3. Resident #8 had diagnoses which included osteoporosis. A facility progress note, dated 05/19/23, documented Resident #131 was pacing the southwest hallway and pushed on the outer door, setting off the alarm. Resident #8 yelled at Resident #131 to leave the door alone. Resident #131 stepped, inside the room of Resident #8. Resident #8 yelled at Resident #131 to get out. Resident #131 started to leave the room, then stepped back into the room and grabbed the right arm of Resident #8, and mumbled something to Resident #8. The nurse intervened and told Resident #131 to leave the ladies alone and it was not Resident #131's room and to leave. Resident #131 was walked to the north side lobby and offered a drink. A facility progress note, dated 05/20/23, documented Resident #8 had returned from urgent care with their resident representative. The resident representative informed the facility, they had taken Resident #8 to urgent care and both lower arms were x-rayed. The progress note documented nothing was broken. An Orders Administration note, dated 05/20/23 at 7:12 p.m., documented Resident #8 received a tablet of Norco 5-325 mg for pain to both arms. The medication was effective. A Health Status note, dated, 05/20/23 at 7:57 p.m. ,documented Resident #8 was telling the nurse about the x-rays, and showing their forearms. The note documented the nurse noted bruising to the right forearm. A Health Status note, dated, 05/21/23 at 10:07 a.m., documented the resident representative informed the nurse that they were taking Resident #8 back to the urgent care due to the urgent care had informed them, there was a fracture to the right arm of Resident #8. A Health Status note, dated, 05/21/23 at 5:25 p.m., documented Resident #8 had returned to the facility wearing a short splint on their right wrist and forearm. The note documented Resident #8 was moving their fingers and arm easily. The note documented the resident representative of Resident #8 stated they had gone to the emergency room due to the fingers of Resident #8 felt numb. An Orders Administration note, dated 05/21/23 at 7:05 p.m., documented pain to the right arm of Resident #8. The note did not document a number on a pain scale. A Health Status note, dated, 05/23/23 at 8:24 a.m., documented the right arm of Resident #8 was wrapped with splints in place. The note documented Resident #8 complained of pain to the lower right forearm as 10 out 10. An Incident note, dated 05/24/23 at 5:35 p.m., documented an assessment was completed due to the incident with Resident #131. Resident #8 had went to the doctor and had the sling removed. The note documented bruising to the right arm of Resident #8. An Orders Administration note, dated 05/24/23 at 6:26 p.m., documented Resident #8 received a tablet of Norco 5-325 mg for pain to the right arm. The medication was documented as effective. A Health Status note, dated, 05/25/23 at 4:41 p.m., a documented bruising was noticeable to the right arm of Resident #8. An Orders Administration note, dated 05/25/23 at 8:10 p.m., documented Resident #8 received one tablet of Norco 5-325 mg for pain to the right arm. The medication was effective. An Orders Administration note, dated 05/28/23 at 6:13 p.m., documented Resident #8 was monitored for pain. The note documented Resident #8 had pain. The note did not document the level of pain on a pain scale. On 06/13/23 Resident #8 discharged from the facility with their resident representative. Resident #131 had diagnoses which included, dementia with psychotic disturbance, dementia with behavioral disturbance, and assaultive behavior. Review of the clinical record for Resident #131 revealed a comprehensive assessment had not been completed. Review of the clinical record for Resident #131 revealed a baseline care plan was completed on 04/21/23. No comprehensive care plan was completed in the clinical record. Review of progress notes for Resident #131, from 04/21/23 to 5/20/23, revealed Resident #131 hit, scratched, head butted, punched, cursed at, and twisted fingers of staff; picked up chairs and slammed them down on the floor in the lobby. Other documented behaviors of Resident #131 were; pacing, wandering, exiting the facility, urinating and defecating on the floors in public areas and in the presence of other residents, and refusing medications. Progress notes documented Resident #131 had required one on one supervision infrequently, for short periods of time. From 04/21/23 to 05/20/23, Resident #131 was documented to have received one on one supervision two days, on 04/23/23 and 05/03/23. No other documentation of one on one supervision was provided. Progress notes documented Resident #131 refused medications on seven days. Review of the May 2023 MAR, revealed Resident #131 refused medications, chlorpromazine HCL (an antipsychotic medication) 100 mg used for psychotic disturbance, five out of 19 opportunities in May, melatonin ( a sleep aide medication) 3 mg, five out of 19 opportunities, Depakote (an anticonvulsant medication) 125 mg used for dementia with behavioral disturbance, four out of nine opportunities, and Depakote sprinkles 125 mg used for dementia with behavioral disturbance, one time out of 32 opportunities. An Incident note, dated 05/02/23 at 5:45 p.m., documented Resident #131 was in the north lobby with several other residents and was standing behind another resident's wheelchair so they could not move. Resident #131 was asked to move twice and refused. Resident #131 punched Resident #133, who then returned a punch, hitting Resident #131. The note documented the residents were separated and Resident #131 was taken to the southwest lobby and assessed for injuries with no discolorations or marks noted. Resident #133 was counseled on behavior and assessed, no marks or discolorations were noted. No documentation was provided Resident #131 had been placed on one on one supervision. An Orders Administration note, dated 05/19/23 at 6:53 p.m., documented Resident #131 had walked up to a CMA and grabbed them by their stomach and wrist, drew back a fist and started to hit the CMA. When Resident #131 was told No, Resident #131 mumbled something angry and walked away. No documentation was provided that Resident #131 had been placed on one on one supervision. An Orders Administration note, dated 05/19/23 at 7:12 p.m., documented Resident #131 was pacing the hallway and went to the north lobby, walked up to a CMA, hit them in the side, walked to the north door, turned around, came back, and hit the CMA again on the other side. The note documented Resident #131 then went to the southwest lobby, took a resident's wheelchair and ran the wheelchair into the back of a nurse's legs several times. Resident #131 was told to return the wheelchair to where it came from, and Resident #131 cursed at the nurse twice, then put the wheelchair back. No documentation was provided that Resident #131 had been placed on one on one supervision. An Incident note, dated 05/19/23 at 8:10 p.m., documented Resident #131 was pacing in the southwest hallway and pushed on the outside door, setting off the alarm. Resident #8 yelled out to Resident #131 to leave the door alone. Resident #131 then stepped just inside the room of Resident #8. Resident #8 yelled at Resident #131 to get out of their room. Resident #131 started to leave, then stepped back into the room, grabbed Resident #8 by the hand, and mumbled something to Resident #8. The nurse told Resident #131 to leave the ladies alone and is was not Resident #131's room and to leave. Resident #131 left the room and was walked to the north lobby. No documentation was provided Resident #131 had been placed on one on one supervision. A Health Status note, dated 05/20/23 at 11:47 a.m., documented Resident #131 was discharged to another facility via the facility van, and accompanied by the DON and another staff. On 07/13/23 at 4:32 p.m., CNA #1 was asked if they had observed resident to resident abuse. They stated they had not personally seen it occur, but stated Resident #131 had grabbed a female resident by their hand/arm and shook it really hard. CNA #1 was asked how they were made aware of the incident. They stated Resident #8 told them it occurred. CNA #1 was asked if other residents had reported similar incidents with Resident #131. They stated residents had not reported it to them, but did state they did not trust Resident #131 not to hurt them, and if Resident #131 hit them, they would retaliate. CNA #1 stated, several residents reported to them they did not feel safe. CNA #1 was asked how they were made aware of the behaviors of Resident #131. They stated they were not made aware of Resident #131's history and behaviors. They stated they figured it out the hard way. CNA #1 was asked if they had received any special training for residents with assaultive behaviors. CNA #1 stated they received online training. They were asked what they learned from the training. They stated to maintain a calm environment, calm the resident, and to reapproach them later or offer them a snack. On 07/13/23 at 4:57 p.m., LPN #1 was asked what they knew about Resident #131 taking their medications. They stated Resident #131 did not take them very often. LPN #1 was asked what type of behaviors Resident #131 exhibited. They stated Resident #131 would curse, get in others faces, draw back and hit. LPN #1 stated Resident #131 would grab and shake others, and give mean looks. LPN #1 was asked how they managed the behaviors of Resident #131. They stated they could talk to the Resident #131 at times, and the resident could comprehend, and back off, but there were times Resident #131 would do what they wanted. LPN #1 stated Resident #131 scared the other residents. They were asked how they knew other residents were scared of Resident #131. They stated the other residents told them they were scared of Resident #131. LPN #1 was asked how they managed the violent behaviors of Resident #131. They stated they tried to keep a calm voice. LPN #1 stated sometimes they just had to turn around and walk away to give Resident #131 time to settle down. LPN #1 was asked if Resident #131 had hurt other residents. They stated they knew Resident #131 had grabbed a female resident. They stated the female resident had yelled at Resident #131 because they had come into their room, so Resident #131 turned around and went back into their room and grabbed their arm. LPN #1 was asked how they knew of the incident. They stated Resident #8 and their room mate had informed them. LPN #1 was asked how other residents were kept safe from Resident #131. They stated when they worked, Resident #131 was monitored all of the time. LPN #1 stated the nurses assigned a CNA to be one on one with Resident #131 when they could not keep eyes on Resident #131. They stated someone always had eyes on Resident #131. LPN #1 was asked who instructed them to conduct the one on one supervision. They stated no one had told them to provide one on one supervision, they had done that on their own. On 07/13/23 at 5:21 p.m., LPN #1 was asked who had provided one on one supervision at the time Resident #131 grabbed Resident #8. They stated nobody, the one on one supervision started after that event. LPN #1 was asked what the physician said about Resident #131 refusing medications. They stated the CMAs started crushing the medications and putting them in food they knew Resident #131 would eat, but the resident would still refuse. LPN #1 was asked if the physician was informed of those refusals. They stated, Yes. LPN #1 was asked what the physician's response was. They stated they did not know. On 07/13/23 at 5:29 p.m., the DON was asked if Resident #131 had refused their medications. They stated they did not know and would have to look. By the end of the survey, the DON had not provided a response. On 07/14/23 at 12:09 p.m., the DON, with two regional directors present, was asked who was responsible for reviewing admission referrals. They stated themselves, the RDO, and the BOM. The DON was asked who was responsible for the ultimate decision to admit or not. They stated the team as a whole made the decision. The DON was asked what factors were used to determine an admission. The RDO stated financial's, medical needs, personality, and background checks. The RDO was asked what type of training was provided for assaultive behavior. They stated de-escalation, agitation, and they had gone over personal space. The RDO was asked where the training had been documented. They stated the DON should have the in-service in their office. By the end of the survey, in-services had not been provided for assaultive behavior. The RDO was asked what interventions were put in place regarding aggressive behavior. They stated if someone displayed aggressive behavior, the resident was on one on one supervision for eight hours, then they titrated down to 15 minute intervals. They stated a medication review was completed and monitoring continued to ensure behaviors did not continue. The RDO was asked where one on one supervision was documented. They stated it was documented on flow sheets as well as progress notes. On 07/13/23 at 3:09 p.m., the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy situation related to the facility failed to provide goods and services by ensuring adequate portions, options for extra food, and/or an alternative of equal nutritive value was offered to the residents in order to maintain optimal physical and psychosocial well being. On 07/13/23 at 3:09 p.m., the Administrator was notified of the existence of the immediate jeopardy. On 07/14/23 at 4:45 p.m., the facility provided an acceptable plan of removal for the immediacy. The plan documented the following: Plan of Removal 07/14/23 Menus will be reviewed by a dietitian and adjusted to meet dietary standards, as needed. RDO or Dietary Manager will place all food orders to ensure there is an adequate supply. If facility is out of a staple food item, it will purchased from a local supplier. RDO, RNC, RBOM, Dietary Manager, Administrator have the authority to purchase an food item needed from local supplier or food company as needed. RDO or Dietary Manager will order enough menu items for a minimum of five additional residents on top of current census and planned admissions for the week. Dietary Manager was hired on 07/14/2023. She has a start date of 07/18/2023. Dietary manager will receive training for certification. Residents of different faith like Muslim will be offered equal valued food options. They will be offered the meal of the day with a substitution of the meat they are unable to eat. [Resident] will be offered a substitute meat off of their preference list while STILL GETTING THE REGULAR PLATE OF FULL NUTRITIONAL VALUE. Residents have the right to eat another item if they choose. If they choose an alternate option, it will be documented in notes. Staff will have training for residents of different culture food preference, this will be done by the dietitian, and/or dietary manager, or other specified person. Dietary staff will have training on menus, serving sizes, altered diets, how to read the dietary meal cards, offering alternate choices, how to fortify foods, etc. This will ensure the quantity of food available for each meal is adequate and that residents have the opportunity to have additional food. Staff will start this training on the first day of employment, until they are trained and comfortable with doing the position on their own. Staff will have a book with the forms that will need for the kitchen. Policies, Resident dietary orders, material showing how to substitute foods in the same food group and how much is a portion, information on ideas to fortify food groups when needed, pureed, etc. They will be in-service on this book 7/14/2023 and when hired. The dietary book was completed on 07/13/23 using information provided by the dietician. Oversight of the meals will be completed each meal by a department manager who will be in the dining room overseeing food portions, palatability, and that the dietary department follows the proper menu created by the dietician to ensure that all residents are given the appropriate nutritional value. Oversight of basic dietary supplies will be completed by the dietary manager or other specified person twice a week and provided to the RDO who currently does the food order. Any supplies that are low will be reordered or picked up locally whichever is quickest. Snacks of nutritional value will be supplied nightly before bedtime. An option will be available to residents who are pureed, dietetic, etc. Dietary staff along with nursing staff [will be inserviced by 07/14/23] on getting the snack out and offering them. They will be in-serviced 7/14/2023. Resident Preference List will be done upon admission by social services during the admission process, quarterly, and annually by the dietitian, Dietary manager, or other specified person. Preferences will also be updated at QAPI meetings and weight meetings. Staff will complete updated preference lists for each resident on 07/14/2023. Dietary cards will be completed and/or updated with any new information or changes per new orders/ likes or dislikes. I have a form for diet preference for annual update and a form for new admissions. Care plans will be updated quarterly and as needed. Staff will be in-service, and we will start updating 7/14/2023. On 07/17/23 after interviews, review of all in-services, documentation, and all components of the plan of removal had been completed and the immediacy was lifted effective 07/14/23 at 4:45 p.m. The deficient practice remained at a level of actual harm. An undated form titled, Abuse Policy and Procedure, documented in part, .We will endeavor to protect our occupants from maltreatment, which means .neglect, physical abuse .It recognizes resident rights to be free from physical or mental abuse .1. General Policy. All allegations of resident maltreatment, including .neglect, abuse .shall be promptly reported to Administrator and investigated by the Facility management. Administrator will immediately report the allegation to the Oklahoma State Department of Health and the Local Police . Based on observation, record review, and interview, the facility failed to: 1. provide goods and services by ensuring adequate portions, options for extra food, and/or an alternative of equal nutritive value was offered to the residents in order to maintain optimal physical and psychosocial well being for nine (#132, 98, 85, 81, 84, 5, 4,14, and #30) of 11 residents who were sampled for nutrition. 2. ensure residents were free from resident to resident abuse for four (#8, 131, 31, and #32) of seven residents reviewed for abuse. The Resident Census and Conditions of Residents report documented 45 residents resided in the facility. Findings: 1. On 07/02/23 Resident #132 stated, The food situation is, we aren't getting enough food. When asked if they thought they had lost weight, they stated, Yes, I don't get enough food everyday. They stated there had been no snacks offered in the last month. On 07/10/23, DA #1 stated we are told how much to feed the residents. They stated if they served them more, they would get in trouble. The DA stated last Saturday nights dinner was ravioli and the serving size was not enough. On 07/10/23 at 12:07 p.m., residents were observed at the noon meal. The meal was observed to be an unmeasured scoop of turkey pot pie, six thin slices of zucchini, salad with no salad dressing, a cinnamon roll and a beverage. The servings of turkey pot pie were observed to be inconsistent, with servings ranging from approximately one half to one cup each. The Weekly Menu documented the meal was to consist of one cup of turkey pot pie with biscuit topping, one half cup of zucchini, one half cup of salad with dressing, one each cinnamon roll, and beverage of choice Residents stated they did not get enough food. When asked if they could ask for more, one resident stated, No, and they don't serve second servings. Resident #132 was observed to have eaten everything on their plate. Staff were observed to pick up the plate, then the resident left the table. Resident #132 stated they were not full. On 07/10/23 at 4:59 p.m., Resident #98 was asked if they recalled what they had for dinner the previous Saturday. They stated yes, ravioli and tomatoes and zucchini and tea, the serving size was too small. I was still hungry. On 07/11/23 at 10:11 a.m., DA #1 stated my alternative menu is whatever is available in the refrigerator that can be put together. I have not been instructed to make a snack tray ever. We don't get the supplies for that. On 07/12/23, the puree for the noon meal was observed. Service for the meal was also observed. The meal was observed to be an unmeasured portion of barbeque pulled pork, one quarter cup of breaded fried okra, one half cup of baked beans, fruit salad, a biscuit and a beverage. The staff were not observed to puree bread for the residents who received a puree diet. The Weekly Menu for the meal documented four ounces of pulled pork with barbeque sauce, one half cup of baked beans, three quarters cup breaded okra, one biscuit, one butter, one half cup of five cup salad, and beverage of choice. An undated meal card for Resident #30 documented they did not eat pork. A review of the facility menu revealed pork was served as the main entree for lunch or dinner for 14 of 28 meals. On 07/11/23 at 10:15 a.m., DA #2 stated they have been told they cannot make Resident #30 a special meal when pork is served. DA #2 stated they were told by corporate management to feed the resident a grilled cheese sandwich. They stated, I have been here six days and Resident #30 has eaten a grilled cheese sandwich every day. On 07/11/23 at 1:21 p.m., the dietitian stated an alternative menu should have variety. They stated a grilled cheese or peanut butter and jelly sandwich was not an acceptable substitution for an extended period of time. The dietician stated they made note of seven residents with a significant weight change (gain/loss) during their last visit. On 07/12/23 at 9:43 a.m., Resident #85 stated they doesn't like scrambled eggs. The resident stated they have asked several times for hard fried eggs but they keep sending scrambled. They stated this morning they didn't get enough to eat and were still hungry. The resident was asked if they had asked for more food. Resident #85 stated, no because they only bring enough for the people on the hall and they don't have extra. The resident was asked how this makes them feel. They stated it makes them mad, they think staff are lazy. The resident stated, it feels like they don't care that we are hungry. On 07/13/23 at 10:56 a.m., interviews were conducted with residents regarding portion sizes at meals. Resident #81 stated, I hate going to bed hungry It makes me mad and makes me want to leave. It makes me sad, if I'm not full I know others aren't full. That's wrong. They don't give us enough to get full. Resident #98 stated, It makes me feel terrible, but that's the way it is. Resident #84 stated most of the time we don't get enough food. We pay them enough money to buy us enough food. Makes me feel low down, that I'm not a person, That they don't care about me. On 07/12/23 at 12:30 p.m., Resident #5 stated, Lunch was good, but I didn't get enough to eat. I asked for more, but they ran out. Sometimes they have more but sometimes not. When they don't I just stay hungry until the next meal. I understand they don't have enough food. When asked how often do you get snacks, the resident replied, Not often. When asked if they received a snack last night, the resident stated, Yes. I was hungry, it was half of a peanut butter and jelly sandwich. They don't think about snacks for bedtime. I think the kitchen girls get busy and forget. On 07/12/23 at 12:55 p.m., Resident #4 stated the portion sizes are not enough to feed a bird. Everything they cook they burn and expect you to eat it. When asked if they receive second helpings, the resident stated, No, they say they don't have any more. He stated, it makes me mad. They take our money but won't put it back into the home for food or maintenance. On 07/13/23 at 11:06 a.m., Resident #14 stated when they asked for second helping at meals and are told there is not enough food, it makes them feel terrible. Especially when there are not snacks provided at night. 2. Resident #31 had diagnoses which included MERRF, (a multisystem mitochondrial syndrome characterized by progressive myoclonus and seizures). The resident is 5'11 and weighs 124 lbs. The resident is non ambulatory and uses a wheelchair. Resident #32 had diagnoses which included unspecified psychosis not due to a substance or known physiological condition, traumatic brain injury. schizophrenia unspecified, major depressive disorder, and anxiety disorder. The resident is ambulatory, can ambulate independent of assistance and occasionally uses a walker. A progress note, dated 05/19/23, documented Haldol Deconoate was not available and the pharmacy had been notified. A physician order, dated 05/21/23, documented to administer Haldol Decanoate 100 mg and 50 mg IM every 28 days. The MAR, dated May 2023, documented Haldol Decanoate was administered on 05/22/23. The MAR, dated June 2023, documented the medication was due but not administered on 06/19/23. A risk management report, date 6/28/23 documented resident #32 hit resident #31. The anger and hitting were not preceded by any other altercation. Resident #32 was removed from the area and was taken by the administrator to a nearby hospital for evaluation. A progress note for Resident #32, dated 06/28/23 at 2:18 p.m., documented staff reported an episode of physical aggression from the resident towards resident #31 and towards a CNA. The patient left the facility with the Administrator for transfer to psychiatric hospital at 2:15 p.m On 07/03/23 at 2:55 p.m., Resident #31 stated they were outside smoking around noon when Resident #32 jumped up suddenly and hit them on the head. Resident #31 stated they put their arms up to protect their head/face but Resident #32 continued punching them, approximately seven or eight times. They stated the incident happened suddenly. Resident #31 stated they had observed Resident #32 hit staff before. Resident #31 stated the incident made them feel uncomfortable and after the incident they would avoid where Resident #32 was if they were out of their room. On 07/06/23 at 11:47 a.m., CNA #2 recounted the incident of resident to resident abuse. They stated residents were outside smoking and they were there to supervise. CNA #2 stated Resident #32 was pounding on the door to get out to smoking area. They stated Resident #32 jumped up and started punching #31 over and over in the face during the smoke break. CNA #2 stated Resident #31 tried to defend/protect their face by putting their arms up but Resident #32 continued punching Resident #31. They stated they had attempted to verbally redirect Resident #32, placed their hand on the shoulder of Resident #32, but they continued to punch Resident #31. CNA #2 stated Resident #32 began punching them. CNA #2 they were struck in the shoulder, chest, jaw, and under their left eye resulting in bruising and a panic attack. CNA #2 stated Resident #32 had exhibited increased aggression a couple of weeks prior to the incident with Resident #31. They stated Resident #32 would become angry if it was not time for a smoke break and they desired to smoke. They stated the resident would become verbally loud and would curse at the staff. On 07/06/23 at 4:05 pm., RN #1 stated Resident #32 had an incident with staff and Resident #31 outside. More recently Resident #32 punched a staff member in the face. Resident #32 missed his Haldol once because it was not in the building. The nurse who was unable to give the dose, which is given once a month, did not convey it wasn't given. When asked how the staff keep residents safe, CNA# 1 stated, we try to keep staff around him. CNA #1 stated the staff tries to keep the resident's smoke breaks separate from other residents. That the separate breaks have been in place since the second time the resident hit someone. On 07/07/23 at 11:52 a.m., PMHNP #1. was asked what the importance was for a resident to receive the Haldol Deconoate as ordered by the physician. They stated it was very important to receive this medication as ordered by the physician. They were asked what effects were likely if a resident received their scheduled Haldol Deconoate nine to ten days late. They stated it could contribute to an increase in aggression, psychosis, and violence. On 07/07/23 at 2:32 p.m., the Administrator stated Resident #32 had not received their medication [Haldol Deconoate] in June and without that medication the resident became violent and assaulted staff and residents. They stated the day after the incident with Resident #31, Resident #32 was observed hitting and shaking the glass doors in the lobby. They stated staff moved the other residents out of the lobby for their safety.

2. Resident #9 admitted with diagnoses which included anorexia, protein calorie malnutrition, obesity, and dysphagia. A facility Weights and Vitals Summary, dated 07/11/23, documented Resident #9 weighed: a. 06/02/23 - 205.3 lbs b. 07/10/23 - 175.6 lbs. These weights indicated a 29.7 pound/14.5% loss in five weeks. A review of physician orders for Resident #9 revealed no orders for supplements for weight loss. A Nutrition/Dietary note, dated 04/21/23 at 11:09 a.m., documented Resident #9 had a BMI of 36 and was obese and oral intake of food was 76-100%. The note read in part, .Resident lost weight since last month, which is positive, but overall patient gained weight (BMI 36). It is desirable that patient loses some weight. However, meal intake should be at least 50% 3X/day in order to meet nutritional needs. A Nutrition/Dietary note, dated 06/16/23 at 1:30 p.m., documented Resident #9 had a BMI of 35.10% with a recommendation to continue the current nutrition plan of care. A Nutrition/Dietary note had not yet been completed for July 2023. 3. Resident #14 had diagnoses which included diabetes mellitus and muscle wasting and atrophy. A physician order, dated 12/28/17, documented the resident was on a regular diet and to encourage PO intake for nutritional maintenance. The Dietary Profile, dated 12/28/17, did not document likes/dislikes in the designated section of the form for Resident #14. A Nutrition/Dietary Note, dated 04/21/23, documented the resident had a BMI of 39, weighed 246.8 pounds, ate 76-100% of meals with some refusals, would benefit from some weight loss, and to continue the plan of care. A Nutrition/Dietary Note, dated 05/18/23, documented the resident had a BMI of 39, weighed 247.0 pounds, ate 51-75% of meals with a lot of refusals, and to encourage PO intake to meet nutritional needs. A Nutrition/Dietary Note, dated 06/16/23, documented the resident had a BMI of 38, weighed 230 pounds, experienced an 8% weight loss in one month and a 10% weight loss in six months, intake of meals was fair, reweigh the resident and encourage PO intake, and the physician would be notified. Review of the facility's weights documented the resident weighed: a. 01/06/23 - 255.8 lbs b. 04/07/23 - 246.0 lbs c. 07/07/23 - 227.0 lbs. These weights indicated a 7.72% loss in three months from 04/07/23 to 07/07/23 and an 11.26% loss in six months from 01/06/23 to 07/07/23. Review of the clinical record did not reveal the physician had been notified of the weight loss for Resident #14. On 07/03/23 at 3:14 p.m., Resident #14 was asked if they had gained or lost weight recently. Resident #14 stated they used to weight approximately 262 pounds and now weighed approximately 222 pounds. They were asked what time frame they had lost weight. They stated in the past couple of months. Resident #14 stated they had needed to lose some weight in the past but they were not getting enough food to get filled up and was still hungry after meals. They stated they were told food cost had been an issue since March or April 2023. They stated they never knew what they will provide for a meal. They stated sometimes they received half of a piece of meat instead of a whole piece. Resident #14 stated the facility would run out of bread, milk, eggs, and sugar. On 07/11/23 at 11:48 a.m., Resident #14 was asked how they felt about their current weight. Resident #14 stated they had wanted to lose some weight but not like this. The resident stated they refused meals at times if they did not like what was served. They stated there was not always an alternative option so they would eat snacks they had in their room from family. They stated the facility served small portions like they were toddlers. The Care Plan, revised 07/12/23, read in part, .I am over my recommended BMI .06/08/18 .I would like to lose weight .Goal .I want to be adequately nourished .revision date 06/21/23 .I will voice satisfaction of intake through next review date .revision date 06/21/23 . The last revision for the interventions for the care plan were documented on 08/31/22. On 07/12/23 at 5:31 p.m., the DON was asked about the nutritional status for Resident #14. The DON stated the resident had been losing weight, the resident's family brought food at times, they did not usually eat breakfast, and refused meals at times. The DON was asked what interventions had been implemented to prevent significant/severe weight loss. They stated they would need to review the clinical record to determine if health shakes had been ordered for Resident #14. The DON was asked what options were available for the resident if they did not want the meal that was served. The DON stated they could get a sandwich or a salad as an alternative. On 07/12/23 at 6:16 p.m., the DON stated there were no dietary interventions in place for Resident #14 to prevent significant/severe weight loss but they would see if the physician wanted to order health shakes. The DON was asked why interventions had not been implemented and weight loss identified by the facility. They stated, There just wasn't because I didn't review them. On 07/12/23 at 7:12 p.m., the administrator was asked when the last dietary profile, to determine food preferences, had been completed for Resident #14. They stated the only dietary profile was completed upon admission in 2017. The administrator was asked how dietary options for alternative foods were made available to meet residents preferences. They stated the residents would notify the staff of what they wanted for their meal, they notified the residents of what they had available to make as an alternative, and the resident could choose. They were asked why the preference section on the dietary profile had not been completed in 2017. They stated the dietary manager was supposed to complete dietary preferences but the dietitian and charge nurses had been assisting since they did not have a current dietary manager. 4. Resident #98 had diagnoses which included diabetes and obesity. The Dietary Profile, dated 05/15/23, did not document likes/dislikes in the designated section of the form for Resident #98. Review of the facility's weights documented the resident weighed: a. 05/15/23 - 232 lbs (on admission) b. 06/27/23 - 211 lbs. These weights indicated a 9.05% weight loss from 05/15/23 to 06/27/23. The Dietician's Recommendations for Primary Care Provider form, dated 05/16/23, read in part, .CURRENT WEIGHT: 232 BMI: 33 .RECOMMENDATION: 1) Mens MVI 2) Magnesium malate 3) Omega-3 fish oil . The recommendation was not addressed by the physician until 07/12/23. The Nutrition/Dietary Note, dated 06/16/23, documented the June 2023 weight was pending and it was recommended the weight be recorded for Resident #98. The Care Plan, revised 06/26/23, read in parts, .has a nutritional problem or potential nutritional problem r/t obesity-high BMI .Goal .The resident will maintain adequate nutritional status .Interventions .Invite the resident to activities that promote additional intake .report to MD .significant weight loss: 3 lbs in 1 week, [greater than] 5% in one month, [greater than] 7.5% in 3 months, or [greater than] 10% in 6 months . On 07/12/23 at 5:34 p.m., the DON was asked what the nutritional status was for Resident #98. They stated the resident ate in the dining room and ate most of their meals. The DON was asked how they utilized the weights to determine if a resident had experienced a significant or severe weight loss. They stated the report from the electronic clinical record indicated if the residents had lost 5% or 10%. The DON stated, I guess we need to monitor the weights. The DON was asked what interventions had been implemented for weight loss for Resident #98. They stated they would need to review the clinical record to determine if the resident was ordered a house supplement. On 07/12/23 at 6:16 p.m., the DON stated there were no dietary interventions in place for Resident #98 to prevent significant/severe weight loss. On 07/12/23 at 6:54 p.m., the administrator was asked when residents were assessed for food preferences/likes and dislikes. They stated upon admission. They were asked why the food preferences were not documented for Resident #98 on the Dietary Profile. They stated they had attempted to obtain the residents food preferences when they were transporting him to the facility but the resident was not cooperative with the questions. The administrator stated they had not had time to interview the resident after admission to determine their food preferences. On 07/13/23, at 3:09 p.m. the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy situation related to the facility failed to provide goods and services by ensuring adequate portions, options for extra food, and/or an alternative of equal nutritive value was offered to the residents in order to maintain optimal physical and psychosocial well being. On 07/13/23 at 3:15 p.m., the Administrator was notified of the existence of the immediate jeopardy. On 07/14/23 at 4:45 p.m., the facility provided an acceptable plan of removal for the immediacy. The plan documented the following: Plan of Removal 07/14/23 Residents of different faith like Muslim will be offered equal valued food options. Residents can choose to eat another item if they choose. If they choose a sandwich option, it will be documented in notes. Staff will have training for residents of different culture food preference, this will be done by the dietitian and/or dietary manager. Dietician will assist in creating an appropriate nutritional alternate meal for residents with specific religious or other diets. Food will be ordered accordingly in addition to all other food and snacks for the week. All dietary recommendations will be reviewed by doctor and accepted or rejected. Rejected recommendation will have explanation as to why rejected. All recommendations approved by physicians will be updated in their orders. Dietary cards will be updated by the dietary manager. Dietary recommendations are already being worked on by DON with some changes already made. Care plans will be updated when needed by MDS. Staff will be in service by 7/14/2023. If supplements are added to a resident's diet and they continue to refuse, this will be documented, and alternatives will be pursued. Care plans will reflect options tried. Weights will be monitored by Dietitian, DON, MDS and Administrator for all sufficient or sever loss or gain. The team will come up with a plan addressing the weight difference and how to prevent it and update the care plan. A Nutrition Report will be run bi-weekly to monitor weights. We are actively searching for a dietary manager. If one cannot be found within the next 30 days we will try and find someone who we can send to school for dietary manager. However, if this is not an option, oversight will continue to be completed by a department manger each meal. Positions for cook, aide, and dietary manager have been posted on indeed, social media, Oklahoma nursing network with little to no response. People who respond have no experience cooking or do not wish to cook. We will continue to search to fill the positions. A food service satisfaction survey will be completed by all residents monthly Starting 7/25/2023. On 07/17/23, after interviews, review of all in-services, and documentation, all components of the plan of removal had been completed and the immediacy was lifted effective 07/14/23 at 4:45 p.m. The deficient practice remained at a level of actual harm. Based on observation, record review, and interview, the facility failed to monitor nutritional status, identify significant/severe weight loss, and provide interventions for significant/severe weight loss for four (#30, 9, 14, and #98) of 11 sampled residents who were reviewed for nutrition. The Resident Census and Conditions for Residents form, signed by the DON, dated 07/06/23, documented 44 residents were provided meals from the kitchen and two residents had experienced a significant weight loss/gain. Findings: 1. Resident #30 had diagnoses which included Alzheimer's disease and stage three chronic kidney disease. The Dietary Profile, dated 01/26/23, documented the resident was Muslim, ate a regular diet, regular texture, and had an admission weight of 175 lbs. The admission assessment, dated 02/03/23, documented the resident was mildly impaired in cognition, required extensive assistance for all ADLs, and was totally dependent on staff for meals. Review of the weights in the clinical record documented the resident weighed: a. 02/08/23 - 171 lbs b. 02/12/23 - 165 lbs c. 03/04/23 - 122 lbs d. 04/27/23 - 117.6 lbs e. 05/17/23 - 114.4 lbs f. 06/15/23 - 117.4 lbs g. 07/11/23 - 118 lbs The resident's undated meal card documented they did not eat pork. A review of the facility menu revealed pork was served as the main entree for lunch or dinner for 14 of 28 meals. On 07/11/23 at 9:52 a.m., DA#1 stated they had worked in the dietary department for three weeks and had their food handlers license. They stated they had received training the first three days they worked from another employee before they had quit. DA #1 stated they asked what else they could cook if they did not have what was on the menu. They stated the administrator referred them to the corporate level employees. DA #1 stated yesterday (07/10/23) they were supposed to have sweet and sour pork but they did not thaw it out in time so they made country fried steak instead. They stated they had to ask somebody for the menu change to ensure they did not get into trouble. DA #1 stated if a resident did not like what was served they could offer them a peanut butter and jelly or grilled cheese sandwich, soup, chicken, or whatever they had in the freezer, refrigerator, or pantry that could be easily made. They stated one resident did not eat pork and when they had asked to substitute the pork for chicken they were informed by the corporate RDO to not make special meals. DA #1 was asked if they had snacks available for bedtime snacks. They stated they did not know but they usually did not have snack items available. They stated no one had informed them they were to provide bedtime snacks. They stated a staff member had bought snacks for the residents in the past. On 07/11/23 at 10:15 a.m., DA #2 stated they had been told they could not make Resident #30 a special meal when pork was on the menu. DA #2 stated they were told to provide the resident a grilled cheese sandwich. DA #2 stated they had been at the facility the past six days and Resident #30 had eaten a grilled cheese sandwich in place of the scheduled meal all six days. On 07/11/23 at 1:21 p.m., the dietitian stated an alternative menu should have variety. They stated a grilled cheese or peanut butter and jelly sandwich was not an acceptable substitution for an extended period of time. The dietician stated they made note of seven residents with a significant weight change (gain/loss) during their last visit. On 07/11/23 at 1:51 p.m., the DON was asked who was responsible to monitor residents for weight loss. They stated they and the dietitian monitored for weight loss. The DON was asked who was responsible to review the residents weights and meal percentages. They stated they were responsible. On 07/12/23 at 4:24 p.m., Physician #1 was asked about weight loss for Resident #30. They stated to review their progress notes for information regarding the resident's weight loss. The physician stated if the resident had advanced dementia, all they could do was assist the resident to eat and provide nutritional support.

On 03/28/22 at 7:07 p.m., the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy related to supervision during meals. The facility had no procedures in place for providing supervision during meals. On 03/28/22 at 5:00 p.m., a resident who had a physician's order for a pureed diet was given a sandwich and chips from another resident which resulted in the resident coughing. No staff were available to supervise or intervene during the meal service. At 7:35 p.m., the DON was informed of the existence of the immediate jeopardy. A request was made for an acceptable plan to remove the immediacy. On 03/30/22 at 1:18 p.m., the plan of removal was accepted by the OSDH. The plan of removal was as follows: IJ Plan of removal 03/28/2022 03/29/2022 Dining room was set up at 7:00am [sic] this morning for breakfast. Residents who require monitoring during mealtime was at dining room and a CNA member was present during mealtime in dining area to watch for any eating concerns, like coughing, chocking [sic], trying to get other food, trying to eat foods not on diet, etc. Effective immediately staff assigned to mealtime in dining area are verbally in-serviced until written in-service is finished, then all facility staff will be in-services [sic]. Charge nurse will on the assignment sheet list the staff that will be assigned to monitor dining room area. Charge nurse will assign who will be passing out meal trays on the assignment sheets and they will monitor residents eating in their room. Charge nurse will assign a CPR certified staff member to monitor the residents during mealtime for concerns such as coughing, chocking [sic], trying to get others food, trying to eat foods not on diet, etc. Residents will be assessed to see if other [sic] are at risk. Speech therapy will be in to assess residents and recommendation on concerns will be expressed to DON. DON will then contact physician to inform them and see if they agree. DON will notify social services so that POA or guardians can be informed and approve or not. If POA or guardians approve then DON or designee will but [sic] orders into PPC [sic] and will give written notice to kitchen personal [sic], so diet can be updated. DON will notify MDS so that care plan can be updated. Staff will encourage resident to follow diet and explain the risk of choosing different diet. Staff will monitor them eating and make sure there are no issues while eating it, should issues arise staff will intervene and get nursing, if necessary, by yelling or asking the kitchen staff to get help. All staff will be in-services [sic] on the sign and symptoms of chocking [sic], and they will be posted in dining areas as reminders. If resident chooses to eat in their room staff will encourage then [sic] to come eat with others and the risk of eating alone, if they choose to eat in their room anyway staff assigned on the assignment sheet to pass out trays will go around to the rooms and check to make sure they not having issues. In-service [sic] All diet [sic] will be reviewed to ensure the correct diet is being served. Diet cards will be reviewed to ensure correct diets at this time. After speech therapy is done with assessments then doctors orders, diet cards and care plans will be updated with those changes. Families will be informed on the risk of the resident eating meals not prepared according to diet order. A note will be placed in the residents' notes. A letter is done and will be sent to all families. Care plans will be reviewed and updated if needed after speech therapy is finished with assessments. Policy on resident dining will be written and in-serviced to all staff. Policy on Food Brought in the Facility by the Family or Visitors has been updated to notify family of risk of not following diet. This will be done by 03/31/2022 by 4:00pm.[sic] On 03/31/22 from 4:00 p.m., to 7:30 p.m., interviews were conducted with staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. The staff stated they had been in-serviced and were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. Staff were observed as they supervised residents during mealtime in the dining room and in the resident rooms. At 7:30 p.m., the DON and the administrator were notified the IJ was lifted effective 03/31/22 at 4:00 p.m. The deficient practice remained at a harm with one or a very limited number of residents affected. Based on record review, observation, and interview the facility failed to ensure: a. a resident with a physician's order for a modified diet was supervised during meals for one (#17) of three sampled residents who were on modified diets. The DON identified 20 residents who had physician orders for modified diets. The Resident Census and Conditions of Residents report, documented 29 residents required assistance with eating. b. a resident was assessed for the safety of bolsters on an air-mattress and the utilization of a Geri-chair for one (#14) of one sampled residents reviewed for the use of an air-bed with bolsters and a Geri-chair. The DON identified 12 residents utilized air-mattresses with bolsters and one resident that utilized a Geri-chair. This resulted in Resident #14 to sustain a hematoma due to a fall when climbing over the air-mattress bolsters. The DON stated 34 residents resided in the facility. An undated, facility policy for Food and Nutrition Services, read in parts, .It is the policy of the facility to ensure that facility staff supports the nutritional well being of the residents .The facility will employee sufficient staff .to carry out the functions of the food and nutrition service .The resident will receive and consume foods in the appropriate form .as prescribed by the physician .recieved a therapuetic diet when there is a nutritional problem . 1. Resident #17 had diagnoses which included dementia, dysphagia, and protein-calorie malnutrition. A physician's order, dated 10/27/21, read in parts, .Regular diet Pureed texture . A speech therapy evaluation, dated 10/28/21, documented a bedside swallowing evaluation was completed using mechanical soft textures and puree consistencies. The evaluation documented mechanical soft solids caused mild clinical s/s of dysphagia with oral phase impairments characterized by excessive mastication time. The evaluation read in parts, .Diet is changed to puree with thin liquid with distant supervision . A physician's progress note, dated 11/24/21, documented resident #17 had dysphagia, was tolerating a pureed diet well and to monitor and make adjustments to diet and eating habits as needed. Resident #17's quarterly Minimum Data Set (MDS) (Assessment tool used to identify resident care needs.), dated 01/18/22, documented the resident had severe cognitive impairment, and required supervision and set up help with meals. On 03/28/22 at 5:05 p.m., resident #17 was in the common area on the southwest side of the facility eating dinner with other residents. Resident #25 gave resident #17 half of a tuna fish sandwich. Resident #17 ate the sandwich. No staff members were in the dining room to intervene. Resident #17 had a pureed diet on the table. At 5:09 p.m., LPN #2 was observed near the nurses' station. The LPN identified the residents who were dining in the southwest dining area and then proceeded to the nurses' station. At 5:11 p.m., in the southwest dining area, three female residents and one male resident were observed eating unsupervised by staff. Resident #17 had a pureed meal in a Styrofoam container on the table. Resident #25 gave Resident #17 some Fritos chips, resident #17 ate the chips and coughed after eating the chips. No staff members were in the dining room supervising the residents. At 5:13 p.m., resident #17 coughed and held hand over mouth. LPN #2 stated staff were not required to stay in the dining room to monitor the residents during meals. LPN #2 stated resident #17 had an order for a pureed diet. LPN #2 was asked if residents on pureed diets needed to be observed during meals. LPN #2 stated , We probably should be sitting there with them. At 5:56 p.m., LPN #2 was sitting at the nurses station. LPN #2 stated the residents had the choice of eating in the main dining room, the southwest dining area or their rooms. LPN #2 was asked if the facility provided supervision in the dining areas during meal time. LPN #2 stated the facility did not assign anyone to supervise the dining room. LPN #2 was asked if a resident who had an order for a pureed diet should eat a sandwich. The LPN stated no, they could choke. On 03/29/22 at 12:26 p.m., the SLP stated resident #17 received speech therapy services upon admission. The SLP stated a swallow evaluation was completed on 10/28/21. The SLP stated resident #17 was not able to tolerate a mechanical soft diet, a recommendation was made for a pureed diet, which was ordered by the physician. The SLP stated resident #17 was very malnourished and had significant weight loss upon admission. The SLP stated resident #17 did not have teeth, was not able to chew food, and was placed on a pureed diet and remained on a pureed diet. The SLP was asked what distant supervision during meals meant. The SLP stated resident #17 needed to eat in the common dining areas due to their cognition, need for assistance in opening packages, and needed cues and encouragement during meal times. The SLP stated resident #17 was at risk for choking. The SLP stated, When you cannot chew your food, you are at risk of choking. The SLP stated resident #17's swallowing problem was the inability to chew food small enough to swallow and this caused a choking hazard. The SLP stated resident #17's diet had not been upgraded to a mechanical soft diet and would not be able to be upgraded until another swallow evaluation was completed. On 03/28/22 at 6:58 p.m., the DON stated the current diet ordered for resident #17 was a pureed diet with regular liquids. The DON stated resident #17 did not have an order for finger foods. 2. Resident #14 had diagnoses to include: cognitive communication deficit; dementia; history of falling; muscle weakness/wasting/atrophy; and history of traumatic brain injury. An incident report dated 10/22/19 at 7:35 a.m., read in parts, .resident in the floor and his chair against the bed .small abrasion noted to left knee .Resident stated that he slid out of the chair . A progress note, dated 11/18/19 at 11:40 a.m., read in part, .Resident scooted down to foot of geri chair 3 x's .Resident continued to try and scoot out of geri chair . A care plan updated 02/19/20, read in part, .have bed bolster .Ensure bed is in low position and that my fall mat is beside my bed . A progress note, dated 02/20/20 at 00:15 a.m., read in parts, .Resident had pulled bolster off and had his feet on floor .Told him to please stay in the bed as he could fall and get hurt .bolster replaced . A progress note, dated 02/20/20 at 00:43 a.m., read in part, . Resident had pulled bolster off and had his feet on floor .bolster replaced . A progress note, dated 02/22/20 at 05:17 a.m., read in parts, .Told CNA that he wanted the bolster off his bed. When asked why, I don't want it. A progress note, dated 07/24/21 at 11:06 p.m., read in part, .Resident trying to crawl over the side of bed. Bolster placed on bed . A care plan updated 08/15/21, read in parts, .use a gerichair when I am out of bed for comfort/positioning .have bolsters on my bed . A progress note, dated 09/10/21 at 4:39 p.m., read in parts, .Trying to come out of bed. Had legs and buttocks laying bolster over and had feet on floor . A progress note, dated 09/16/21 at 9:09 a.m., read in parts, .observed resident sitting on floor with back against bed . A progress note, dated 09/16/21 at 4:29 p.m., read in parts, .Trying to throw his legs over the bolster. Explained to him that he had already fallen today. Repositioned, bolster secure . A progress note, dated 09/18/21 at 12:50 a.m., read in parts, .Has no complaint from fall .continue to try and get out of bed . An incident report, dated 09/18/21 at 7:56 a.m., read in parts, .res (sic) was on the floor .res (sic) back was leaning up against the bed, buttock on the floor mat in a sitting position . A progress note, dated 09/19/21 at 8:00 p.m., read in part, .bolster on and secured . A progress note, dated 10/08/21 at 9:00 a.m., read in parts, .res (sic) fell onto floor with noted right forehead hematoma .new order .may transport to ER . An Emergency Department Summary of Care, dated 10/08/21 at 10:23 a.m., read in parts, .had a contusion on the right side of his forehead, the top of the contusion was scraped and had some blood .fell out of his chair and hit his forehead . A progress note, dated 10/08/21 at 1:48 p.m., read in parts, .res (sic) returned to facility .noted at this time a skin tear to res (sic) right knee . A progress note, dated 10/08/21 at 8:57 p.m., read in parts, .Earlier this evening, found resident trying to get out of bed as he had his legs over the bolster .and was placed in his chair .taken to lobby. Non-skid piece under resident so that he couldn't scoot to edge of chair easily . An incident report, dated 10/08/21 at 9:00 a.m., read in parts, .res was on the floor .laying on his right side .beside his broda chair .noted hematoma to right side of forehead .res stated i thought i could walk . A progress note, dated 10/09/21 at 4:30 p.m., read in part, .Resident was trying to put his legs over the bolster and get out of bed . A progress note, dated 10/10/21 at 5:20 p.m., read in parts, .bolster on and secured for safety . A progress note, dated 11/09/21 at 1:13 p.m., read in parts, .Putting feet and legs over the bolster and on the floor .Explained he could fall. Bolster on and secure . A progress note, dated 11/28/21 at 1:26 a.m., read in parts, .Had legs over the bolster and feet on floor. Replaced back on the bed . An incident report, dated 12/15/21, at 5:00 p.m., read in parts, .found resident lying on the floor beside the bed .Bolster in place . A progress note, dated 12/28/21 at 6:48 a.m., read in parts, .cautioned resident about falling off bed has bolster in place . A quarterly assessment, dated 01/25/22, documented the resident had severe cognitive impairment for daily decision making; required extensive assistance for bed mobility; required total assistance for transfers; had impaired range of motion on one side of the upper body; was always incontinent of bowel and bladder; had experienced one fall since the prior assessment; and restraints/alarms were not in use. An incident report, dated 03/11/22 at 7:40 a.m., read in parts, .res [sic] was sitting upright on buttocks with his back leaning on the side of the bed .lifted res [sic] to bed .res [sic] stated 'I was getting up' . A progress note, dated 03/12/22 at 4:44 p.m., read in parts, .recent fall .bolster on and secure . A care plan, last updated 03/28/22, read in parts, .require assistance with my adl's .My ability to reposition myself in bed varies .roll side to side with no problem but cannot get myself back up if I slide down in bed .use a gerichair when I am out of bed for comfort/positioning .8-15-21 I now use a Broda chair when out of bed and not in a gerichair .have bolsters on my bed . .history of traumatic brain injury .I will remain free from serious injury r/t falls .I depend on staff to anticipate my needs .Ensure my bed is in a low position .my bolsters and fall mat are in place .Staff to ensure foot rest is up on gerichair & chair is locked when I am in it .I have bed bolster(s) .Provide frequent visual checks for my comfort and safety . On 03/29/22 at 11:12 a.m., Resident #14 was observed seated in a reclined position in a Geri-chair in his room. His arms were tucked in with blanket, and his left foot was hanging down over the side of the foot rest, beside chair. On 03/30/22 at 3:15 p.m., Resident #14 was observed to be seated in a Geri-chair in the resident's room. Resident #14 had scooted/squirmed down toward the foot of the geri-chair. Resident #14 was positioned with buttocks on the elevated foot rests of the chair. Resident #14 continued to gradually scoot/squirm toward the foot of the Geri-chair. Surveyors notified staff and staff repositioned Resident #14. A progress note, dated 03/30/22 at 7:47 p.m., read in parts, .Tried to climb out of his chair. Pulled him up and told resident that he could fall if he kept scooting . On 04/04/22 at 11:28 a.m., Resident # 14 was observed in bed, wrapped in bedding, positioned slight side ways in bed. His head was off the pillow to the right/toward wall, both feet/legs dangling over bolster/bed to the left. No floor mat was in place. An unidentified laundry staff entered room, announce self, put away clean laundry, and left the room. At 11:31 a.m., CNA #1 entered room to assist the resident back into bed and provide care. The CNA was asked if the resident frequently climbed over the bolster/side of bed. She stated yes. CNA #1 was asked if the resident ever scooted out of the foot of his Geri-chair. The CNA stated the resident scoots down in the gerichair at times. On 04/05/22 at 9:28 a.m., CNA #2 was asked what was the reason Resident #14 utilized a Geri-chair. CNA #2 stated she did not know but was aware Resident #14 does scoot out of the Geri-chair and has fallen to the floor. CNA #2 was asked why the resident was placed in a Geri-chair. CNA #2 stated the resident was placed in a Geri-chair when the resident wanted to get out of bed. CNA #2 stated they had worked for several years and Resident #14 had always utilized a Geri-chair. CNA #2 was asked why the resident had an air-mattress with side bolsters. CNA #2 stated hospice provided the mattress with bolsters. CNA #2 was asked if the resident has ever attempted to come over the bolsters and possibly get up and/or had fallen. CNA #2 stated the resident frequently puts their feet and legs over the bolsters. The CNA stated she was not aware of any falls. At 9:40 a.m., CNA #3 was asked why Resident #14 was always seated in a Geri-chair. The CNA stated the chair was provided by hospice. CNA #3 was stated Resident #14 has scooted out of the Geri-chair and climbed over the bolsters on the air mattress. CNA #3 was asked why Resident #14 was on an air-mattress with bolsters. The CNA stated, Because the resident tries to get out of bed, he slips his legs out. The CNA denied awareness of the resident having falls from the air-mattress/bed. At 9:45 a.m., CMA #1 was asked why Resident #14 was in a Geri-chair. The CMA stated the Geri-chair was for safety, the resident did not balance well in a wheel-chair. CMA #1 was asked if Resident #14 had ever climbed or scooted out of the Geri-chair. The CMA stated yes but was not aware if the resident had fallen. CMA #1 was asked why Resident #14 had an air-mattress with bolsters. The CMA stated the bolsters were placed because the resident had thrown his legs out of the bed and they are to prevent the resident from falling to the floor. CMA #1 was asked if the resident had ever fallen when he climbed over the top of the bolsters. The CMA stated, Yes, but not sure when and has not been recently. At 9:50 a.m., the DON stated Resident #14 was placed in a Geri-chair for positioning. The DON was asked if the resident had ever scooted out of the chair. The DON stated, The Geri-chair is not a restraint because it does not prevent him from moving, it is more for positioning. The DON stated hospice provided the air-mattress and bolsters for comfort and due to increased risk for pressure ulcers. The DON stated the bolsters were not restraints because the resident had slid out of the bed. The DON was not aware of any injuries. The DON reviewed the progress notes regarding a fall on 10/08/21, and stated the resident had been to the emergency room after a fall from the bed that resulted in a hematoma on his forehead. The DON was asked if the resident had been assessed for the safest interventions regarding the Geri-chair and/or the air-mattress with bolsters. The DON stated there was nothing different put into place.