Every finding on record at Higher Call Nursing Center

Based on observation and interview, the facility failed to ensure food was palatable for 1 of 2 meals sampled for taste, temperature, and timeliness in being served. The administrator identified 38 residents ate from the kitchen. Findings: On 05/28/26 at 12:57 p.m., the lunch meal provided to the residents, was tasted by the surveyor. The lasagna was observed to have looked like meat with pea size white substances throughout and white yellow cheese across the top. The lasagna had a bad after taste which prevented a second bite. Mixed vegetables were unseasoned and bland, and the garlic bread was a plain piece of white sandwich bread cut diagonally. The kitchen did not have enough lime bars to provide for the surveyor to taste. The menu showed the 05/28/26 lunch meal was to be Italian style lasagna, California vegetable blend, garlic bread, and lime bars. A Food Palatability, Presentation, and Temperature Standards policy, dated 05/29/26, read in part, It is the policy of this organization that all food items prepared and served to residents shall be of the highest culinary quality. Food palatability-encompassing taste, aroma, visual arrangement, texture, and thermal properties -shall be afforded the same operational priority as clinical safety and metabolic accuracy. The facility dietary team, under the supervision of the Certified Dietary Manager (CDM) and consulting Registered Dietitian (RD), shall maintain rigorous quality assurance monitoring via systematic self-auditing and formalized resident feedback mechanisms. On 05/28/26 at 11:30 a.m., the ombudsman stated the food was the biggest complaint they had from the facility, and the rumors of how terrible the food was had even reached other nursing homes. The ombudsman stated there was only one person they spoke with in the facility that did not have issues with the food. On 05/28/26 at 11:45 a.m., Resident #8 gave the thumbs down sign when they were asked about the food. On 5/28/26 at 12:45 p.m., the cook stated they had to improvise on the lasagna because we did not have all of the ingredients. On 05/29/26 at 10:53 a.m., Resident #9 stated the facility did not feed them breakfast, so by lunch they were hungry. Resident #9 stated the facility needed to cook some better food because all they had was sandwiches, sandwiches, sandwiches. On 5/29/26 at 10:31 a.m., Resident #1 stated they were only allowed one piece of sausage at breakfast or one piece of bacon. Resident #1 stated the regional dietary manager kept cutting the budget for the kitchen and now they did not always get enough to eat. On 05/29/26 at 11:20 a.m., Resident #2 stated the place used to be great, but now the food quality was nasty especially on the weekends. Resident #2 stated portions were very small, not even enough to keep a bird alive. Resident #2 stated the regional dietary manager had cut the budget so much that residents could not have seconds. Resident #2 stated since the regional dietary manager came everything had changed in the way of the food. On 06/01/26 at 1:23 p.m., Resident #6 stated the food was bearable, but the facility did not have much for diabetics even with the alternative menu, and the snack cart never had fresh vegetables. Resident #6 stated they ate salads several times last week but would like some fresh vegetables like celery sticks, carrot sticks, or apple slices for a snack instead of cookies, pudding, and snack cakes. Resident #6 stated they loved the cook, but the cook could only do with what they have. On 06/01/26 at 2:34 p.m., the social services director stated they had been at the facility since 09/2025, and the food had been the number one topic for complaints. The social services director stated the amount of food had been an issue because the residents wanted seconds. On 06/01/26 at 5:06 p.m., the cook, via phone, stated they did not have enough sauce, so they used tomato sauce and seasoned it for the lasagna. The cook stated they also did not have the shredded mozzarella, so they used sliced Swiss across the top. The cook stated they had to improvise and be creative probably about two to three times per week. On 06/01/26 at 5:40 p.m., the administrator stated they had spent over the budget on food. The administrator stated the food was one of the last things residents had control over, so it was often the priority for the residents.

Based on observation, record review, and interview, the facility failed to ensure food items were stored correctly in the kitchen's refrigerator and freezer and labeled with the preparation and use-by date for 2 of 2 observations.The administrator identified 38 residents received meals from the kitchen.Findings: On 05/28/26 at 12:46 p.m., the following foods were observed in the refrigerator of the kitchen, and then identified by the dietary aide:a. thawed chicken thighs sitting in clear liquid inside an unsecured bag inside of a plastic bin at the bottom of the refrigerator. The date on the bin showed 05/28/26,b. four cracked eggs sitting inside undated cartons in the refrigerator, andc. partially used turkey lunch meat with no label or date in the refrigerator.On 05/28/26 at 12:49 p.m., the following foods were observed in the freezer of the kitchen, and then identified by the dietary aide:a. chicken fajita meat in a twisted closed bag in the freezer with no label or date,b. chicken strips in a twisted closed bag in the freezer with no label or date,c. hamburger patties in a plastic bag inside of a box that was open to air in the freezer with no label or date,d. sausage patties in a plastic bag inside of a box that was open to air in the freezer with no label or date, ande. corn dogs in a twisted closed plastic bag that had a tear leaving the corn dogs open to air in the freezer. There was no label or date on the bag.On 05/29/26 at 8:10 a.m., newly delivered pasteurized eggs in fresh unmarked cartons in the refrigerator were observed to have several cracked eggs. The chicken thighs were no longer present inside the refrigerator.An undated facility policy titled Food Labeling and Date marking, read in part all food containers must include common name of food item, date prepared or opened, discard date and initials of staff member.On 05/28/26 at 12:46 p.m., the dietary aide stated the eggs must have gotten cracked that morning. The dietary aide identified the fajita meat, sausage patties, hamburger patties, and turkey lunch meat. The dietary aide stated the items did not have dates written to indicate when they were opened or when they would need to be removed from rotation. The dietary aide stated the facility did not currently have a dietary manager, but the regional dietary manager came a couple times a week.On 05/28/26 at 12:48 p.m., cook #1 stated the chicken thighs were leftovers from yesterday and they were going to be used later that evening.On 05/29/26 at 8:10 a.m., the regional dietary manager stated staff removed the cracked eggs as they got to them. The regional dietary manager stated all of the open food items were supposed to be closed, labeled, and dated when stored. On 05/29/26 at 8:20 a.m., cook #1 stated they had used the chicken thighs to make chicken salad last night. On 06/01/26 at 3:45 p.m., the administrator stated they had been notified by the regional dietary manager about the food not being labeled or stored correctly.

Based on record review and interview, the facility failed to ensure a resident received pain medication in a timely manner for 1 (#2) of 3 sampled residents reviewed for pain management. The administrator identified 38 residents resided in the facility. Findings:A quarterly assessment, dated 03/09/26, showed Resident #2 had a diagnosis of rheumatoid arthritis and had pain frequently. The assessment showed Resident #2's pain had been rated at a 10/10 within the previous 5 days. The assessment showed Resident #2's cognition was intact with a brief interview for mental status (BIMS) score of 15. An admission summary note, dated 4/26/26 at 2:37 p.m., showed Resident #2 had returned from the hospital at 12:45 p.m. via stretcher and new orders were put into the computer. A physician's order, dated 04/26/26, showed oxycodone (opioid pain medication) 10-325 milligrams one tablet by mouth every six hours as needed for moderate pain. A health status note, dated 04/30/26 at 8:20 p.m., showed the ADON was notified the pharmacy needed a prior authorization for Tresiba (a long-acting insulin) and the ADON stated they would do it in the morning. A 05/2026 medication administration record showed Resident #2 had rated their pain at a 9/10 on 05/01/26 and was therefore provided the oxycodone at 5:30 a.m. The record showed Resident #2 was provided a second dose of oxycodone for pain rated at an 8/10 on 05/01/26 at 1:25 p.m. The record showed Resident #2 did not receive another dose of oxycodone until 05/05/26 at 10:02 a.m. for pain rated at an 8/10. The record was completely blank between the two dates. On 06/01/26 at 1:23 p.m., Resident #2 stated They don't always get our medications ordered timely. The med aide on the weekend slacks off and has a [NAME] attitude. Our meds don't get ordered in time to not have a lapse. My discs are herniated and I take my pain medications through a pain doctor, but they waited until I ran out before they called for a refill. On 06/01/26 at 4:50 p.m., the ADON stated Resident #2 did not get oxycodone fast enough because the pharmacist had car trouble which added a day to delivery, and the insurance wanted a preauthorization that took time. The ADON stated they would provide documentation to show the medication was ordered timely and the facility did what they could. No documentation showing the medication had been ordered timely was provided. On 06/01/26 at 5:45 p.m., the administrator stated they understood if the medication had been reordered timely, then the facility would have had time to provide the requested prior authorization and the pharmacist's car breaking down would not have impacted having the medication available in the facility to provide to Resident #2 as ordered by the physician.

Based on observation, record review, and interview, the facility failed to ensure medications were stored securely. The administrator identified 38 residents resided in the facility. Findings:On 05/28/26 at 1:06 p.m., a clear plastic bag containing multiple different medications waiting for destruction, was observed sitting on the floor of the ADON's office. The ADON's office door was observed to be wide open, and no staff were inside or around the open office door. A Safe Medication Storage, Security, and Temperature Controls policy, dated 05/29/26, read in part, It is the policy of this facility that all medications and biologicals shall be securely maintained under lock and key, stored under strict environmental conditions, and properly labeled at all times. Access to medication storage areas- including regional medication rooms, localized mobile medication carts, and automated dispensing appliances- is restricted exclusively to licensed nursing staff, practitioners, and the Consultant Pharmacist.On 05/28/26 at 1:14 p.m. the ADON stated if the medications are not controlled, the staff bring them to me, and I log and shred them. The ADON stated they would go lock up the medications until they had time to destroy them.On 06/01/26 at 3:45 p.m., the administrator stated they believed the ADON thought it was okay to leave them sitting out because the surveyor was sharing the office with them.

Based on observation, record review, and interview, the facility failed to ensure: a. prepared food items were labeled with the preparation and use-by dates; b. fresh food items were discarded when wilted and soft to the touch; c. food items were discarded after manufacturer expiration dates; and d. temperature logs were completed for 1 of 2 community refrigerators. The administrator identified 41 residents received meals from the kitchen.Findings:On 01/06/26 at 8:45 a.m., the following observations were made in the refrigerator in the kitchen:a. five serving containers with lids were without labels, preparation, or use-by dates and contained a white pudding type substance,b. two prepared turkey lunchmeat sandwiches, in plastic wrap, were without labels, preparation, or use-by dates,c. an opened one-gallon container of classic Caesar prepared dressing had a manufacturer use-by date of 08/24/25,d. a plastic container with six zucchini squash were wilted and soft to the touch, and e. six heads of iceberg lettuce were wilted, soft to the touch, and discolored. On 01/06/26 at 9:30 a.m., the following observations were made in the south community refrigerator:a. an opened container of mayonnaise with a manufacturer expiration date of 12/04/25,b. an opened container of barbeque sauce with a manufacturer expiration date of 09/21/25, andc. an opened carton of lactose free reduced fat milk without open or use-by dates.On 01/06/26 at 9:33 a.m., a refrigerator log was observed on the South community refrigerator and had no dates or temperatures completed for 01/03/26, 01/04/26, and 01/05/26.An undated facility policy titled Food Labeling and Date marking, read in part all food containers must include common name of food item, date prepared or opened, discard date and initials of staff member.An undated facility policy titled LTC [Long Term Care] Resident Refrigerator, read in part, write the date you received, date opened, date expired and residents name each food item to keep track.temperature: keep your refrigerator at 40 degrees Faren height or below. when a food item has reached its expiration date, staff must notify the resident and ask whether they would like to discard the item or keep it. The resident must be informed that expired food items may not be returned to the resident refrigerator.On 01/06/26 at 9:10 a.m., the dietary manager stated they knew they were supposed to have items in the refrigerator labelled and dated, but staff had not done it consistently. The dietary manager stated fresh food items should be checked for freshness and discarded if not fresh.On 01/09/26 at 11:09 a.m., the administrator stated housekeeping checked the community refrigerators daily for temperature and once a week for outdated food and cleanliness. The administrator stated they were aware of open dates on the temperature log on the South community refrigerator, and they were not checked.

Based on record review and interview, the facility failed to ensure a resident's annual MDS assessment accurately documented the resident's fall history for 1 (#36) of 16 sampled residents whose MDS assessments were reviewed.The DON identified 41 residents received MDS assessments.Findings:A facility policy titled MDS 3.0 Completion, dated August 2024, read in part, According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the state.A progress note, dated 07/30/25 at 3:45 a.m., showed Resident #36 reported they had rolled out of bed onto the floor. The note showed the resident had reported left shoulder pain and right knee pain. The note showed that the resident's right knee appeared slightly larger than the left.A care plan, dated 07/30/25, showed Resident #36 had a fall on 07/30/25. A corresponding intervention in the care plan showed the resident would use a fall mat next to their bed and was educated not to sleep on the edge of their bed.An annual assessment, dated 10/15/25, showed Resident #36 had not had any falls since admission, entry, reentry, or the prior assessment. On 01/08/26 at 2:31 p.m., MDS coordinator #1 reviewed Resident #36's annual assessment, dated 10/15/25, and stated the annual assessment was not accurately coded regarding falls.

Based on observation, record review, and interview, the facility failed to ensure infection control was maintained during wound care for 1 (#2) of 2 sampled residents reviewed for wound care.The DON identified 15 residents received wound care.Findings:On 01/08/26 at 12:27 p.m., Resident #2 was observed to receive wound care from RN #1. RN #1 was observed lowering themselves to the floor, onto their knees, then placed both gloved hands, onto the tiled floor. RN #1 was observed to touch Resident #2's bare skin and place a gauze dressing to the resident's left shin. RN #1 was observed to leave the room, while wearing their gown, to apply hand sanitizer from a container outside the room. RN #1 was observed to don gloves halfway onto their hands, reach into their pocket, retrieve a pen, then obtained gauze soaked in Dakin's solution, and placed it onto a wound on the resident's right heel. RN #1 was observed to put on the gloves the rest of the way and wrote the date on a dressing. RN #1 took an iodoform gauze soaked in Dakin's solution, placed it into a wound on the right heel, and applied a boarder gauze dressing with the same gloved hands.An undated facility policy titled Wound Assessment, Treatment, and Monitoring Policy, read in part Wound care shall be performed by licensed nursing staff using clean or sterile technique as ordered.On 01/08/26 at 12:39 p.m., RN #1 stated they had not realized they did not change their gloves correctly. They stated they were not very skilled at dressing changes and did not feel they had a routine down yet.On 01/08/26 at 2:19 p.m., the DON stated RN #1 was nervous and should have better prepared for the wound care.

Based on record review and interview, the facility failed to ensure a resident did not receive unnecessary psychotropic medications for two (#5 and #19) of five residents reviewed for unnecessary medications. The CMS form 802 documented 27 residents received psychotropic medications. Findings: 1. Resident #5 Resident #5 had diagnoses including depressive episodes and hip pain. A quarterly assessment dated [DATE] documented the resident received an antidepressant medication and an antianxiety medication. A physician's order, dated 04/19/24, documented Resident #5 received 10 mg of buspirone (an antianxiety medication) twice a day. A review of Resident #5's health record did not document side-effect monitoring was in place for antianxiety medication. 2. Resident #19 Resident #19 had diagnoses including anxiety and depression. A physician order, dated 03/14/24, documented Resident # 19 had a PRN order for lorazepam (a psychotropic medication). On 05/15/24 at 09:24 am, RN #1 stated residents receiving antianxiety medications should be monitored for medication side effects. They also stated PRN orders for psychotropic medications should be evaluated frequently. On 05/15/24 at 2:15 pm, the DON stated antianxiety monitoring should be documented in the TAR and all residents receiving antianxiety medications should be monitored for side effects. They also stated PRN orders for psychotropic medications should be evaluated every two weeks.

Based on observation, record review, and interview, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. The DON identified 37 residents who received meals from the kitchen. Findings: An undated policy titled Food Safety Requirements, read in part, .Food will also be stored, prepared and served in accordance with professional standards for food service safety .Monitoring food temperatures and functioning of the refrigeration equipment daily .Labeling , dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date .foods shall be prepared as directed until recommended temperatures for the specific foods are reached .Staff shall follow procedures for dishwashing . On 05/13/24 at 8:30 am, a review of the refrigerator and freezer temperature log for May did not document any temperatures had been recorded since 05/06/24. On 05/13/24 at 8:32 am, a reach in cooler was observed to contain open packages of sliced ham, shredded cheese, and chicken noodle soup, none of these items were dated. On 05/13/24 at 8:34 am, the bulk container of sugar was observed to be open, and a scoop was observed inside. The bulk container of flour was also observed to contain a scoop. All four trash cans in the kitchen were observed to be uncovered. On 05/13/24 at 8:40 am, the dish machine temperature log for May was observed, it did not document the temperature, or the concentration of sanitizer had been recorded for the first 13 days of May. On 05/13/24 at 8:45 am, the food temperature log for May was reviewed. The log did not document a meal temperature had been recorded since the noon meal on 05/06/24. On 05/14/24 at 11:16 am, Cook #1 stated that the temperature logs for the freezers and coolers should be recorded by the cook on duty, they also stated open containers of food should be closed and a date should be written on them. They further stated scoops should not be left in bulk containers and that the temperature of all meals should be recorded prior to serving. Cook #1 stated the person washing dishes was responsible for monitoring the dish machine and the temperature and chemical concentration should be recorded three times a day.

Based on record review and interview, the facility failed to enter required information on a Skilled Nursing Facility Advance Notice of Beneficiary Notice of Non-coverage (SNFABN) form prior to having a resident sign the document for one (#20) of three sampled resident reviewed for beneficiary notification. A facility daily census report documented 37 resident resided in the facility. Findings: Resident #20 was admitted on [DATE] and discharged on [DATE]. A review of the residents records found a Skilled Nursing Facility Advance Notice of Beneficiary Notice of Non-coverage (SNFABN) form had been signed by Resident #20 on 05/01/24. The document stated the resident may be charged for services out of pocket starting on 05/03/24. The area of the document where the services to be charged were to be listed along with the reason Medicare may not pay and the estimated cost of those services were blank. The area on the form where the resident checks one of three boxes to declare of they want to continue or discontinue the services that Medicare may not pay for was also blank. On 05/15/24 at 11:44 a.m., the BOM stated the document was required to be filled out with accurate information prior to having a resident sign the SNFABN. They stated the one for Resident #20 was blank.

Based on observation, record review, and interview, the facility failed to ensure the resident was assessed for their ability to safely use bed rails and the resident or their representative gave informed consent in writing prior to the use of bed rails for one (#7) of one resident reviewed for bed rail use. A facility daily census report documented 37 resident resided in the facility. Findings: A facility Proper Use of Bed Rails policy, dated 2023, documented a resident must be assessed for safe use of bed rails and informed consent must be obtained from the resident or their representative prior to use of bed rails. A quarterly assessment, dated 04/11/24, documented the resident required substantial assistance to reposition themselves in bed. The assessment documented the resident had moderate cognitive impairment. A review of Resident #20's medical record did not find documentation of the resident being assessed for or giving informed consent to use bed rails. No documentation of the resident having any accidents related to the bed rails was found. On 05/13/24 at 10:03 a.m. the resident's bed was observed to have half rails in the up position on each side other their bed. The resident stated they needed the rails to support themselves. On 05/15/24 at 1:33 p.m., the DON stated they had reviewed the resident records and did not find documentation the resident had been assessed prior to the use of the bed rails or had signed a consent form for the use of bed rails. On 05/16/24 at 10:48 a.m., the DON stated the staff had not followed policy when they allowed the resident to use the bed rails without following proper procedure. They had not followed policy.

Based on observation and interview, the facility failed to ensure infection control protocols were followed during wound care for one (#5) of two residents reviewed for wounds. The DON identified 8 residents in the facility with wounds. Findings: An undated facility policy titled Hand Hygiene read in part, .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors . The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves . Resident #5 had diagnoses which included MRSA and stage 3 pressure ulcers to the left and right heel. On 05/14/24 at 10:14 am, LPN #1 was observed changing the wound dressings on Resident #5's heels. LPN #1 was observed three times removing soiled gloves and putting on clean gloves without performing hand hygiene. On 05/14/24 at 10:23 am, LPN #1 was observed to remove the existing wound dressings from Resident #5's heels and then to support the residents uncovered left heel directly on LPN #1's uniform pants. LPN #1 then completed the dressing change on the left heel. Next, LPN #1 supported the residents uncovered right heel on their uniform pants. On 05/15/24 at 9:19 am, CNA #1 stated you should perform hand hygiene before putting on gloves and after removing gloves. On 05/15/24 at 11:09 am, the DON stated hand hygiene should be performed when changing gloves. They also stated it was not acceptable to rest an uncovered wound directly on your uniform.

On 03/26/24 at 3:33 p.m., an Immediate Jeopardy (IJ) situation was determined to exist related to the facilities failure to ensure Resident #1's right to remain in their room was not violated. Resident #1 was made to leave their room after stating repeatedly they did not feel well and did not want to go to the dining hall for a meal. On 03/25/24 at 3:30 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On 03/25/24 at 3:33 p.m., the administrator was notified of the immediate jeopardy situation. On 03/28/24 at 1:21 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The facility plan of removal, dated 03/26/24 at 6:00 p.m., read in part, Grievance book has been established and is an ongoing measure to ensure issues are being taken care of in a timely manner . At Quality Assurance Performance Improvement (QAPI) meeting we discussed our policy and facility policy on the residents right to refuse any care, activities, or anything they want to refuse . In-service staff on Self Determination on March 26 2024 . Risk management will monitor the facility issues weekly during regularly scheduled meetings throughout the remainder of the year . QAPI will monitor quarterly for the remainder of this year . The IJ was lifted effective 03/28/24 at 2:18 p.m., when all components of the plan of removal had been completed. The deficiency remains at an isolated level with a potential for harm. Based on observation, record review, and interview, the facility failed to ensure a resident's right to remain in their bed and to decline a meal for one (#1) of four sampled residents reviewed for resident rights. A Resident List Report, dated 01/23/24, documented 31 residents were residing at the facility. Findings: A Resident Rights, policy, undated, read in part, .The Resident has a right to a dignified existence, self-determination, and communication with an access to persons and services inside and outside the Facility . Resident #1 had diagnoses which included atherosclerotic heart disease, chronic obstructive pulmonary disease, Alzheimer's Disease, and generalized muscle weakness. A facility video recording of the interior of the building, dated 11/02/23, shows at 8:22 a.m. LPN #1 walking Resident #1 from their room to the dining room using a gait belt. A progress note, dated 11/02/23 at 10:25 a.m., written by LPN #1 documented LPN #1 ignored Resident #1's refusals to remain in bed and physically removed the resident from their room and moved them to the dining room. On 01/24/24 at 12:41 p.m., CNA #2 stated that on 11/02/23 Resident #1 had informed them and LPN #1 they did not want to get out of bed as they did not feel well. CNA #2 stated LPN #1 forced the resident out of their room and into the dining room using a gait belt. On 01/24/24 at 1:06 p.m., CNA #1 stated that on 11/02/23 they stated they observed LPN #1 walking behind Resident #1 in the hallway. They stated they heard the resident state they were out of breath and did not want to continue. They stated LPN #1 told the resident they had to walk because it was part of their therapy. On 01/24/24 at 1:20 p.m., CMA #1 stated that on 11/02/23 they observed LPN #1 bring Resident #1 into the dining room using a gait belt. They stated LPN #1 was basically dragging the resident through the dining room. On 01/25/23 at 9:30 a.m., the DON stated by not allowing Resident #1 to remain in bed on 11/02/23, LPN #1 had violated the resident's rights.

On [DATE] at 3:33 p.m., and Immediate Jeopardy (IJ) situation was determined to exist related to the facilities failure to prevent mental and physical abuse to Resident #1 using a gait belt to walk the resident from their room to the dining hall after the resident had stated they did not want to leave their room. Three employees that witnessed the abuse did not intervene to stop the abuse. On [DATE] at 3:30 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On [DATE] at 3:33 p.m., the administrator was notified of the immediate jeopardy situation. On [DATE] at 1:21 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The facility plan of removal, dated [DATE] at 5:00 p.m., read in part, Grievance book has been established and is an ongoing measure to ensure issues are being taken care of in a timely manner . At Quality Assurance Performance Improvement (QAPI) meeting we discussed our policy and facility policy on not allowing abuse or neglect in the facility . In-service staff on abuse and neglect [DATE] . Monitoring will happen weekly in Risk management and quarterly in QAPI through regularly scheduled meetings . The IJ was lifted effective [DATE] at 2:18 p.m., when all components of the plan of removal had been completed. The deficiency remains at an isolated level with s potential for harm. Based on observation, record review, and interview, the facility failed to protect a resident's right to be free from mental and physical abuse by a staff member for one (#1) of four residents reviewed for abuse. A Resident List Report, dated [DATE], documented 31 residents were residing at the facility. Findings: An Abuse Prevention Policy and Procedure, revised date [DATE], read in part .The facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical and/or mental abuse, corporal punishment, involuntary seclusion or misappropriation of resident property by a facility staff member . Resident #1 had diagnoses which included atherosclerotic heart disease, chronic obstructive pulmonary disease, Alzheimer's Disease, and generalized muscle weakness. A care plan focus, dated [DATE], documented that Resident #1 was a full code. A facility video recording of the interior of the building, dated [DATE], recorded LPN #1 walking Resident #1 from their room to the dining room using a gait belt. It documented Resident #1 falling and being picked up by LPN #1 and then continuing to be walked through the dining area. It recorded Resident #1 falling for the final time and being placed in a wheelchair by three staff and removed from the dining room. A progress note, dated [DATE] at 10:25 a.m., written by LPN #1 documented Resident #1 had informed staff they did not feel well and did not want to get out of bed and go to the dining room for a meal. The note documented LPN #1 dismissed the resident's statements of not feeling well. It documented Resident #1 reported being cold, having tremors, being dizzy, and not wanting to walk. It documented LPN #1 had heard this excuse from Resident #1 each morning and they had to encourage the resident every morning to walk to the dining room. It documented the LPN felt the excuses were the same as every other morning. It documented LPN #1 physically moved Resident #1 from their room to the dining room using a gait belt. It documented the resident had fallen in the dining room and had become unresponsive. It documented once in bed the resident did not have respiration or blood pressure. It did not document if the resident had received CPR from facility staff. It did document EMS staff did initiate CPR when they arrived. On [DATE] at 12:41 p.m., CNA #2 stated that on [DATE] they had asked if Resident #1 wanted to go to the dining room to eat. They stated the resident had declined because they felt dizzy and unwell. They stated they informed LPN #1 of what the resident had said. They stated LPN #1 said the resident must go to the dining room because they were a feeder [a term used to describe residents that required assistance with eating meals]. CNA #2 stated they informed Resident #1 they had to go to the dining room. They placed a gait belt on the resident and sat them on the side of the bed. They stated the resident reported the room was spinning, did not feel well, and did not want to eat so the CNA laid the resident back down then informed LPN #1. They stated LPN #1 went to Resident #1's room and told the resident they had to get up then grabbed the gait belt and pulled the resident to a standing position. The resident then attempted to sit back down saying they were dizzy and did not want to eat. They stated LPN #1 lifted the resident back up and they repeated that scenario three of four times. LPN #1 instructed CNA #2 to get the residents walker and they and the resident departed the resident's room. CNA #2 stated as they walked LPN #1 would continue to lift the resident up with the gait belt and one time LPN #1 told the resident You're not stupid. CNA #2 stated they became irritated with the situation and departed to assist other residents. They stated when they saw the resident next, they were in a wheelchair going to the resident's room and the resident appeared limp. They stated about twenty minutes later LPN #1 came to the dining room and said the shit was going to hit the fan because the resident was a full code. On [DATE] at 1:06 p.m., CNA #1 stated on [DATE] they witnessed LPN #1 using a gait belt to assist Resident #1 move down the hallway toward the dining room. They stated the resident was using a walker and appeared unstable. They stated they heard LPN #1 tell the resident they had to walk because it was part of their therapy. They stated LPN #1 was holding the gait belt about mid back of the resident and when they got to the dining room the resident looked like they were going to fall. CNA #1 stated at that time they had gone to help other residents. They stated the next time they saw the resident they were in a wheelchair. LPN #1 pushed the wheelchair out of the dining room and CNA #1 observed the resident's face and lips were blue. On [DATE] at 1:20 p.m., CMA #1 stated they had observed LPN #1 bring Resident #1 into the dining room on [DATE] about 8:30 a.m. They stated they saw the LPN bring the resident in by a gait belt and that the resident was very unstable. They stated the resident was using a walker and LPN #1 was basically dragging the resident in by the gait belt. They stated the resident slumped forward on the walker and then fell . They stated LPN #1 made the resident get up then walked another ten to fifteen feet and fell again. LPN #1 made the resident get up again then the resident fell for the last time. They stated LPN #1 stood over the resident for two to three minutes then told CMA #1 to get a wheelchair. When they returned, they placed the resident in the wheelchair and returned the resident to their room. They stated they put the resident in their bed, and they told LPN #1 that the resident was not breathing. They stated LPN #1 replied it did not matter because the resident was a DNR [do not resuscitate]. They stated between ten and fifteen minutes later they looked at the resident's chart and found out the resident was a full code. They stated LPN #1 said they guess they should go back and break some ribs. CMA #1 stated they had not seen anyone attempt CPR on Resident #1. On [DATE] at 9:30 a.m., the DON stated that LPN #1 conduct toward Resident #1 on [DATE] was absolutely abuse and violated their abuse policy.

On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure cardio-pulmonary resuscitation was provided according to standards of practice to Resident #1 who had become unresponsive and failed to assess a resident when they became unresponsive. On [DATE] 6:45 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On [DATE] at 6:50 p.m., the Administrator was notified of the Immediate Jeopardy situation. On [DATE] at 5:00 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The facility's plan of removal, dated [DATE] at 5:00 p.m., read in part, .LPN #1 was terminated following results of investigation on [DATE] . The DON or designee educating all licensed nurses on the facility's policy and procedure for initiating CPR and location of code status for each resident . RN shift supervisor given responsibility to direct/assign staff roles during code/initiation of code . A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented. DON to monitor for code status compliance by interviewing licensed nurses about facility CPR policy and procedure, as well as requesting return demonstration of CPR process. Compliance checks will be conducted 2 times monthly for three months. Findings will be reported at the monthly QAA Committee meeting . DON or designee will audit new admissions to compare the resident's advance directives to the physician orders for accuracy. This audit will continue weekly for three months. Findings will be reviewed at the monthly QAA Committee meeting . DON or designee performed a Code Blue drill and was performed with licensed nursing staff on all shifts until every nurse had participated at least once. Code Blue drills will continue to be held 2 times a month for 3 months. Findings will be reviewed at the monthly QAA Committee meeting . The IJ was lifted, effective [DATE] at 12:54 p.m., when all components of the plan of removal had been completed. The deficiency remains at an isolated level with s potential for harm. Based on record review, observation, and interviews, the facility failed to ensure a resident who had become unresponsive was immediately assessed by a licensed nurse and received cardio-pulmonary resuscitation (CPR) according to standards of practice for one (#1) of three sampled resident reviewed for abuse. A Resident List Report, dated [DATE], documented 31 residents residing at the facility. Findings: A Cardiopulmonary Resuscitation (CPR) policy, implemented date [DATE], read in part, .If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services . Resident #1 had diagnoses which included atherosclerotic heart disease, chronic obstructive pulmonary disease, Alzheimer's Disease, and generalized muscle weakness. A care plan focus, dated [DATE], documented that Resident #1 was a full code. A facility video recording of the interior of the building, dated [DATE], recorded LPN #1 walking Resident #1 from their room to the dining room. It recorded Resident #1 falling three times during the walk. It recorded LPN #1 and PT #1 standing over the resident after the last fall at 8:26 a.m. It recorded LPN #1, PT #1, and CMA #1 transferred Resident #1 from the floor to a wheelchair at 8:30 a.m. It recorded the three staff members then departing the dining area with the resident at 8:31 a.m. As they departed the dining area CMA #1 could be heard on the recording saying the resident's ankle was dragging on the floor and LPN #1 replying they were aware. A progress note, written by LPN #1, dated [DATE] at 10:25 a.m., documented at approximately 8:00 a.m. LPN #1 was informed Resident #1 did not want to leave their bed. It documented LPN #1 spoke with Resident #1 and although the resident objected, they did walk to the dining room. It documented that at some point Resident #1 sat on the dining room floor and became unresponsive. It documented LPN #1, CMA #1, and PT #1 transferred the resident to a wheelchair and moved the resident to their assigned room. It documented the resident was placed into their bed and then LPN #1 determined the resident was without respiration and blood pressure. It documented LPN #1 placed a backboard under Resident #1, began CPR, and called 911. The note documented the emergency responders had taken over CPR when they arrived. On [DATE] at 12:41 p.m., CNA #2 stated that on [DATE] they observed LPN #1 walk Resident #1 to the dining room where the resident fell several times. CNA #2 stated they departed the area to help other residents and when they returned Resident #1 was being pushed out of the dining area by LPN #1 and the resident appeared limp in the wheelchair. They stated about twenty minutes later LPN #1 came back to the dining room and said the shit was going to hit the fan because the resident was a full code. At 1:06 p.m., CNA #1 stated on [DATE] they witnessed LPN #1 using a gait belt to assist Resident #1 move down the hallway toward the dining room. They stated the resident looked unsteady. They stated they then went to assist other residents. They stated the next time they observed the resident they were being pushed out of the dining room by LPN #1. CNA #1 stated Resident #1's face and lips appeared blue. At 1:20 p.m., CMA #1 stated they had observed LPN #1 bring Resident #1 into the dining room on [DATE] at about 8:30 a.m. They stated they observed the resident fall several times. They stated the last time the resident fell LPN #1 stood over the resident for about two to three minutes. The stated LPN #1 told CMA #1 to get a wheelchair and when they returned, they placed the resident into the wheelchair. They stated they moved the resident to their assigned room and placed them in their bed. They stated at that point they told LPN #1 the resident was not breathing to which the LPN replied that it did not matter as Resident #1 was a DNR [do not resuscitate]. CMA #1 stated about 15 to twenty minutes later they checked the resident's records and discovered the resident was a full code [a phrase that indicates the use of basic life support measures and CPR was desired by the resident]. They stated LPN #1 had then said they should go back and break some ribs. On [DATE] at 9:10 a.m., CMA #1 stated they had not seen anyone perform CPR on Resident #1 on [DATE]. On [DATE] at 11:41 a.m., the DON stated they received a telephone call at approximately 8:45 a.m. on [DATE]. They stated LPN #1 had called and stated Resident #1 had died . They stated they informed the LPN the resident was a full code and LPN #1 had argued the resident was not. They stated they arrived at the facility a little after 9:00 a.m. and went directly to Resident #1's room. They stated when the entered the room LPN #1 was performing compressions on Resident #1 who was laying on a bed. They stated LPN #1 was performing compressions while holding their cell phone to their face with their shoulder. They stated a nasal cannula was inside the resident mouth, there was no back board under the resident, and the LPN was pushing too deep. She stated they believed the compressions would have caused broken ribs. They stated they observed the compressions for one to two minutes after which they assessed the resident and found no pulse or respirations. The DON stated LPN #1 should have assessed Resident #1 when they had the final fall and became unresponsive in the dining room. They stated LPN #1's attempt at CPR was very bad as the resident was in a bed without a backboard, the nasal cannula providing oxygen was in the resident's mouth, and the chest compressions were too deep. They stated LPN #1 did not follow facility policy during the incident. On [DATE] at 12:43 p.m., PT #1 stated they had entered the dining room on [DATE] at 8:30 a.m. and noticed Resident #1 falling. They stated LPN #1's back was to them and was unsure if they were assisting the resident or not. They stated they did not see anyone assess the resident in the dining room. They stated they believed the resident was on the floor of the dining room for about five minutes. They stated CMA #1 arrived with a wheelchair and stated the resident's lips were turning blue to which LPN #1 replied, No they are not. They stated at that time the residents bottom dentures were coming out of their mouth, so they removed them. They stated LPN #1, CMA #1, and themselves placed the resident in a wheelchair and moved them to their room. They stated the resident's feet were dragging on the ground while in the wheelchair. They stated they attempted to communicate with the resident on the way to their room, but the resident never responded. They stated, once in the resident's room and while the resident was in the wheelchair, they and LPN #1 both felt for a pulse. PT #1 stated they did not find a pulse. They stated they left the room to retrieve a pulse oximeter [a device placed on a patient's finger to assess vital signs]. They stated the device never indicated a pulse was present. They stated LPN #1 had said the resident was dead and there was nothing more to do as the resident was a DNR. They stated LPN #1 departed the room and while they were gone, they and CMA #1 transferred the resident to the bed. They stated LPN #1 returned to the room with a stethoscope and listed for heart and lung sounds from the resident. They stated LPN #1 then said they needed to make some calls, and everyone left the room. PT #1 stated they left the room before 9:00 a.m. They stated after the resident was taken from the facility LPN #1 came to them, gave them a hug and stated, Don't worry I'll change some things. On [DATE] at 3:30 p.m., LPN #1 returned the surveyor's telephone call and agreed to an interview. They stated that on [DATE] they had walked Resident #1 to the dining room for the morning meal. They stated the resident had complained several times on the way to the dining room that they felt they would fall and did fall just prior to reaching the table. They stated they could tell the resident was not breathing and they instructed a staff member to get a wheelchair. They stated they told PT #1 the resident was not breathing and needed to be taken back to their room. They stated they checked the resident's pulse in the dining room and found no pulse. They stated they believed the resident was a DNR because of a conversation with the DON six months earlier about the resident's code status. LPN #1 stated they took responsibility for not performing CPR as they believed the resident was a DNR. They stated after the resident was placed in a bed, they called the DON and asked if the resident was a DNR. They stated the DON did not say the resident was a full code. They stated when they got off the phone they went outside and smoked a cigarette. They stated, after smoking the cigarette they retrieved a back board and returned to the resident's room. They stated they then performed CPR for an unknown period and called 911. They stated they were not sure if the DON observed them perform CPR.

Based on observation, record review, and interview, the facility failed to prevent the use of a gait belt as a physical restraint for one (#1) of four sampled residents reviewed for resident rights. A Resident List Report, dated 01/23/24, documented 31 residents were residing at the facility. Findings: Resident #1 had diagnoses which included atherosclerotic heart disease, chronic obstructive pulmonary disease, Alzheimer's Disease, and generalized muscle weakness. A facility video recording of the interior of the building, dated 11/02/23, shows at 8:22 a.m. LPN #1 walking behind Resident #1 who was hunched over a walker. LPN #1 was holding a gait belt that was secured around the lower chest of Resident #1. LPN #1's grip on the belt was between the shoulder blades of the resident. At 8:23 a.m., the recording shows the two inside the dining room. LPN #1 continued to walk behind Resident #1 holding the gait belt secured to the resident. A progress note, dated 11/02/23 at 10:25 a.m., written by LPN #1 documented Resident #1 declined to leave their room to go to the dining room for a meal. If further documented LPN #1 ignored the resident's statements and used a gait belt to remove the resident from their room and took them to the dining room. On 01/24/24 at 12:41 p.m., CNA #2 stated that on 11/02/23 they had asked Resident #1 if they wanted to get up for breakfast. CNA #2 stated the resident declined stating they did not feel well and felt dizzy. CNA #2 stated they informed LPN #1 who stated the resident had to go to the dining room because they were a feeder [a term used to describe residents that required assistance with eating meals]. CNA #2 stated although Resident #1 stated repeatedly, they did not want to get out of bed LPN #1 used the gait belt to force the resident out of bed and to walk to the dining room. At 1:06 p.m., CNA #1 stated that on 11/02/23 they observed LPN #1 walking Resident #1 out of the resident's room. They stated LPN #1 was holding a gait belt attached to Resident #1. CNA #1 stated they were behind the two and heard the resident state they were out of breath and could not walk. They heard LPN #1 respond that it was part of the resident's therapy to walk and continued to force the resident to walk using the gait belt. They stated they observed LPN #1 holding the gait belt around the mid back of the resident. They stated the resident was visibly out of breath. At 1:20 p.m., CMA #1 stated that on 11/02/23 they observed LPN #1 bring Resident #1 into the dining room using a gait belt. They stated the resident was holding onto a walker and was obviously unstable. They stated LPN #1 was basically dragging the resident through the dining room. On 01/25/24 at 9:30 a.m., the DON stated the way LPN #1 had used the gait belt on Resident #1 made it a physical restraint.

Based on observation, record review, and interview, the facility failed to protect residents from potential abuse by delaying an investigation of possible abuse for one (#1) of four residents reviewed for abuse. A Resident List Report, dated [DATE], documented 31 residents were residing at the facility. Findings: An Abuse Prevention Policy and Procedure, revised date [DATE], read in part .An immediate investigation into the alleged incidence, during the shift if [sic] occurred on .The facility will take all steps necessary to ensure that further potential abuse will not occur while the investigation is in progress . Resident #1 had diagnoses which included atherosclerotic heart disease, chronic obstructive pulmonary disease, Alzheimer's Disease, and generalized muscle weakness. A facility video recording of the interior of the building, dated [DATE], recorded LPN #1 walking Resident #1 to from their assigned room to the dining room by use of a gait belt. The video recorded the resident falling repeatedly and eventually being placed in a wheelchair and removed from the dining room. A progress note, dated [DATE] at 10:25 a.m., written by LPN #1 documented Resident #1 had informed staff they did not feel well and did not want to get out of bed and go to the dining room for a meal. The note documented LPN #1 ignored the resident's statements of not feeling well as well as the resident's complaints of being cold, having tremors, and being dizzy and physically moved Resident #1 to the dining room using a gait belt. On [DATE] at 2:44 p.m., the DON stated she received a telephone call from LPN #1 at about 8:50 a.m. on [DATE] in which the LPN stated Resident #1 had died . The DON stated they then went to the facility, arrived about 9:10 a.m. and found LPN #1 in Resident #1's room performing chest compressions. She stated there was no crash cart, no back board and LPN #1 was alone. The DON stated they informed LPN #1 to document everything that happened. They stated they were informed by a family member that Resident #1 had not died in their room but the dining room. They stated that information prompted them to investigate but they did not start the investigation until Monday [[DATE]]. The DON stated they had started the investigation at 6:00 a.m. on Monday and suspended LPN #1 by 9:00 a.m. On [DATE] at 3:10 p.m. the ADON stated that on [DATE] between 9:00 a.m. and 10:00 a.m., CNA #1 and CNA #2 had approached them and stated that LPN #1 had made Resident #1 get up from bed against their will and go to the dining room. The CNA's stated the resident died in the dining room. The ADON stated they informed the DON that morning of what they had been told by the CNA's. They stated they and the DON talked to LPN #1 about resident rights. They stated Saturday [[DATE]] they received more information from a family member about what had occurred. The family member stated a resident had called the family member and told them what had happened. On [DATE] at 8:44 a.m., CNA #1 stated that on [DATE] they had informed the ADON that LPN #1 had held Resident #1 up by a gait belt and moved them to the dining room. They also stated they informed the ADON of the inconsistency between the time LPN #1 said the resident had died and the time they started CPR. On [DATE] at 8:56 CNA #2 stated that on [DATE] they had informed the ADON that LPN #1 had yanked Resident #1 from their bed using a gait belt. I told her the resident had looked blue when they were taken out of the dining room. On [DATE] at 9:30 a.m., the DON stated they found out about Resident #1's death on the day they died [[DATE]]. They stated a family member spoke to them on Saturday [[DATE]] and reported that LPN #1 had called the family over the weekend to tell them the resident had died while in bed. The DON stated they found out about the resident being forced to walk to the dining area on Monday [[DATE]] when they started the investigation. They stated they did not start an investigation over the weekend because the weekend staff was not on duty when the resident died . They stated they did not instruct LPN #1 not to enter the building until Monday because they knew LPN #1 was not scheduled to work over the weekend. They stated LPN #1 started work Monday as scheduled and had access to the residents prior to being suspended later that morning.

Based on record review and interview the facility failed to notify a resident's family of a significant weight loss for one (#5) of three sampled residents reviewed for weight loss. A Resident List Report, dated 01/23/24, documented 31 residents residing at the facility. Findings: A facility policy titled, Notification of Changes, dated 10/2023, read in part, .The facility must inform the resident, consult with the resident's physician and / or notify the resident's family member or legal representative when there is a change requiring such a notification .2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health . A monthly weight report, dated April 2023 through March 2024, documented Resident #5 weight 124.8 pounds in January 2024. It further documented the resident's weight declined to 97.0 pounds in February 2024 which was a 22.28% decline in total body weight in one month. On 03/26/24 at 1:20 p.m., a family member of Resident #5 stated the facility had failed to inform them of the resident's weight loss. They stated they only found out about it when a family friend visited the resident and reported their condition to them. They stated they want to know anytime the resident's condition changes or their treatment changes. At 2:27 p.m., the DON stated they were unable to find any documentation Resident #6 had been informed of the significant weight loss. They stated they had told the facility staff many times of they must contact the family when such changes occur. They stated the staff did not follow policy in that situation.

Based on record review and interview the facility failed to conduct skin and wound assessments and as ordered by a physician for one (#6) of three sampled residents reviewed for wound care. A Resident List Report, dated 01/23/24, documented 31 residents residing at the facility. Findings: Resident #6 had diagnoses which included pressure ulcers and quadriplegia. A physician order, dated 01/22/24, documented starting on 01/23/24 a skin assessment was to be performed on Resident #6 daily and documented in the resident's electronic medical record. A physician order, dated 01/22/24, documented wound assessments were to be conducted weekly on Thursday and documented in the resident's electronic medical record starting on 01/25/24. A review of Resident #6's electronic medical record from the dates of 01/23/24 through 03/26/24 found daily skin assessments were not documented in the resident's electronic medical record on 03/16/24, 02/28/24, 02/17/24, 02/12/24, 02/11/24, 02/10/24, and 02/04/24. The medical record was reviewed from 01/25/24 through 03/26/24 for weekly wound assessments on Thursdays. There were no assessments documented on 02/01/24, 02/08/24, 02/15/24, 02/29/24, 03/07/24, 03/14/24, and 03/21/24. On 03/26/24 at 10:30 a.m., LPN #3 reviewed Resident #6's electronic medical record and stated skin and wound assessments were missing. They stated those documents were not kept in any other location in the medical record. On 03/26/24 at 11:00 a.m., the DON stated they could not locate the mission assessment documentation and so they must not have been completed. They stated all physician orders were expected to be followed.

On 04/01/23, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents who had fallen had interventions put in place to prevent the recurrence of falls. Failed to monitor and evaluate the effectiveness of the interventions and modify the care plan with each fall. Failed to conduct a root cause analysis and/or evaluate the cause for each fall. The facility did not have a fall prevention program, nor have the staff received education regarding falls and fall prevention in the last 12 months. On 04/01/23 at 12:05 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 04/01/23 at 12:17 p.m., the Administrator was notified of the IJ situation. On 04/01/23 at 2:56 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The facility's plan of removal, dated 04/03/23 at 2:29 p.m., read in part, 1. All residents that are in the facility will be audited and those that have not had a fall assessment completed within the last 14 days will have one completed within 24 hours. 2. All current residents that have been in the facility for longer than 21 days and are identified as a fall risk will have their comprehensive care plan updated within 48 hours. 3. A fall prevention program will be implemented and put into place immediately. 4. In person in-services will be initiated immediately for all staff regarding the Fall Policy and the Fall Prevention Program. Staff that do not/cannot attend in-service will be required to sign the in-service roster prior to their next shift. Fall Policy and Fall Prevention Program will be covered including fall assessments, resident centered approaches to fall prevention and fall monitoring. 5. All new admissions will have a Fall Assessment completed within 24 hours of admission and fall interventions will be a part of their baseline care plan. 6. In-service will be initiated immediately for all licensed staff regarding suicide ideation policy and immediate EOD. 7. Policies used for in-service were obtained through sister facilities and sources that are known to be compliant with current regulations. The IJ was lifted, effective 04/03/23 at 2:40 p.m., when all components of the plan of removal had been completed. The deficiency remains at an isolated level with a potential for harm. Based on record review and interview the facility failed to ensure the following for two (#18 and #91) of three residents reviewed for falls: a. fall interventions were put into place to prevent recurrence of falls; b. monitor and evaluate the effectiveness of interventions and modify the care plan with each fall; c. failed to conduct a root cause analysis and/or evaluate the cause for each fall, and d. educate the staff regarding falls and fall prevention in the last 12 months. The administrator identified seven residents who had falls with major injury in the last 12 months. A review of medical records showed Res #18 had eight falls on the following dates: 09/25/22, 10/28/22, 11/11/22, 11/18/22, 12/02/22, 01/18/23, 2/15/23, and 03/25/23. An internal incident report, dated 02/15/23, read in parts, .(Res #18) was on the floor .complained of pain in left hip and when (Res #18) tried to move it he screamed out in pain . An incident report submitted to OSDH on 02/15/23, read in parts, (hospital name withheld) admitted resident with a broken hip . A care plan, dated 11/07/22, was not updated with each fall to include a fall intervention. A review of medical records showed Res #91 had 20 falls on the following dates: 05/19/22, 05/24/22. 06/05/22, 06/08/22, 06/25/22, 08/06/22, 08/13/22, 08/17/22, 09/13/22, 09/19/22, 10/26/22, 11/27/22, 12/18/22, 12/19/22, 12/27/22, 01/07/23, 01/11/23, 01/23/23, and two falls on 02/24/23. An internal incident report, dated 02/24/23, read in parts, .I went to resident's room and seen [sic] him on the floor .Resident barely able to straighten right leg and screams in pain with movement . An incident report submitted to OSDH on 02/24/23, read in parts, .Resident was transported to admitted for a broken hip . A care plan, dated 08/08/22, was not updated with each fall to include a fall intervention. There was no documentation to show falls were investigated to determine causal factors or the staff had received education regarding falls and fall prevention. On 04/01/23 at 9:00 a.m., CNA #2 reported they thought the stars outside resident rooms meant those residents were at high risk for falls. CNA #2 reported they had received no education regarding falls or fall prevention. On 04/01/23 at 9:30 a.m., the DON reported the care plan should have been updated with each fall to include fall interventions. On 04/01/23 at 9:45 a.m., CMA #1 reported they could identify residents at risk for falls because they had been around them for so long, I just know. CMA #1 reported they had received no education regarding falls or fall prevention. On 04/01/23 at 11:00 a.m., the Administrator reported they did not have a fall prevention program and the stars outside residents' rooms was an antiquated system they no longer followed. The Administrator reported they did not investigate falls on a consistent basis to determine casual factors. The Administrator reported the care plans should have been updated with each fall to include fall interventions.

On 03/30/23, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide mental health treatment and services for Res #23 who had a serious mental illness, suicidal ideation, and threats to self-harm. On 03/30/23 at 2:00 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 03/30/23 at 2:17 p.m., the Administrator was notified of the IJ situation. On 03/30/23 at 6:40 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The facility's plan of removal, dated 03/30/23 at 6:40 p.m., read in part, 1. All residents that are in the facility will have a Trauma Informed Assessment completed within 24 hours. New admissions will have a Trauma Informed Assessment completed within 24 hours of admission. Residents that are identified through the assessment as needing immediate treatment/services will be referred for treatment. 2. All residents with PSTD or suicidal ideation that are in the facility shall receive an adequate comprehensive care plan to address the resident's POC including psychosocial wellbeing within 48 hours. 3. In-services will be initiated immediately for all staff concerning trauma informed care policy and abuse, neglect, and psychosocial wellbeing, suicide ideation policy and immediate EOD, adequate behavior monitoring and change of condition notification. Any behavior that is not baseline for any resident should be immediately reported to the charge nurse. This may include, refusing medications, meals, social interaction/activities, increased isolation. Staff that do not/cannot attend in-service will be emailed copies of all material covered. Signed acknowledgment of that in-service will be required prior to their next shift. Policies covered: Trauma Informed Care, Notification of Change, Suicide Prevention, Use of Psychotropic Medication, Abuse and Neglect. Policies were compared with sister facilities and the Compliance Store. 4. The facility will continue to reach out and look for adequate therapy services for psychosocial wellbeing of the residents. Sister facility (17 miles) recently obtained therapy services and we have reached out to attempt to contract those same services. 5. An audit will be initiated immediately and finished within 1 hour concerning all residents on a level II PASSR to determine if baseline care plan is monitoring resident's psychosocial wellbeing. 6. In-service will be initiated immediately for all licensed staff regarding suicide ideation policy and immediate EOD. 7. Policies used for in-service were obtained through sister facilities and sources that are known to be compliant with current regulations. The IJ was lifted, effective 03/30/23 at 6:45 p.m., when all components of the plan of removal had been completed. The deficiency remains at an isolated level with a potential for harm. Based on record review and interview, the facility failed to ensure a resident with serious mental illness who had suicidal ideation and complaints of self-harm received the necessary treatment and services for one (#23) of one resident reviewed for mental health services. The Resident Census and Conditions of Residents, dated 03/30/23, documented a census of 39 residents. Res #23 was admitted with diagnoses which included major depressive disorder, anxiety, and PTSD. Findings: A letter from the Oklahoma Health Care Authority, dated 05/23/22, read in parts, .it was necessary for you to receive a resident review Level II assessment to determine your level of mental illness .Client experiences a serious mental illness as defined by CMS . The PASRR Resident Review, dated 05/18/22, documented the following recommendations in parts, .1. Psychiatric care .ensure proper DSM-5 (mental illness) diagnoses and accordingly a standard of care treatment plan that factors in evidence-based knowledge and avoids polypharmacology (which is no more than four psychotropic medications) and avoids benzodiazepines. 2. Primary Care .avoid opioids and sedatives at all cost if possible .especially in those with substance use disorders, who are elderly, who are on other controlled substances, and/or who have pulmonary disorder. 3.highly encourage and arrange for COVID vaccination, including the booster shot. If patient has COVID presently, then follow CDC guidelines for isolation. 4. Nutrition .facilitate a diet conducive to adequate weight. If the patient is obese .facilitate weight loss. 5.ensure the patient is adequately groomed and with good hygiene. 6. Guardian or proxy if patient needs help or is unable to make medical decisions. 7. Subspeciality follow-up care: cardiology, GI, ophthalmology, physical therapy . 8.Contact Mental Health Provider for Re-Assessment/Treatment/Medication adjustment if symptoms exacerbate. 9. Person-Centered approach to prevent decompensation and negative response/behaviors. 10. Psychiatric Follow Up Services - Monthly . The PASARR Resident Review, dated 5/18/22, read in parts, .hospitalization s: Many inpatient admissions to treat mental illness. Inpatient admission at (name withheld) for suicidal ideation .was admitted to (name withheld) - for paranoia, depression and anxiety .was admitted to (name withheld) for throwing things, cursing staff, dumping tray on the floor, threatening staff and peers, refusing medications .reportedly has multiple past suicide attempts, with scars on arms from attempts .This individual has a complex and extensive psychiatric history .Routine behavior monitoring is ordered for this individual. Staff should be familiar with this individual's behaviors, should monitor behaviors, and provide social support for this individual's unique need secondary to mental illness . A facility assessment, dated 08/15/22, read in parts, .The need for assistance with behavioral needs has become very evident. Our staff need additional training to help meet the needs of our residents .Our medical director is assisting us with finding a psychiatric physician to meet the needs of our residents A Behavior Note, dated 09/09/21 at 11:31 p.m., read in part, Resident verbalizes suicidal thoughts and has a plan to cut herself by any means necessary. She states she is very sad about her husband's death. There was no documentation the physician had been notified of Res #23's suicidal thoughts and plans to self-harm. There was no documented monitoring of the resident. There was no care plan to address the resident's diagnoses of anxiety and PTSD. The Care Plan did not incorporate the recommendations from the PASRR evaluation report or any resident behaviors. A physician's order, dated 12/07/22, read in parts, Behavior monitoring: document, and alert PCP PRN of behaviors: All behaviors are to be documented in progress notes . There was no documentation to show Behavior monitoring until three months after Res #23 reported suicidal ideation and threats of self-harm. There were no in-services regarding residents with PTSD, suicidal ideation, threats of self- harm, or residents' with mental health issues for the past 12 months. On 03/29/23 at 4:00 p.m., the DON reported they did not have documentation to show the staff intervened and/or monitored Res #23 after they reported suicidal ideation and threats of self-harm. The DON reported the care plan was not adequate to address the needs of the resident. She also reported the PASRR recommendations had not been incorporated into Res #23's plan of care. On 03/30/23 at 9:52 a.m., LPN #1 reported she had received no formal training regarding residents with PTSD, suicidal ideation, threats of self-harm and residents' with mental health issues. On 03/30/23 at 10:07 a.m., Physician #1 reported they couldn't recall if they were notified of Res #23's threat of self-harm and suicide. The physician reported the resident self-isolated and became severely depressed after the death of their spouse. On 03/30/23 at 1:10 p.m., Res #23 reported they were depressed at a level nine (Informal scale 1-10 with 10 being severe depression). The resident reported thoughts of suicide and self harm but didn't have a plan because nothing was available in the home to harm themselves. Res #23 reported they did not feel their needs were being met. Res #23 reported needing therapy but stated they had been told they weren't eligible to receive outpatient or telemed therapy. Res #23 reported they didn't trust staff enough to tell them how were truly feeling. On 03/30/23 at 1:35 p.m., the Administrator reported the resident was not eligible for therapy services on an outpatient basis due to the resident being inpatient in a long-term care facility. She reported there was no therapist available or able to provide services to the resident. The Administrator reported they had not looked at private pay options or transferring the resident to a facility where their needs could be met.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for two (#15 and #31) of two sampled residents who were reviewed for falls. The resident census and condition report documented 37 residents resided in the facility. Resident #15 and Resident #31, both experienced two falls with injury which required transfer to the hospital for sutures or staples to [MEDICAL CONDITION]. Findings: 1. Resident #15 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 02/06/19, documented the resident was severely impaired in cognitive skills for daily decision making, required total assistance with most activities of daily living, and had no falls. A care plan, initiated on 05/14/18 and revised on 02/14/19, documented: Focus The resident is at moderate risk for falls, related to unsteady gait due to bending over as resident walks. Goal The resident will be free of falls through the review date. The resident will be free of minor injury through the review date. The resident will not sustain serious injury through the review date. Interventions Anticipate and meet the resident's needs Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Educate the resident's family/caregivers about safety reminders and what to do if a fall occurs Follow facility fall protocol Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. Focus The resident has had an actual fall with no in jury. Goal The resident will resume usual activities without further incident through the review date. Interventions For no apparent acute injury, determine and address causative factors of the fall. Pharmacy consult to evaluate medications. A nurse's note, dated 03/09/19 at 7:45 p.m., documented the nurse was called to the South day room by a CNA. The note documented the resident was found on the floor by the entertainment center with her wheelchair behind her. The note documented there was a pool of blood noted on the floor from the resident's head and hands. The note documented there was a laceration to the residents right temple approximately 2 cm x 0.2 cm. A nurse's note, dated 03/09/19 at 7:58 p.m., documented 911 was called. A nurse's note, dated 03/09/19 at 11:25 p.m., documented the resident returned to the facility. The note documented the resident received sutures to her right forehead. No new interventions were identified to prevent further falls. A nurse's note, dated 04/22/19 at 10:50 a.m., documented the nurse was called to the foyer by staff. The note documented the resident was lying on her back on the floor. The note documented the resident complained of pain to the back of her head. The note documented the resident's neuro checks were within normal limits and her confusion was within normal limits. No new interventions were identified to prevent further falls. A nurse's note, dated 04/23/19 at 7:50 p.m., documented the resident was found laying on the floor on the hallway on her back. The note documented the resident complained of pain to the back of her head. The note documented a laceration to the back of the head was noted. The note documented EMS was notified and the physician and family were notified. A nurse's note, dated 04/23/19 at 11:20 p.m., documented the resident returned to the facility and had three staples at the laceration site on the back of her head. No new interventions were identified to prevent further falls. An incident report, dated 04/23/19, documented the charge nurse was called to the hallway and found the resident laying on her back on the floor. The report documented the resident had a laceration approximately 1.5 inches to the back of her head. The report documented 911 was called and the resident was transported to the ER. The report documented the resident required three staples to close the laceration. There was no documentation regarding interventions. An annual assessment, dated 05/01/19, documented the resident was severely impaired in cognitive skills for daily decision making, required total assistance with most activities of daily living, and had two falls with no injury since the prior assessment. A nurse's note, dated 05/23/19 at 6:40 p.m., documented an RN was called to the hallway by staff. The note documented the resident was lying on her back on the hallway floor. The note documented a skin tear was noted to the right forearm and was approximately one inch. The note documented the wound was cleansed with normal saline and a 4x4 and steri strips were applied. The note documented there were no other injuries. On 07/08/19 at 11:25 a.m., the resident was sitting in a wheelchair in the common area. On 07/08/19 at 1:44 p.m., the resident was observed sitting in her wheelchair on her hall. On 07/09/19 at 11:23 a.m., the resident was observed sitting in her wheelchair in the common area. On 07/09/19 at 2:00 p.m., the resident was in her wheelchair in the hallway and was trying to stand up. A CNA came to her and asked her to sit down and told her she would take her to lay down. On 07/09/19 at 2:20 CNA #5 was asked if she was aware the resident had experienced falls. She stated yes but she thought they had occurred on the evening shift. She was asked how she kept the resident safe. She stated they just kept an eye on her and if she became restless she would lay her down. On 07/10/19 at 9:43 a.m., LPN #1 was asked if she was aware the resident had experienced falls. She stated yes. She stated she usually fell when she was digging in her closet or was bending over trying to pick something up off of the floor. The LPN was asked how they kept the resident safe. She stated on day shift they tried to keep her occupied. 2. Resident #31 had [DIAGNOSES REDACTED]. An incident report, dated 03/09/19 at 7:45 p.m., documented the resident was found on the floor by a CMA in the south day room next to the entertainment center. The report documented the resident had a laceration to her right temple. The report documented the family and physician were notified. The note documented the resident was sent to the ER and received five stiches to her right temple. A telephone order, dated 03/09/19, documented the resident was sent via ambulance to the ER for a [MEDICAL CONDITION]. No new interventions were identified to prevent further falls. An annual assessment, dated 03/14/19, documented the resident was severely impaired in cognitive skills for daily decision making, required total assistance with activities of daily living, and had one fall with injury except major. A nurse's note, dated 05/24/19 at 3:20 p.m., documented the resident was found on the floor and had a laceration to her right temple and to her right eyebrow. The resident had a skin tear to her right forearm. 911 was called and the resident was transferred to the emergency room . A nurse's note, dated 05/24/19 at 7:05 p.m., documented the resident returned to the facility and had received seven stitches. No new interventions were identified to prevent further falls. A quarterly assessment, dated 06/12/19, documented the resident was severely impaired in cognitive skills for daily decision making, required total assistance with activities of daily living, and had one fall with injury except major. A care plan, dated 03/14/19 and revised on 06/25/19, documented Focus The resident was a high risk for falls related to confusion, gait/balance problems, incontinence, and being unaware of safety needs. Goal The resident will not sustain serious injury through the review date. Interventions Anticipate and meet the resident's needs Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Follow facility fall protocol. Focus The resident has had an actual fall with a minor injury Goal The resident will resume usual activities without further incident through the review date. Interventions For no apparent acute injury, determine and address causative factors of the fall. Pharmacy consult to evaluate medications. On 07/08/19 at 9:05 a.m., the resident was observed in the dining room in a Broda chair. The resident was sitting at the assisted dining table being fed by staff. On 07/08/19 at 12:10 p.m., the resident was observed lying supine in a low bed with a fall mat. On 07/08/19 at 1:42 p.m., the resident was observed lying supine in a low bed with a fall mat. On 07/09/19 at 7:00 a.m., the resident was lying in bed supine with her eyes closed. The bed was low and there was a fall mat on the floor. On 07/09/19 at 11:24 a.m., the resident was lying in bed supine with her eyes closed. The bed was low and there was a fall mat on the floor. On 07/09/19 at 11:39 a.m., the resident was brought in to the dining area by staff for lunch. On 07/09/19 at 2:05 p.m., the resident was observed lying on her left side in bed with her eyes closed. Her bed was in the low position and fall mat was on the floor. On 07/09/19 at 2:28 p.m., CNA #5 was asked if she was aware the resident had experienced falls. She said she thought she had a fall sometime in the past couple of months. She was asked how she ensured the resident was safe. She stated if she was restless or tired she would put her to bed. On 07/10/19 at 9:25 a.m., LPN #1 was asked about the resident's falls. She stated the falls were usually in the evening. She stated she was probably trying to get up and walk. The LPN was asked how they kept the resident safe. She stated if they saw her they would try to see what she was trying to do. On 07/10/19 at 12:24 p.m., the DON was asked what interventions were put in place after the resident had fallen. She stated they needed to redirect the resident. She stated they needed to keep the resident where the staff was so she could be monitored.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for two (#15 and #31) of two sampled residents who were reviewed for falls. The resident census and condition report documented 37 residents resided in the facility. Resident #15 and Resident #31, both experienced two falls with injury which required transfer to the hospital for sutures or staples to head lacerations. Findings: 1. Resident #15 had diagnoses which included Alzheimer's disease with late onset. A quarterly assessment, dated 02/06/19, documented the resident was severely impaired in cognitive skills for daily decision making, required total assistance with most activities of daily living, and had no falls. A care plan, initiated on 05/14/18 and revised on 02/14/19, documented: Focus The resident is at moderate risk for falls, related to unsteady gait due to bending over as resident walks. Goal The resident will be free of falls through the review date. The resident will be free of minor injury through the review date. The resident will not sustain serious injury through the review date. Interventions Anticipate and meet the resident's needs Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Educate the resident's family/caregivers about safety reminders and what to do if a fall occurs Follow facility fall protocol Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. Focus The resident has had an actual fall with no in jury. Goal The resident will resume usual activities without further incident through the review date. Interventions For no apparent acute injury, determine and address causative factors of the fall. Pharmacy consult to evaluate medications. A nurse's note, dated 03/09/19 at 7:45 p.m., documented the nurse was called to the South day room by a CNA. The note documented the resident was found on the floor by the entertainment center with her wheelchair behind her. The note documented there was a pool of blood noted on the floor from the resident's head and hands. The note documented there was a laceration to the residents right temple approximately 2 cm x 0.2 cm. A nurse's note, dated 03/09/19 at 7:58 p.m., documented 911 was called. A nurse's note, dated 03/09/19 at 11:25 p.m., documented the resident returned to the facility. The note documented the resident received sutures to her right forehead. No new interventions were identified to prevent further falls. A nurse's note, dated 04/22/19 at 10:50 a.m., documented the nurse was called to the foyer by staff. The note documented the resident was lying on her back on the floor. The note documented the resident complained of pain to the back of her head. The note documented the resident's neuro checks were within normal limits and her confusion was within normal limits. No new interventions were identified to prevent further falls. A nurse's note, dated 04/23/19 at 7:50 p.m., documented the resident was found laying on the floor on the hallway on her back. The note documented the resident complained of pain to the back of her head. The note documented a laceration to the back of the head was noted. The note documented EMS was notified and the physician and family were notified. A nurse's note, dated 04/23/19 at 11:20 p.m., documented the resident returned to the facility and had three staples at the laceration site on the back of her head. No new interventions were identified to prevent further falls. An incident report, dated 04/23/19, documented the charge nurse was called to the hallway and found the resident laying on her back on the floor. The report documented the resident had a laceration approximately 1.5 inches to the back of her head. The report documented 911 was called and the resident was transported to the ER. The report documented the resident required three staples to close the laceration. There was no documentation regarding interventions. An annual assessment, dated 05/01/19, documented the resident was severely impaired in cognitive skills for daily decision making, required total assistance with most activities of daily living, and had two falls with no injury since the prior assessment. A nurse's note, dated 05/23/19 at 6:40 p.m., documented an RN was called to the hallway by staff. The note documented the resident was lying on her back on the hallway floor. The note documented a skin tear was noted to the right forearm and was approximately one inch. The note documented the wound was cleansed with normal saline and a 4x4 and steri strips were applied. The note documented there were no other injuries. On 07/08/19 at 11:25 a.m., the resident was sitting in a wheelchair in the common area. On 07/08/19 at 1:44 p.m., the resident was observed sitting in her wheelchair on her hall. On 07/09/19 at 11:23 a.m., the resident was observed sitting in her wheelchair in the common area. On 07/09/19 at 2:00 p.m., the resident was in her wheelchair in the hallway and was trying to stand up. A CNA came to her and asked her to sit down and told her she would take her to lay down. On 07/09/19 at 2:20 CNA #5 was asked if she was aware the resident had experienced falls. She stated yes but she thought they had occurred on the evening shift. She was asked how she kept the resident safe. She stated they just kept an eye on her and if she became restless she would lay her down. On 07/10/19 at 9:43 a.m., LPN #1 was asked if she was aware the resident had experienced falls. She stated yes. She stated she usually fell when she was digging in her closet or was bending over trying to pick something up off of the floor. The LPN was asked how they kept the resident safe. She stated on day shift they tried to keep her occupied. 2. Resident #31 had diagnoses which included dementia with behaviors and multiple fractures of the pelvis. An incident report, dated 03/09/19 at 7:45 p.m., documented the resident was found on the floor by a CMA in the south day room next to the entertainment center. The report documented the resident had a laceration to her right temple. The report documented the family and physician were notified. The note documented the resident was sent to the ER and received five stiches to her right temple. A telephone order, dated 03/09/19, documented the resident was sent via ambulance to the ER for a head laceration. No new interventions were identified to prevent further falls. An annual assessment, dated 03/14/19, documented the resident was severely impaired in cognitive skills for daily decision making, required total assistance with activities of daily living, and had one fall with injury except major. A nurse's note, dated 05/24/19 at 3:20 p.m., documented the resident was found on the floor and had a laceration to her right temple and to her right eyebrow. The resident had a skin tear to her right forearm. 911 was called and the resident was transferred to the emergency room. A nurse's note, dated 05/24/19 at 7:05 p.m., documented the resident returned to the facility and had received seven stitches. No new interventions were identified to prevent further falls. A quarterly assessment, dated 06/12/19, documented the resident was severely impaired in cognitive skills for daily decision making, required total assistance with activities of daily living, and had one fall with injury except major. A care plan, dated 03/14/19 and revised on 06/25/19, documented Focus The resident was a high risk for falls related to confusion, gait/balance problems, incontinence, and being unaware of safety needs. Goal The resident will not sustain serious injury through the review date. Interventions Anticipate and meet the resident's needs Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Follow facility fall protocol. Focus The resident has had an actual fall with a minor injury Goal The resident will resume usual activities without further incident through the review date. Interventions For no apparent acute injury, determine and address causative factors of the fall. Pharmacy consult to evaluate medications. On 07/08/19 at 9:05 a.m., the resident was observed in the dining room in a Broda chair. The resident was sitting at the assisted dining table being fed by staff. On 07/08/19 at 12:10 p.m., the resident was observed lying supine in a low bed with a fall mat. On 07/08/19 at 1:42 p.m., the resident was observed lying supine in a low bed with a fall mat. On 07/09/19 at 7:00 a.m., the resident was lying in bed supine with her eyes closed. The bed was low and there was a fall mat on the floor. On 07/09/19 at 11:24 a.m., the resident was lying in bed supine with her eyes closed. The bed was low and there was a fall mat on the floor. On 07/09/19 at 11:39 a.m., the resident was brought in to the dining area by staff for lunch. On 07/09/19 at 2:05 p.m., the resident was observed lying on her left side in bed with her eyes closed. Her bed was in the low position and fall mat was on the floor. On 07/09/19 at 2:28 p.m., CNA #5 was asked if she was aware the resident had experienced falls. She said she thought she had a fall sometime in the past couple of months. She was asked how she ensured the resident was safe. She stated if she was restless or tired she would put her to bed. On 07/10/19 at 9:25 a.m., LPN #1 was asked about the resident's falls. She stated the falls were usually in the evening. She stated she was probably trying to get up and walk. The LPN was asked how they kept the resident safe. She stated if they saw her they would try to see what she was trying to do. On 07/10/19 at 12:24 p.m., the DON was asked what interventions were put in place after the resident had fallen. She stated they needed to redirect the resident. She stated they needed to keep the resident where the staff was so she could be monitored.