Licensed Practical Nurse #10 hears the call bell ringing somewhere on the third floor, but she has no idea which resident needs help.
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When Licensed Nurse 3 arrived at 3 AM to help, she found medications that were due at midnight still hadn't been given to residents.
Federal inspectors found the facility violated pain management requirements by failing to properly assess and treat the resident after her fall.
Hot foods must be kept above 140 degrees Fahrenheit to prevent bacterial growth, while cold foods require temperatures below 41 degrees.
The resident, identified as R1 in inspection records, was under state guardianship and deemed "wholly disabled" to manage personal and financial affairs.
The June 8 incident at New Vista Post-Acute Care Center involved two residents and cleaning tools from an unattended housekeeping cart.
Federal inspectors found staff at Choctaw Residential Center repeatedly ignored orders requiring hand rolls be applied to Resident #74 three times daily.
Three days later, they watched as a registered nurse entered the resident's room and found the equipment delivering three liters per minute.
The cook assembled cookies, milk and thickener without measuring, then poured the runny mixture into dessert bowls.
Resident 4 was admitted on August 31, 2024, with diagnoses including traumatic subarachnoid hemorrhage, acute respiratory failure, and difficulty swallowing.
Hospital staff specifically warned the nursing home's social services team about the unauthorized removal attempt in October 2024.
The Minimum Data Set nurse who conducted the assessment acknowledged the error during interviews with inspectors on May 4.