to provide weekly skin assessments prior to the development of the stage III pressure sore. No weekly skin assessments were provided. The care plan, dated 04/20/12, documented the resident had a pressure sore (no stage identified) on the left buttock with interventions which included the use of an anti-pressure device mattress on the bed, treatment as ordered and monitor for effectiveness, instruct, encourage, assist the resident to reposition at least every two hours and as needed, keep skin clean and dry and linens wrinkle free, monitor progress and report to the physician. A weekly pressure ulcer progress report, dated 04/27/12, documented the resident had a stage III pressure sore on the left buttock which measured 1.5 cm x 0.5 cm x 0.2 cm and had scant drainage present. The section for preventive measures was blank. The section for pressure relieving pads documented a cushion was in use. A wound care specialist initial evaluation, dated 04/27/12, documented the resident had a stage III pressure wound on the left buttock of at least seven days duration. The report documented the wound had light serous exudate. The report documented the resident was on a group 1 mattress and a pressure reducing device was used in the chair. The report documented the resident was to be repositioned according to facility protocol and off-loading the wound was recommended. The report was signed by the wound specialist physician. A weekly pressure ulcer progress report, dated 05/11/12, documented the resident had developed a stage II pressure sore on the right buttock which measured 1.0 cm x 1.0 cm x 0.2 cm and had light serous drainage present. The section for preventive measures was blank. The section for pressure relieving pads was blank. A wound care specialist evaluation, dated 05/11/12, documented the stage III pressure wound on the left buttock measured 2.0 cm x 1.0 cm x 0.2 cm and had not improved. The report documented the stage III pressure wound on the right buttock with a duration of greater than 1 day measured 1.0 cm x 1.0 cm x 0.2 cm and had light serous drainage. The report documented the physician had recommended to off-load the wound, limit sitting to 60 minutes, and reposition the resident according to facility protocol. A physician's telephone order, dated 05/17/12, documented the resident was to be evaluated and treated by hospice for conditions unrelated to the pressure sores. A wound care specialist evaluation, dated 05/25/12, documented the stage III pressure wound on the left buttock had resolved. The report documented the stage III pressure wound on the right buttock with a duration of greater than 15 days measured 1.6 cm x 1.5 cm x 0.3 cm, had light serous drainage, was 50% covered in slough, and the wound had deteriorated. The report documented the stage III pressure wound of the coccyx with a duration of greater than one day measured 1.0 cm x 0.5 cm x 0.2 cm, had light serous drainage, and was 80% covered in slough. The report documented the physician had recommended to off-load the wound, limit sitting to 60 minutes, and reposition the resident according to facility protocol. The care plan was not updated to address the physician's recommendations. A wound care specialist evaluation, dated 06/08/12, documented the pressure ulcer on the right buttock was improving. The report documented the pressure wound on the coccyx had resolved at the time of the examination. The report documented the resident had developed a stage II pressure wound of greater than one day duration on the left buttock which measured 0.5 cm x 0.3 cm x 0.1 cm with light serous drainage. The report documented the resident had been placed on a group 2 mattress on the bed and a gel cushion was used in the chair. On 06/29/12 at 2:45 p.m., the assistant director of nurses (ADON) performed wound care to the pressure sores on the resident's left and right buttock. A healing stage II pressure sore was observed on the resident's right and left buttock. Both pressure sores were approximately 1 cm in size and had pink granulation tissue with no excessive drainage. Two dry scabbed areas were noted on the resident's coccyx. The resident was lying on a pressure reducing mattress and a cushion was observed in the resident's wheelchair. The ADON was asked if the pressure sores had developed in house or if the resident had been in the hospital and returned with pressure sores. The ADON stated the pressure sores had developed in house. The ADON stated the resident had gone through a period of time when she wanted to sit up in the recliner for long periods of time without lying down. The ADON was asked what measures had been implemented to prevent the development of pressure sores. The ADON stated she had only been employed since March 2012 so she was not sure what had been done in the past. The ADON stated the resident was repositioned by staff at least every two hours and she was provided incontinent care as needed. The ADON was asked when the cushion had been placed in the recliner. The ADON stated she was aware of a cushion being used in the wheelchair and she thought the resident's daughter had tried different pillows in the recliner. The ADON did not know for certain when a cushion had been placed in the recliner. On 06/30/12 the resident was observed lying in bed on the right side from 9:05 a.m. until 11:00 a.m. and was placed in the wheelchair for the noon meal. On 06/30/12 at 1:35 p.m., the care plan nurse was asked to look at the care plan to determine when a cushion had been placed in the resident's wheelchair and recliner. The nurse looked at the current care plan and stated she did not see the use of cushions addressed in the care plan but would look in old care plan. On 06/30/12 at 2:00 p.m., the ADON was asked about the facility protocol for doing skin assessments for the residents identified at risk for developing pressure sores. The ADON stated there was not a specific protocol for performing skin assessments. The ADON was asked who did skin assessments and when they were done. The ADON stated the certified nurse aides (CNAs) notified her if they observed changes in the residents' skin when they were given showers or incontinent care. The ADON stated they did not routinely do skin assessments unless someone had a problem. The ADON was asked how the CNAs knew which residents were at risk for developing pressure sores. The ADON stated she was not certain that the CNAs knew which residents were at risk for developing pressure sores because there had been a lot of new staff. On 06/30/12 at 2:30 p.m., the care plan nurse provided the old care plan dated 01/03/11 which documented the resident used a gel cushion in the wheelchair. The nurse stated she did not know when a cushion had been placed in the recliner. The nurse was asked what made the resident be at risk for developing pressure sores. The nurse stated the resident's immobility, incontinence, and increased tremors related to [MEDICAL CONDITION] increased the resident's risk for developing pressure sores. The nurse stated the resident had a decrease in appetite which had just recently improved. The nurse stated the resident had gone through a period of time when she did not want to go to bed to rest but preferred to sit up all day in the recliner. The nurse was asked if the resident's refusal to lie down had been addressed in the care plan. The nurse stated she did not see where it had been addressed. The nurse was asked who determined what measures would be implemented to prevent the development of pressure sores. The nurse stated it was discussed and decided as a group during weekly stand-up meetings what measures would be implemented. The nurse stated the resident had been placed on an air mattress at one time and had rolled off of the bed and that mattress was replaced with a different mattress.