Wagoner Health & Rehab

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.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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