Based on observation, record review and interview, the facility failed to provide ADL care to dependent residents for two (#21 and #64) of three sampled residents reviewed for ADLs. The administrator identified 95 residents resided in the facility. Findings: 1. Resident #21 had diagnoses which included dementia. A Significant Change Assessment, dated 09/09/24, documented Resident #21's daily decision making was severely impaired. It documented the resident was dependent on staff for personal hygiene. On 10/27/24 at 9:41 a.m., Resident #21 was observed seated in their gerichair in their room. Their hair was observed uncombed, and their facial hair was observed to be straggled, and unshaven. On 10/28/24 at 1:34 p.m., Resident #21 was observed in bed. Their hair was observed uncombed, and their facial hair was observed to be straggled, and unshaven. On 10/29/24 at 9:53 a.m., Resident #21 was observed seated in their gerichair in their room. Their hair was observed uncombed, and their facial hair was observed to be straggled, and unshaven. 2. Resident #64 had diagnoses which included dementia. A Quarterly Assessment, dated 09/12/24, documented Resident #64's cognition was severely impaired. It documented the resident had upper extremity impairment to one side. On 10/27/24 at 9:53 a.m., Resident #64 was observed seated in their wheelchair in their room. Their hair was observed uncombed and their facial hair was observed to be unshaven. On 10/28/24 at 1:35 p.m., Resident #64 was observed seated in their wheelchair in their room. Their hair was observed uncombed and their facial hair was observed to be unshaven. On 10/28/24 at 2:30 p.m., Resident #64 was observed being shaved by CNA #4. CNA #4 stated they shaved the male residents as often as they could. On 10/29/24 at 1:38 p.m., the administrator, DON, and corporate #1 was asked what was their expectation for the resident's hair to be combed and shaved. They stated it needed to be brushed in the shower, when they got up, or when it needed it. They stated not all mens hair grows the same and shaving should be completed two to four times a week or when they were looking scruffy. They were asked how staff were aware of how often to provide the care. The DON stated they expected residents to look presentable.

Based on observation, record review, and interview, the facility failed to ensure medications were not left at a resident's bedside for one (#55) of 24 sampled residents observed for bedside medications. The administrator identified 95 residents resided in the facility. Findings: Resident #55 had diagnoses which included dementia. Resident #55 had the following physician orders, dated 08/19/24, documented Vicks Vapor rub 4.8 % - 1.2 % -2.6% topical ointment, apply by topical route two times per day to toenails for nail fungus; nystatin 100,000 unit/gram topical powder apply by topical route two times per day under bilateral breasts for rash; and Aquaphor or equivalent to bilateral lower extremities every day for dryness and itching. There were no self administrating of medications orders. An Annual Assessment, dated 09/12/24, documented Resident #55's cognition was moderately impaired. On 10/27/24 at 12:50 p.m., Resident #55 was observed seated in their wheelchair in their room. Resident #55 was not interviewable. Two medication cups with white cream and one medication cup with a powder substance was observed on the counter near the sink. Resident #55 was observed to be able to propel their wheelchair in their room. On 10/28/24 at 1:37 p.m., the medication cups were observed on the counter near the sink in the resident's room. On 10/29/24 at 9:02 a.m., Resident #55 was observed seated in their wheelchair in their room. They were observed feeding themselves breakfast. The medicine cups containing the creams and powder were observed at the sink. On 10/30/24 at 8:45 a.m., CMA #2 was observed to enter Resident #55's room. The medicine cups containing the creams and powder were observed at the sink. On 10/30/24 at 8:47 a.m., CMA #2 was asked what were in the medicine cups. They stated, Probably remedy powder. They stated the resident had yeast. CMA #2 was observed to don gloves and applied a portion of the powder substance on the resident. CMA #2 was asked if it was normal to leave medicine in the resident's room. They stated the residents can have it if they have a physician's order to leave it. CMA #2 stated they did not know if the resident had an order. On 10/30/24 at 8:49 a.m. LPN #4 was asked if Resident #55 had a physician's order to have medication at bedside. They stated the resident did not have an order and should not have any medication left in their room.

Based on record review and interview, the facility failed to submit payroll based staffing information to CMS as required for the 3rd quarter of 2024. The administrator identified 95 residents resided in the facility. Findings: A PBJ Staffing Data Report - FY Quarter 3 2024, documented there was no data submitted for the third quarter. On 10/31/24 at 10:08 a.m., the administrator stated they did not think anyone had been completing it. They were asked what was the process for ensuring it was accepted. They stated, I don't think it was getting done.

Based on observation, record review, and interview, the facility failed to ensure privacy was provided while administering peg tube medication to one (#8) of one sampled resident observed for peg tube medication administration. The DON identified two residents who received nutrition and hydration solely through a peg tube. Findings: A Quality of Care policy, undated, read in part, .Provide utmost Privacy for care delivered . Resident #8 had diagnoses which included gastrostomy status. A Significant Change Assessment, dated 07/03/23, documented Resident #8's cognition was severely impaired. On 09/13/23 at 8:16 a.m., LPN #4 was observed to administer medication via Resident #8's peg tube. LPN #4 was not observed to close the door before providing care. Multiple people were observed walking past Resident #8's room and were observed to look in the room during medication administration. On 09/13/23 at 8:33 a.m., LPN #4 was asked how staff provided privacy during care. LPN #4 stated they should have closed the door.

Based on record review and interview, the facility failed to ensure a resident's comprehensive assessment was completed timely for one (#138) of 22 sampled residents reviewed for MDS assessments. The Resident Census and Conditions of Residents report, dated 09/12/23, documented 92 residents resided in the facility. Findings: Resident #138 had diagnoses which included diabetes mellitus type two. A admission Assessment, dated 08/31/23, was not completed for Resident #138. On 09/14/23 at 12:34 p.m., MDS Coordinator #1 was asked when were admission MDS assessments completed. They stated by the 14th day after admission. MDS Coordinator #1 was asked what the process was to ensure MDS assessments were completed timely. They stated they make out a schedule and the EHR identifies when assessments were due. MDS Coordinator #1 was asked to review Resident #138's assessment. They were asked if the assessment was complete. They stated it was not. MDS Coordinator #1 was asked if the assessment should have been completed. They stated, Yes.

Based on observation, record review, and interview, the facility failed to ensure staff cleaned an insulin vial prior to administration for one (#38) of one sampled resident observed for insulin administration. The DON identified 15 residents received injectable insulin. Findings: Resident #38 had diagnoses which included diabetes mellitus type two. A Physician's Order, dated 08/31/23, documented to administer six units of insulin aspart for a FSBS of 200. On 09/13/23 at 7:27 a.m., LPN #4 was observed to obtain Resident #38's unopened insulin box. LPN #4 was observed to open the box and obtain the insulin vial. LPN #4 was observed to remove the cap on the insulin vial and draw up six units of insulin. LPN #4 was observed to administer the insulin to Resident #38. LPN #4 was not observed to clean the insulin vial prior drawing up the insulin. On 09/13/23 at 7:35 a.m., LPN #4 was asked when staff were to clean the insulin vials. They stated prior to drawing up the insulin. LPN #4 was asked when staff were to clean new, unopened insulin vials. They stated, We just pop the top and draw up the insulin. On 09/13/23 at 2:27 p.m., the DON was asked when were staff to clean a new, unopened, insulin vial. She stated she would clean it after she removed the top.

Based on observation, record review, and interview, the facility failed to ensure a treatment cart was secured for one of three sampled carts observed. A Number of Medication Carts document, undated, documented seven carts were in the facility. Findings: A Medication Cart policy, undated, read in part, .cart must be locked when not in use . On 09/13/23 at 7:45 a.m., CMA #2 was observed at the treatment cart on hall 400. They were observed to push the lock in and go into a resident's room. The lock on the treatment cart was not observed all the way in the cart. There was no staff observed around the cart. On 09/13/23 at 7:47 a.m., LPN #1 was observed to walk by the treatment cart. They were asked what was in the cart. LPN #1 was observed to pull the lock out and open the drawers to the treatment cart without using keys to unlock the cart. Multiple insulin vials, cards of medication, and boxes of breathing treatments were observed in the cart. LPN #1 was asked how staff ensured treatment carts were secured. They stated, Suppose to be locked. LPN #1 was asked if the cart was unlocked prior to opening the drawers to the cart. They stated, Yes.

Based on observation, record review, and interview, the facility failed to ensure a resident received a therapeutic diet as ordered for one (#68) of 10 sampled residents observed for dining services. The RD identified 10 residents received ground meat diets. Findings: Resident #68 had diagnoses which included dementia. A Care Plan, dated 03/15/22, read in part, .nutrition risk .chewing difficult .missing/broken teeth .Diet: Regular .with ground meats .Interventions .Provide diet as prescribed . A Physician's Order, dated 07/03/23, documented Resident #68 was to receive a regular diet with ground meats. On 09/12/23 at 12:43 p.m., Resident #68 was observed to receive a corn dog and tater tots for lunch. The corn dog was not observed to be ground meat per Resident #68's physician's order diet. On 09/12/23 at 12:47 p.m., Resident #68 was observed to pick up the corn dog and bite off a piece of the breading from the corn dog. Resident #68 was observed to try and break off a piece of the meat inside the corn dog with their fingers, but was not successful. Resident #68 put the corn dog back on their plate, removed the breading from their mouth, and put it on their plate. On 09/12/23 at 12:55 p.m., the RD was observed to ask Resident #68 about their lunch meal. Resident #68 was observed to pick up the corn dog, bite off a piece of the breading, chewed on it, then removed it from their mouth, and placed it on their plate. The RD was observed watching Resident #68 during this observation. On 09/12/23 at 12:59 p.m., the RD was asked how staff ensured diets were followed. They stated they have a label that was updated daily, and they checked diet orders in the book next to the serving station. The RD was asked what was considered ground meat. They stated the meat was ground up and gravy could be on it. The RD was asked if a corn dog was considered ground meat. They stated, No. The RD was asked what was Resident #68's physician's ordered diet. They stated they thought it was regular with ground meat. The RD was asked if Resident #68 had problems chewing the corn dog. They stated, [Resident #68] seemed to. They were asked if Resident #68's diet had been followed. They stated, Probably not.

Based on observation, record review, and interview, the facility failed to ensure kitchen equipment, storage shelf, and the ceiling above the food preparation area was maintained to promote sanitation. The DON identified 89 Residents received nutrition from the kitchen. Findings: A Cleaning of Food and Infection Prevention/Control policy, revised 01/2021, read in part, .Non food contact surfaces of equipment .shall be cleaned as often as is necessary to keep equipment free of accumulation of dust, dirt, food particles, and other debris . On 09/12/23 at 8:40 a.m., a tour of the kitchen was conducted. The following observations were made: a. an accumulation of lint, grease, and cob webs on the exhaust vents, and fire suppression system over the fryers and steam table. A sticker documented last service for cleaning hood vents were 01/2023 with next service due in 04/2023, b. an accumulation of grease and lint on the top shelf above the food warmer with Styrofoam clam shells stored on the soiled surface, and c. an accumulation of lint and grease on the cords hanging from the ceiling over the food preparation area. On 09/13/23 at 12:36 p.m., the CDM was shown the lint, cobwebs, and grease accumulation on the above items. The CDM stated the kitchen condition was unacceptable and created a physical hazard for food contamination.

Based on observation, record review, and interview, the facility failed to ensure staff wore a faceshield/goggles while in a COVID-19 positive resident's room for two (#57 and #43) of four sampled residents observed for infection control. The Resident Census and Conditions of Residents report, dated 09/12/23, documented 92 residents resided in the facility. The DON identified four residents were COVID-19 positive. Findings: A COVID-19 Prevention, Response and Reporting policy, dated 09/11/23, read in part, .It is the policy of this facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 .HCP who enter the room of a resident with .confirmed SARS-CoV-2 infection should adhere to .eye protection . Two Physician's Orders, dated 09/12/23, documented Resident #57 and #43 were on isolation. On 09/14/23 at 7:56 a.m., LPN #1 was observed to don on gown, mask, and gloves and went into Resident #57's and #43's room. LPN #1 was not observed to wear eye shield/goggles. A sign was observed hanging next to the residents' door. The sign, dated 09/12/23, read in part, .NEED TO HAVE ON .EYE SHIELD/GOGGLES . On 09/14/23 at 8:04 a.m., LPN #1 was observed to don on gown, mask, and gloves and went into Resident #57's and #43's room. LPN #1 was not observed to wear eye shield/goggles. On 09/14/23 at 8:30 a.m., LPN #1 was observed to open Resident #57 and #43's door. LPN #1 was observed not wearing eye protection. On 09/14/23 at 8:34 a.m., LPN #1 was asked what PPE staff were to wear in COVID-19 positive resident rooms. They stated staff wore gowns, gloves, and N95 mask. LPN #1 was asked if staff wore eye protection. They stated, No. On 09/14/23 at 8:38 a.m., the IP was asked what PPE staff were to wear when in COVID-19 positive resident rooms. They stated gown, N95 mask, gloves, and faceshield/goggles.

Based on record review and interview, the facility failed to complete a level I PASARR upon admission for two (#19 and #66) of eight residents sampled for level I PASARR completed upon admission. The Resident Census and Conditions of Residents report, dated 09/12/23, documented 57 residents had psych diagnosis. Findings: 1. Resident #19 had diagnoses which included anxiety disorder, other recurrent depressive disorders, and Parkinson's disease. A Comprehensive Assessment, dated 09/06/23, documented Resident #19's cognition was severely impaired. Resident #19's clinical record did not contain documentation a PASARR 1 was completed. On 09/15/23 at 10:01 a.m., the DON was asked to provide a level I PASSAR for Resident #19. The DON stated a level I PASARR was not completed. 2. Resident #66 had diagnoses which included dementia, anxiety, and depression. A Quarterly Assessment, dated 09/01/23, documented Resident #66's cognition was severely impaired. Resident #66's clinical record did not contain documentation a level I PASARR was completed. On 09/13/23 at 2:44 p.m., the DON was asked if a level I PASARR was completed on Resident #66. The DON stated a level I PASARR was not completed.

Based on observation, record review, and interview, the facility failed to ensure the menu was followed for four (#78, 45, 70, and #24) of 10 sampled residents observed for dining services. The Resident Census and Conditions of Residents report, dated 09/12/23, documented 92 residents resided in the facility. The DON identified two residents received nutrition and hydration solely through a peg tube. Findings: AWednesday Lunch extended menu, undated, documented bread pudding was to be served for dessert. On 09/13/23 at 12:45 p.m., Resident #78 and #45 had been observed during lunch service. They were not observed to have been served a dessert. On 09/13/23 at 12:47 p.m., CMA #3 was asked what Resident #78 and #45 had been served for dessert. They stated it didn't look like Resident #78 had received a dessert. They stated, I haven't seen the desserts out yet. On 09/13/23 at 1:04 p.m., Resident #70 and #24 were observed sitting at a table in the dining room. They both denied receiving a dessert. On 09/13/23 at 1:17 p.m., the assistant administrator was asked if the lunch service was complete. They stated it was. The assistant administrator was asked when the dessert was served. They stated, Suppose to be directly after meal. The assistant administrator stated, I know some people didn't get served.

Based on record review, observation, and interview, the facility failed to thoroughly investigate a swollen lip and abrasion of unknown origin for one (#7) of three sampled residents reviewed for abuse. The Resident Census and Condition report, dated 03/06/23, documented 76 residents resided in the facility. Findings: An Abuse Policy, undated, read in part, .All facility staff are responsible for reporting suspected .abuse .In the event an incident meets or has the potential to meet one of the definitions of abuse .An investigation of the incident shall commence immediately .A list shall be compiled of all witnesses and other persons who have knowledge of the event .Team members on duty .during the time of the alleged incidents . Resident #7 had diagnoses which included Parkinson's disease. A Quarterly Assessment, dated 12/14/22, documented Resident #7 had severe impaired cognition, required staff assistance with bed mobility, transfers, dressing and personal hygiene. An Accident report, dated 03/02/23 at 8:00 a.m., read in part, .Summary .Incident resulted in treatment and temporary harm .Details: Noted swollen upper lip. Painful to touch. Resident unable to say how it occurred .Contributing Factors: unknown . A Progress Note, dated 03/02/23 at 4:45 p.m., read in part, .Remains on monitoring for swollen lip with abrasion . There was no documentation an investigation had been completed. On 03/06/23 at 1:00 p.m., Resident #7 was observed laying back in their recliner. Resident #7's upper lip was observed swollen. LPN #1 was asked what were examples of an injury of unknown origin. They stated it was an injury they didn't know where the injury resulted from. LPN #1 was asked what happened to Resident #7's lip. They stated they weren't sure what happened. LPN #1 was asked if the swollen lip was considered an injury of unknown origin. They stated, Yes, cause we don't know what happened. On 03/06/23 at 1:10 p.m., the DON and Administrator were asked what happened to Resident #7's upper lip on 03/02/23. The DON stated, I don't know. [Resident #7] was unable to tell us. The DON stated Resident #7 was non verbal. The DON stated the med aid went in to administer Resident #7's medication and saw the swollen lip. The DON stated an abrasion appeared later on Resident #7's right cheek. The Administrator was asked what was the protocol for an injury of unknown origin. She stated the staff assessed the resident and if the injury was suspicious, they would investigate. The Administrator was asked what investigation was completed. The DON stated they talked to the med aid, the nurse, and Resident #7. The DON was asked if they were aware what happened to Resident #7. She stated, No. The Administrator was asked if a thorough investigation had been completed. She stated the resident could have stated what happened. The DON and Administrator were asked if the staff who had taken care of Resident #7 the night before or the staff who had assisted Resident #7 had been interviewed. The DON stated they had not.

Based on record review, observation, and interview, the facility failed to ensure Wellbutrin SR (sustained-released) medication was not crushed per manufacture's guidelines for one (#25) of four sampled residents observed during medication pass. The Resident Census and Conditions report, dated 08/15/22, documented 53 residents received antidepressant. Findings: An Institute for Safe Medication Practices titled Oral Dosage Forms That Should Not Be Crushed, dated 02/21/20, read in part, .the 'Do Not Crush' list, contains medications that should not be crushed because of their special pharmaceutical formulation or characteristics, such as oral dosage forms that are sustained-release in nature .Drug Product .Wellbutrin SR .Reasons/Comments .Slow-release . Resident #25 had diagnosis of depression. Resident #25's quarterly assessment, dated 05/17/22, documented the resident's cognition was severely impaired. Resident #25's physician's order, dated 06/03/22, documented the resident was to receive Wellbutrin SR 100 mg tablet, 12 hour sustained-release twice a day. On 08/19/22 at 9:00 a.m., LPN #1 was observed preparing Resident #25's medications. LPN #1 was observed crushing and administering Wellbutrin SR to Resident #25. On 08/23/22 at 1:05 p.m., the interim DON was asked if Wellbutrin SR can be crushed. They stated it was sustained released so they didn't think it could be.

Based on record review, observation, and interview, the facility failed to investigate bruising of unknown origin for one (#25) of one sampled resident reviewed for abuse. The Resident Census and Condition report, dated 08/15/22, documented 82 residents resided in the facility. Findings: The facility's Reporting Requirements Policy, revised 10/19/21, read in part, .ABUSE .(including injuries of unknown source of suspicious nature) .These allegations shall be reported immediately .Allegations that involve abuse .must be reported within 2 hours . Resident #25 had diagnoses of Parkinson's disease, psychosis, and depressive disorder. Resident #25's quarterly assessment, dated 05/17/22, documented the resident's cognition was severely impaired. Resident #25's progress note, dated 08/15/22 at 11:45 a.m., read in part, .[9:30 a.m.] Upon AM care, [CMA #4] reported to this nurse that [resident] had bruises on [them] .Upon observation, [Resident #25] has a bluish colored quarter-sized bruise on RT temple, a very light blue-colored, orange-sized bruised area on RT shoulder with a little edema, a dark bluish-purple, quarter-sized bruise on [their] RT elbow, a dark bluish-purple, quarter-sized bruise on back of RT hand, and a SM abrasion on RT knee .[Resident #25] does not remember what happened . There was no documentation of an incident to explain bruising. On 08/16/22 at 1:35 p.m., Resident #25 was observed to have quarter sized blue green bruising on their right temple area and another dime sized blue green bruise observed on their right upper check next to their hairline. Resident #25 stated they fell. Resident #25 was asked when and how they fell. Resident #25 was not able to recall. On 08/17/22 at 10:11 a.m., CMA #4 stated Resident #25 can not recall events. CMA #4 stated they noticed the bruising Monday, 08/15/22, when they helped the resident get dressed. CMA #4 stated they notified the nurse. CMA #4 stated they weren't sure when the resident received the bruising. On 08/17/22 at 10:16 a.m., LPN #1 stated the resident couldn't recall things after five minutes. LPN #1 stated they didn't know what had happened to the resident to receive the bruising. LPN #1 stated they were notified Monday morning. LPN #1 stated the DON had called the nurse who worked over the weekend and that nurse wasn't aware of anything. LPN #1 stated it looked like the resident fell but didn't think Resident #25 could have gotten themselves up. They were asked if an event was documented to explain the resident's bruising. They stated, No. LPN #1 was asked what was an injury of unknown origin. They stated, Anything I don't know where it came from. They were asked if the resident's bruising was considered an injury of unknown origin. They stated, Yes, I would think so. LPN #1 was asked what staff were to do if there was an injury of unknown origin. They stated to assess the resident, fill out an incident report, notify the physician, and family. On 08/17/22 at 10:23 a.m., the administrator was asked what was an injury of unknown origin. They stated, Anything we don't know where it came from. They were asked what staff were to do if they noticed an injury of unknown origin. They stated the staff were to complete an incident report, let management know, and assess. On 08/17/22 at 12:58 p.m., the administrator was asked when were staff aware Resident #25 had bruising. They stated on Saturday, 08/13/22. They were asked when management was notified. They stated today. The administrator was asked when should have the bruising had been reported. They stated immediately on Saturday, 08/13/22. They were asked if it was reported timely. They stated it wasn't. On 08/18/22 at 7:53 a.m., the administrator was asked when was the DON aware of bruising. They stated on Monday, 08/15/22. They were asked what did the DON do with the information. The administrator stated the DON didn't follow up. The administrator was asked why staff didn't report. They stated they thought it had already been addressed.

Based on observation, record review, and interview, the facility failed to provide assistance with activities of daily living for one dependent resident (#23) of three sampled residents reviewed for ADLs. The Resident Census and Conditions report, dated 08/15/22, documented one resident was dependent on staff for eating and 63 residents required assistance with eating and transfers. Findings: Resident #23 had a diagnoses which included, transient cerebral ischemic attacks, psychosis, hemiplegia, and dysphasia. Resident #23's care plan, dated 01/11/15, documented the resident required assistance with transfers and frequent checks. Resident #23's care plan, dated 09/01/16, documented resident #23 required two-person assistance with wheel chair and gait belt for all transfers. Resident #23's care plan, dated 10/14/21, documented the resident required aspiration precautions and needed assistance with meals. Resident #23's speech therapy evaluation and plan of treatment, dated 06/11/22, documented the resident required assistance to achieve 90-degree posture for PO intake. The resident had difficulty maintaining posture. The resident required cueing for alternating liquids and solids to encourage liquid intake and assist with clearing residue from oral cavity. Resident #23's physician's order, dated 07/29/22, documented the resident required to sit up 90 degrees, eat at a slow rate with small sips and bites with close supervision and intermittent supervision for all meals and drinks. On 08/16/22 at 9:20 a.m., Resident #23 was observed to transfer from the wheel chair to the bed without assistance. The resident was using the mattress as support to transfer from the wheel chair causing the mattress to raise on one side. The resident was observed to fall uncontrolled into the bed. No staff were observed to be present during transfer. On 08/17/22 at 2:19 p.m., the DON was asked, who provided assistance to the residents when eating in their rooms. They stated staff assisted with cutting up foods and providing assistance with meals. On 08/17/22 at 3:06 p.m. CNA #2 was asked what assistance did Resident #23 require. CNA #2 stated they were a two person assist. CNA #2 was asked what staff did when Resident #23 was on the floor. They stated, I usually ask them if they need anything. Usually when they come out of the room on the floor, they need to be changed, they are hungry or they need something. CNA #2 stated the resident was on the floor every 15 to 30 minutes and it's just considered normal. They stated the resident was on the floor 16 times last night. On 08/17/22 at 3:15 p.m., CNA #3 was asked what assistance did Resident #23 require. They stated that some days Resident #23 required extensive assistance and some days Resident #23 was independent. On 08/18/22 at 3:38 p.m., CMA #6 was asked to describe Resident #23. They stated Resident #23 was on the floor daily. CMA #6 stated they have observed the resident sliding from the bed onto the floor. They were asked why the resident was frequently on the floor. CMA #6 stated the resident usually wanted something. On 08/19/22 at 8:40 a.m., dietary aide #1 was observed serving Resident #23 toast while the resident was lying in bed at a 30-degree angle. Dietary aide #1 was observed to leave the room. No staff were present or observing resident during food intake. On 08/19/22 at 8:43 a.m., Resident #23 was lying in bed at 30-degree angle after eating toast. The breakfast tray was observed on the bed side table at the foot of bed out of reach of resident. Resident #23 was observed sliding out of their bed on to the floor mat. Resident #23 was headed in the direction of the food tray on the bedside table. LPN #2 came in to room and assisted resident up from the floor mat and into their wheel chair. LPN #2 opened the tray of food on bedside table and left the room. Resident #23 was observed to begin to eat readily with no staff supervision. On 08/19/22 at 9:11 a.m., Resident #23 was observed in their wheel chair at the end of the hall accessing the upper freezer area of a refrigerator. Resident #23 was observed to stand up from wheel chair while accessing the freezer. Resident #23 lost their hold on the freezer door and fell backward landing in the wheel chair. Resident #23 returned to the freezer after falling into the wheel chair and got a chocolate ice cream cup. No staff was observed monitoring the resident. Resident #23 ambulated in the wheel chair with ice cream back towards their room. Housekeeper #1 provided a spoon in hall as the resident was returning to their room. The resident consumed the ice cream in the hall with no staff present. On 08/23/22 at 9:46 a.m., the IP was asked what dining interventions were in place for the residents. They stated residents with aspiration precautions were supervised.

Based on record review, observation, and interview, the facility failed to initiate and complete neurological checks for a resident with bruising to their temple area for one (#25) of one sampled resident reviewed for abuse. The Resident Census and Condition report, dated 08/15/22, documented 82 residents resided in the facility. Findings: Resident #25 had diagnoses of Parkinson's disease, psychosis, and depressive disorder. Resident #25's quarterly assessment, dated 05/17/22, documented the resident's cognition was severely impaired. Resident #25's progress note, dated 08/15/22 at 11:45 a.m., documented the resident had bruising to their right side of forehead temple area, right shoulder, right elbow, right back of hand, and a scratch on their right knee. It documented the resident didn't remember what happened. There was no documentation neurological checks had been initiated or completed. On 08/16/22 at 1:35 p.m., Resident #25 was observed to have quarter sized blue green bruising on their right temple area and another dime sized blue green bruise observed on their right upper check next to their hairline. Resident #25 stated they fell. Resident #25 was asked when and how they fell. Resident #25 was not able to recall. On 08/17/22 at 12:58 p.m., the administrator was asked when neurological checks were to be completed. They stated when someone hit their head. They were asked if staff should have completed neurological checks for Resident #25. They shook their head yes. The administrator was asked if neurological checks had been initiated or completed for Resident #25. They stated, I don't feel like they were. On 08/17/22 at 4:15 p.m., the administrator was asked when neurological checks were initiated for Resident #25. They stated when management was notified of bruising today.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to provide adequate staffing to ensure: a. meal supervision was provided for two (#23 and #52) of two sampled residents reviewed for aspiration precautions and b. sixteen residents on the memory care unit were provided supervision to ensure their safety, meet each resident's individualized needs in a timely manner, and meals were received without cross contamination. The facility administrator identified 82 residents resided in the facility. Findings: 1. Resident #23 had diagnosis of dysphagia following cerebral infarction. A physician's order, original order date 10/22/16, read in part, .Aspiration Precautions . A physician's order, original order date 10/22/16, read in part, .Sit up 90 degrees .Eat Slow Rate .Small Sips/bites .Close Supervision .Check for Pocketing on the Right side .Double Swallow .Assist/Feed . Resident #23's care plan, dated 11/27/16, read in part, .[Resident #23] .is at risk for aspiration .Related to .Needs Supervision/cues .Swallowing difficulty . Resident #23's care plan interventions, dated 09/19/17, read in part, .Aspiration precautions. Needs supervision with meal . Resident #23's care plan interventions, dated 03/08/22, read in part, .Provide necessary assistance at meal time . Resident #23's assessment, dated 06/07/22, documented the resident had severely impaired cognition with daily decision making, and required supervision with eating. Resident #23's speech therapy evaluation and plan of treatment report, dated 06/11/22, read in part, .Recommendations .Assist pt achieve 90 degree posture for PO intake. Pt has difficulty maintaining posture. Cue for alternating liquids and solids to encourage liquid intake and assist with clearing residue from oral cavity . On 08/19/22 at 8:40 a.m., dietary aide #1 was observed to deliver Resident #23's breakfast tray to their room. Resident #23 was observed lying in bed, with the head of the bed elevated at approximately 30 degrees. Resident #23 was pointing at the tray. Dietary aide #1 gave the resident the toast while the resident was lying in bed. Dietary aide #1 was observed to leave the resident's room. Resident #23 was observed taking big, fast, bites of toast and coughing between bites. There was no observation of staff assisting the resident with their meal. On 08/19/22 at 9:20 a.m., the administrator was asked how staff ensured residents' dietary needs and restrictions were met. They stated they review this in their meetings and the nurses observed. On 08/19/22 at 12:05 p.m., LPN #2 was asked what assistance with meals did Resident #23 required. They stated it depended on the day. They stated sometimes the resident required set up assistance and sometimes they required more assistance. On 08/23/22 at 8:55 a.m., LPN #2 was asked if there were new interventions placed for residents dining in their rooms. LPN #2 stated there were more people in place watching and assisting residents during dining. LPN #2 was asked if staffing was an issue prior to today during dining. LPN #2 stated, Yes. On 08/23/22 at 9:46 a.m., The IP nurse was asked if new dining interventions were in place. The IP nurse stated, if a resident had orders to be supervised, staff were to ensure the resident at risk was provided supervision. The IP nurse was asked, prior to today, how were residents surpervised. The IP nurse stated, they would frequently check on the residents in their rooms or they try and bring the residents to the desk. The IP nurse was asked what does supervised feeding mean. The IP nurse stated the resident was supervised as long as you can see the resident in your vision and eye sight. On 08/24/22 at 3:29 p.m., the administrator and Interim DON were asked what the policies regarding staffing based upon census. The administrator stated, the DON was responsible for staffing until four day ago. They stated they were fixing the schedule. 2. Resident #52 had diagnoses to include dementia, cerebral infarction with hemiplegia, Parkinson's Disease, auditory/visual hallucinations, ataxia; dysphagia; and abnormal posture. A physician's order, dated 10/15/21, documented the resident was to receive liquids with a thin consistency. A physician order, dated 05/17/22, documented Resident #52 was to be served a diet consistency of soft bite size pieces and finger foods as tolerated with staff supervision. The order documented the resident was to not be served bacon, hard crusty breads, or large chunks of hard vegetables. The ADL Focus care plan, dated 04/01/21, documented Resident #52 required supervision for eating. Interventions included staff would assist with ADL's as needed. The ADL Focus care plan was last reviewed on 06/30/22. The Nutrition Risk Focus care plan, dated 04/01/21, documented Resident #52 was at nutritional risk related to the need for assistance/cues, swallowing difficulty and Parkinson's disease. The Nutritional care plan interventions included: provide diet as prescribed; allow eating/drinking at own pace, and assist the resident as needed. The Nutritional Risk Focus care plan was last updated on 07/14/22. The interventions did not address the resident's assessment status and/or the physician orders regarding Resident #52 required supervision with meals. The Resident CNA Documentation History Detail, for 06/2022 documented Resident #52 was independent had not received supervision for 21 meals. Resident #52 had required limited assistance of staff for 2 meals. A quarterly assessment, dated 07/08/22, documented Resident #52 had severe cognitive impairment for daily decision making, and required supervision of one staff for eating. The Resident CNA Documentation History Detail, for 07/2022, documented the resident had not received supervision for 35 meals. Resident #52 required limited assistance for two meals. Four meals documented the resident refused. The Resident CNA Documentation History Detail, from 08/01/22 through 08/22/22, documented the resident did not receive supervision for 23 of 66 meals. One meal documented the meal did not occur. On 08/16/22 at 8:45 a.m., resident #52 was observed in a private room, seated in a recliner. Resident #52 was leaned to the right arm rest of the chair. On 08/17/22 at 1:19 p.m., Resident #52 was seated in a recliner in her room, a meal container was in front of the on an over-bed table. Staff were not available. On 08/22/22 at 11:40 a.m., LPN #1 was asked how many staff were assigned to the memory care unit. LPN #1 stated only her and 1 aide had been assigned to the memory care unit today. On 08/22/22 at 12:48 p.m., Resident #52 was served the noon meal while seated in a recliner inside a private room. Staff remained in the common areas and other resident rooms. Resident #52 was not provided meal supervision from 12:48 p.m., until after 1:18 p.m. On 08/22/22 at 1:18 p.m., LPN #1 was asked why Resident #52 had not been provided supervision for the meal. LPN #1 stated there are only two staff assigned and working the memory care unit. 3. On 08/16/22 at 9:10 a.m., strong gaseous odors were identified outside the door of Resident #39. Resident #39 was inside the room with the door closed. On 08/16/22 at 9:58 a.m., a maintenance man entered the memory care unit to work on a sink. LPN #1 was heard to inform the maintenance man the nursing staff needed to clean the room before the sink would be looked at but had not had time to clean the room. LPN #1 was observed to obtain cleaning supplies and enter Resident #39's room. The floor of the resident room had large amounts of fecal smears across most of the floor of the room. LPN #1 stated I can't get this up, I am calling housekeeping to see if there is something different to clean with. LPN #1 was attempting to clean the laminate floor with a pad designed mop and liquid substance in a spray bottle. The feces was so dry that no changes were made when LPN #1 made attempts to scrub the floor. On 08/16/22 at 10:35 a.m., LPN #1 was asked how many residents were on the memory care unit. LPN #1 state 16 residents are on the unit at this time. LPN #1 was asked how many staff were working on the locked memory care unit. LPN #1 stated there were two nursing staff on the memory care unit. LPN #1 was asked if that was the planned schedule for staffing on this day or if there had been an unforeseen event that resulted in two staff on the memory care unit. LPN #1 stated there are usually only two nursing staff scheduled on the memory care unit. On 08/18/22 at 7:40 a.m., LPN #1 and CMA #6 were observed to work on the memory care unit. CMA #6 was asked if there were other nursing staff working the memory care unit today. CMA #6 stated, Not today. CMA #6 stated the schedule usually is for two or three each day shift. CMA #6 was asked if the schedule is for three nursing staff, and there are two nursing staff working, was this due to the facility having staff to call-in or if the schedule had two scheduled to work. CMA #6 stated the schedule will only show two nursing staff to work the memory care unit. LPN #1 approached the area when CMA #6 was asked if the nursing staff were able to toilet residents per the resident needs and/or the residents bathed as scheduled. LPN #1 stated the medications are not always administered on time as ordered by the physician if there are only two staff scheduled/working. 4. On 08/22/22 at 11:41 a.m., LPN #1 stated the facility had a new admission to the memory care unit but there had not been enough time to complete the admission due to two staff members working the memory care unit today. On 08/22/22 at 12:18 p.m., Resident #39 ambulated past the area several residents were seated, eating the noon meal. Resident #39 used fingers to obtain food items and eat from the plate Resident #67 was eating from. This was unwitnessed by LPN #1 while working on medication pass and CMA #4 that was serving the plate/containers to residents. After Resident #39 stood several minutes and continued to eat multiple items from Resident #67's plate, the surveyor alerted staff of Resident #39 eating from other resident's food containers. CMA #4 observed Resident #10 reach with bare fingers to obtain food from Resident #43's container/plate. Staff did not attempt to provide fresh plates/food to the residents affected by the cross contamination of other residents eating from food containers not assigned to them. On 08/22/22 at 12:25 p.m., Resident #45 ambulated into the nurse work area/meal service area, and reached into individual dessert container that had remained uncovered on the counter. CMA #4 stop serving meal containers to residents waiting for meal service to re-direct Resident #45 to return to the meal container that had been placed for Resident #45. On 08/22/22 at 12:30 p.m., CMA #4 began to serve dessert to several residents that remained seated at the table for meal service. Many residents had completed the meal, left the table and paced in the common area of the unit. On 08/22/22 at 12:41 p.m., LPN #1 and CMA #4 were overheard to discuss work not completed and if there would be any help available if they made a call. CMA #4 stated no one available, LPN #1 agreed with CMA #4. After hearing the conversation, LPN #1 was asked if they had been discussing the need for additional assistance. LPN #1 stated CMA #4 had called earlier to request additional assistance and was told state is in the building and there is no one to send. LPN #1 stated a text and call were made to discuss with supervisors if memory care unit had others coming to cover the memory care unit due to a large staff meeting. LPN #1 stated the memory care staff were instructed to keep working. On 08/22/22 at 12:48 p.m., Resident #52 was served tray in a private room. Nursing staff were not available to supervise or assist Resident #52. On 08/22/22 at 1:10 p.m., observe Resident #40 open /exit resident room [ROOM NUMBER], followed by Resident #28. Resident #40 was dressed with a long sleeved sweat shirt that was up-side down and on the lower body. One leg was through the bottom of the shirt and a sleeve. The other leg through the bottom of the shirt then through the neck. Residents #40 and #28 walked through the common area of the memory care unit then entered resident room [ROOM NUMBER] and closed the door. LPN #1 and CMA #4 had been with other residents/tasks and did not observe Resident #40 and #28. CMA #4 was asked if there had ever been issues with Resident #28 being sexually inappropriate with other residents. CMA #4 stated, Sometimes. While the surveyor informed CMA #4 of the observation of resident #40 and resident #28, both residents exited room [ROOM NUMBER] and entered the common area. CMA #4 stated Resident #40 is very inappropriate and has to be watched closely. CMA #4 stated it was hard to keep Resident #40 supervised when there is only one aide on the memory care unit. On 08/22/22 at 1:18 p.m., LPN #1 was asked if there was a reason Resident #52 had not been supervised/checked on earlier. LPN #1 stated, It is just the two of us. There is not enough staff to do all that we need to do. LPN #1 was asked if there were any concerns regarding residents putting their hands into other resident's food or touching the desserts that were to be served. LPN #1 stated it is difficult to monitor the residents and keep them out of the food during meal service. LPN #1 was asked if there was a reason staff were unable to prevent cross contamination of foods to be served. LPN #1 stated, There is not enough staff to redirect residents. We try to catch them but not always enough to stay ahead of the residents. On 08/23/22 at 10:20 a.m., the Interim DON was asked if the facility had adequate staffing to meet the needs of the residents on the memory care unit. The Interim DON stated, I do not believe we do not have enough staff. I believe the staff assignments need to be adjusted.

Based on record review, observation, and interview, the facility failed to ensure narcotic gel was accounted for, and administered as ordered for one (#39) of five sampled residents whose medications were reviewed. The Resident Census and Conditions report, dated 08/15/22, documented 82 residents resided in the facility. Findings: Resident #39 had diagnosis which included anxiety and depression with psychotic features. Resident #39's physician's order, dated 06/29/22, documented to administer ABH gel, 0.5 ml at bedtime and as needed. Resident #39's administration record, dated 08/01/22 through 08/22/22, documented the resident received ABH gel every evening as ordered. Resident #39's individual narcotic record, dated 08/12/22 through 08/23/22, read in part, .Name of Drug .ABH gel .Apply 1-2 pumps to inner wrist . This was the narcotic record for the #2 bottle. The narcotic record for #2 bottle, dated 08/12/22 at 10:00 p.m., documented the amount remaining was one bottle. Resident #39's individual narcotic record, dated 08/13/22 through 08/23/22, read in part, .Name of Drug .ABH gel .Apply 1-2 pumps to inner wrist . This was the narcotic record for the #1 Bottle. The narcotic record for #1 Bottle, dated 08/13/22 at 10:00 p.m., documented the amount remaining was one bottle. On 08/17/22 at 8:15 p.m., the narcotic record for #1 Bottle documented one pump was administered. It documented the amount remaining was one bottle. On 08/20/22 at 6:15 p.m., the narcotic record for #1 Bottle documented one pump was administered. It documented the amount remaining was one bottle. On 08/23/22 at 8:55 a.m., the two bottles of ABH gel were observed. #1 bottle was observed to be used. #2 bottle was observed full. LPN #1 was asked how they accounted for the amount remaining in the bottles of ABH gel. LPN #1 stated they were told to put one bottle. LPN #1 was asked how they ensured the count was correct. They stated, That's what we were told to do. You can't really count it. LPN #1 was shown #1 bottle of ABH gel and asked what the count was. They stated they couldn't tell. On 08/23/22 at 9:45 a.m., RN #1 was asked how staff ensured the ABH narcotic gel was administered as ordered. RN #1 stated they first have an order, then look in the narcotic book that has the order as well. RN #1 was asked how staff ensured the amount of ABH gel was accounted for. RN #1 stated they have asked for the medication to be in syringes because they couldn't count it. RN #1 stated they couldn't remember exactly when they had asked for that, but it had been awhile. Resident #39's administration record and narcotic record was reviewed with RN #1. They were asked if the ABH gel had been administered as ordered. They stated, It doesn't look like it. They were asked if the narcotic record reflected an accurate account of the medication. They stated it didn't.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to have an effective administration by not: a. revising the Facility Risk Assessment to reflect the needs of each resident and b. ensuring nursing staff were available to supervise and meet the needs of the residents for residents #23, #52, and the 16 residents that resided on the memory care unit. The resident room roster identified 16 residents resided on the memory care unit. The Administrator identified the facility census was 82. Findings: 1. The facility risk assessment contained a Resident's Census and Condition of Residents form, dated 02/04/2020, to identify the needs of the residents. The Resident Census and Condition of Residents documented the census was 114. On 08/24/22 at 11:57 a.m., the administrator and administrator assistant were asked if the date documented risk assessment was accurate on 08/01/22, if portion for identifying resident needs was not updated since 02/04/2020. The administrator and administrator assistant stated we thought we updated that. On 08/24/22 at 12:27 p.m., an updated Resident Census and Condition of Residents form dated 08/15/22 was provided and identified as the current portion of the Facility Risk Assessment to identify resident's needs. The administrator and Interim DON were asked to review the dates of the Resident Census and Condition of Residents provided as the new assessment reviewed on 08/01/22. The administrator and Interim DON were asked how often should the risk assessment tool be fully reviewed and updated. The Interim DON stated the Facility Risk Assessment should be updated annually and as needed. The Interim DON was asked if the risk assessment tool had been fully updated as required to identify the needs of the residents. They stated, No. 2. Resident #23 had diagnosis of dysphagia following cerebral infarction. A physician's order, original order date 10/22/16, read in part, .Aspiration Precautions . A physician's order, original order date 10/22/16, read in part, .Sit up 90 degrees .Eat Slow Rate .Small Sips/bites .Close Supervision .Check for Pocketing on the Right side .Double Swallow .Assist/Feed . Resident #23's care plan, dated 11/27/16, read in part, .[Resident #23] .is at risk for aspiration .Related to .Needs Supervision/cues .Swallowing difficulty . Resident #23's care plan interventions, dated 09/19/17, read in part, .Aspiration precautions. Needs supervision with meal . Resident #23's care plan interventions, dated 03/08/22, read in part, .Provide necessary assistance at meal time . Resident #23's assessment, dated 06/07/22, documented the resident had severely impaired cognition with daily decision making, and required supervision with eating. Resident #23's speech therapy evaluation and plan of treatment report, dated 06/11/22, read in part, .Recommendations .Assist pt achieve 90 degree posture for PO intake. Pt has difficulty maintaining posture. Cue for alternating liquids and solids to encourage liquid intake and assist with clearing residue from oral cavity . On 08/19/22 at 8:40 a.m., dietary aide #1 was observed to deliver Resident #23's breakfast tray to their room. Resident #23 was observed lying in bed, with the head of the bed elevated at approximately 30 degrees. Resident #23 was pointing at the tray. Dietary aide #1 gave the resident the toast while the resident was lying in bed. Dietary aide #1 was observed to leave the resident's room. Resident #23 was observed taking big, fast, bites of toast and coughing between bites. Resident #23 was observed to finish eating the toast and began to transfer self out of the bed. LPN #2 was observed to come into the resident's room and assist the resident up and into their wheelchair. LPN #2 was observed to set resident up in front of the breakfast tray, uncovered the tray, and left the room. Resident #23 was observed eating oatmeal unsupervised in their room. On 08/19/22 at 9:20 a.m., the administrator was asked how staff ensured residents' dietary needs and restrictions were met. They stated they review this in their meetings and the nurses observed. On 08/19/22 at 12:05 p.m., LPN #2 was asked what assistance with meals did Resident #23 required. They stated it depended on the day. They stated sometimes the resident required set up assistance and sometimes they required more assistance. On 08/19/22 at 12:15 p.m., CMA #5 was asked how staff knew which residents were on aspiration precautions. They stated, I don't. They were asked to describe a situation where a resident would be fed lying down in bed. They stated, I would not feed a resident lying down because of aspiration risk. An undated meal sticker/label was observed for Resident #23. It did not identify the resident was on aspiration precautions. Other than a physician order, there was no system in place to notify staff of the residents with aspiration precautions. On 08/19/22 at 12:52 p.m., the administrator assistant stated they did not have an aspiration precaution policy. On 08/19/22 at 1:22 p.m. the administrator was asked who served meal trays to the residents. They stated dietary and CNAs. They were asked who all can serve trays to the residents. They stated they have seen nursing staff help. The administrator assistant was asked who assisted the residents with the meals. They stated CNAs and staff, such as dietary and some office staff, that have been through training with the previous dietician. The administrator and administrator assistant were asked what were aspiration precautions. The administrator stated the resident needed to sit up for 30 minutes after eating. The administrator assistant stated they need to sit up while they eat and if the resident needed assistance, they would receive the assistance. The administrator and administrator assistant were asked what resident had aspiration precautions. The administrator assistant stated they would have to go through and look at each chart or ask the nurse. The administrator stated the nurses would know who had aspiration precautions. The administrator assistant stated the dietary, and staff who were working with residents would know. The administrator assistant stated CNA/CMAs have section sheets with diets on them. The administrator assistant was asked to describe the section sheets. They stated the section sheet was something to describe the care the resident needed. They were asked how often the section sheets were updated. They stated weekly and with every change. The administrator assistant was asked if all staff who served and assisted the residents with food have access to residents' precautions. They stated they can look on the food container label. They stated the label consisted of the resident's name, room number, diet order, any specialized order, and allergy. The administrator and administrator assistant were asked how the trained staff were aware of the residents with aspiration precautions. The administrator stated the staff were aware if the resident was getting assistance with feeding, through report, or the section sheet. The administrator assistant stated if the resident was on a specialized diet, such as thickened liquid, pureed, mechanical soft diet, the resident was automatically on aspiration precautions. The administrator assistant was asked how staff would know the resident was on aspiration precautions with a regular diet and thin liquids. They stated the staff still needed to make sure the resident was sitting up. They stated that was universal precautions to prevent anyone from choking. The administrator was asked how did staff ensure aspiration precautions were followed. They stated when the resident received their food, ensure the resident was sitting up and ensured resident was up for 30 minutes after eating. The administrator was asked if it was safe to serve a resident, who had physician ordered aspiration precautions, a piece of toast while in bed with the head of the bed up at approximately 30 degrees. They stated no it wasn't safe. The administrator was asked what risk was to the resident. They stated the resident would be at high risk for aspiration. The administrator was asked what it could indicate if the resident was coughing between bites of the toast. They stated possible aspiration. On 08/19/22 at 1:52 p.m., the dietary manager stated aspiration precautions were not on the residents' dietary food label. The administrator was observed looking at the printed label for Resident #23 and confirmed aspiration precautions were not on the label. On 08/23/22 at 8:55 a.m., LPN #2 was asked if there were new interventions placed for residents dining in their rooms. LPN #2 stated there are more people in place watching and assisting residents during dining. LPN #2 was asked if staffing was an issue prior to today during dining. LPN #2 stated, Yes. On 08/23/22 at 9:46 a.m., The IP nurse was asked if new dining interventions were in place. The IP nurse stated, aspiration precautions were in place. If a resident has orders to be supervised, staff are to ensure the resident at risk is provided supervision. The IP nurse was asked, prior to today, how were you supervising residents. The IP nurse stated, we keep checking in the rooms or we try and bring them to desk. The IP nurse was asked what does supervised feeding mean. The IP nurse stated the resident is supervised as long as you can see the resident in your vision and eye sight. On 08/24/22 at 3:29 p.m., the administrator was asked what the policies regarding staffing based upon census. The administrator stated, The DON was responsible for staffing until 4 day ago and we are fixing the schedule. The administrator was asked if there was a policy regarding minimum staffing. The administrator stated, we have a staffing form, called a flip sheet, which is a daily staffing form. I'm sure we have a staffing policy. On 08/24/22 a.m., 3:29 p.m., the Interim DON stated she is not from Oklahoma and thinks the staffing requirement will be different. The Surveyor requested staffing for sheets for each shift for those not in compliance and provided a list of dates in 08/2022. On 08/24/22 at 3:30 p.m., the administrative assistance stated that she had nurse managers come in and did not provide all time sheets for over the weekend. Surveyor asked to provide all staffing time sheets. 3. Resident #52 had diagnoses to include dementia, cerebral infarction with hemiplegia, Parkinson's Disease, auditory/visual hallucinations, ataxia; dysphagia; and abnormal posture. A physician's order, dated 10/15/21, documented the resident was to receive liquids with a thin consistency. A physician order, dated 5/17/22, documented Resident #52 was to be served a diet consistency of soft bite size pieces and finger foods as tolerated with staff supervision. The ADL Focus care plan, dated 04/01/21, documented Resident #52 required supervision for eating. Interventions included staff would assist with ADL's as needed. The Nutrition Risk Focus care plan, dated 04/01/21, documented Resident #52 was at nutritional risk related to the need for assistance/cues, swallowing difficulty and Parkinson's disease. The Nutritional care plan interventions included: provide diet as prescribed; allow eating/drinking at own pace, and assist the resident as needed. The Nutritional Risk Focus care plan was last updated on 07/14/22. The interventions did not address the resident's assessment status and/or the physician orders regarding Resident #52 required supervision with meals. The Resident CNA Documentation History Detail, for 06/2022 documented Resident #52 was independent had not received supervision for 21 meals. Resident #52 had required limited assistance of staff for 2 meals. A quarterly assessment, dated 07/08/22, documented Resident #52 had severe cognitive impairment for daily decision making, and required supervision of one staff for eating. The Resident CNA Documentation History Detail, for 07/2022, documented the resident had not received supervision for 35 meals. Resident #52 required limited assistance for two meals. The Resident CNA Documentation History Detail, from 08/01/22 through 08/22/22, documented the resident did not receive supervision for 23 of 66 meals. On 08/16/22 at 8:45a.m., resident #52 was observed in a private room, seated in a recliner. Resident #52 was leaned to the right arm rest of the chair. On 08/17/22 at 1:19 p.m., Resident #52 was seated in a recliner in her room, a meal container was in front of the on an over-bed table. Staff were not available. On 08/22/22 at 11:40 a.m., LPN #1 was asked how many staff were assigned to the memory care unit. LPN #1 stated only her and 1 aide had been assigned to the memory care unit today. On 08/22/22 at 12:48 p.m., Resident #52 was served the noon meal while seated in a recliner inside a private room. The food container included sliced meat, French-fried potatoes and green beans. The food container was placed on the resident's lap. Resident #52 remained seated semi-reclined in a recliner. Resident #52 was leaned to the right, positioned in a manner with her head on the right arm rest of the recliner. Staff remained in the common areas and other resident rooms. On 08/22/22 at 1:17 p.m., LPN #1 was observed to glance into Resident #52's room while the LPN passed by the doorway. The LPN did not stop or call for assistance for the resident. Resident #52 was not provided meal supervision from 12:48 p.m., until after 1:18 p.m. On 08/22/22 at 1:18 p.m., LPN #1 was asked if the LPN had just did look in on Resident #52. LPN #1 stated yes. LPN #1 was asked how much time had passed from when Resident #52 was served the noon meal and a staff member checked on the resident. LPN #1 stated, It was too long. LPN #1 was asked if Resident #52 had been identified as at risk for aspiration and/or required supervision for meals. LPN #1 stated Resident #52 was identified at risk for aspiration but likes to eat in a private room. LPN #1 stated Resident #52 should have been monitored closer. LPN #1 was asked if there was a specific reason Resident #52 was not provided supervision for the meal. LPN #1 stated there are only two staff assigned and working the memory care unit. 4. On 08/16/22 at 9:10 a.m., on the memory care/locked unit, strong gaseous odors were identified outside the door of Resident #39. Resident #39 was inside the room with the door closed. On 08/16/22 at 9:58 a.m., a maintenance man entered the memory care unit to work on a sink. LPN #1 was heard to inform the maintenance man the nursing staff needed to clean the room before the sink would be looked at but had not had time to clean the room. LPN #1 was observed to obtain cleaning supplies and enter Resident #39's room. The floor of the resident room had large amounts of fecal smears across most of the floor of the room. LPN #1 stated I can't get this up, I am calling housekeeping to see if there is something different to clean with. LPN #1 was attempting to clean the laminate floor with a pad designed mop and liquid substance in a spray bottle. The feces was so dry that no changes were made when LPN #1 made attempts to scrub the floor. On 08/16/22 at 10:35 a.m., LPN #1 was asked how many residents were on the memory care unit. LPN #1 state 16 residents are on the unit at this time. LPN #11 was asked how many staff were working on the locked memory care unit. LPN #1 stated there were two nursing staff on the memory care unit. LPN #1 was asked if that was the planned schedule for staffing on this day or if there had been an unforeseen event that resulted in two staff on the memory care unit. LPN #1 stated there are usually only two nursing staff scheduled on the memory care unit. On 08/18/22 at 7:40 a.m., LPN #1 and CMA #6 were observed to work on the memory care unit. CMA #6 was asked if there were other nursing staff working the memory care unit today. CMA #6 stated, Not today. CMA #6 stated the schedule usually is for two or three each day shift. CMA #6 was asked if the schedule is for three nursing staff, and there are two nursing staff working, was this due to the facility having staff to call-in or if the schedule had two scheduled to work. CMA #6 stated the schedule will only show two nursing staff to work the memory care unit. LPN #1 approached the area when CMA #6 was asked if the nursing staff were able to toilet residents per the resident needs and/or the residents bathed as scheduled. LPN #1 stated the medications are not always administered on time as ordered by the physician if there are only two staff scheduled/working. 5. On 08/22/22 at 11:41 a.m., on the memory care/locked unit, LPN #1 was observed to return to the common area from a resident room. LPN #1 stated that two nursing staff were working the memory care unit today. LPN #1 stated the facility had a new admission to the memory care unit but there had not been enough time to complete the admission On 08/22/22 at12:12 p.m., the first container was served for the noon meal in the common area. On 08/22/22 at 12:18 p.m., Resident #39 was observed to ambulate in common areas. Resident #39 ambulated past the area several residents were seated, eating the noon meal. Resident #38 used fingers to obtain food items and eat from the plate Resident #67 was eating from. This was unwitnessed by LPN #1 while working on medication pass and CMA #4 that was serving the plate/containers to residents. After Resident #39 stood several minutes and continued to eat multiple items from Resident #67's plate, the surveyor alerted staff of Resident #39 eating from other resident's food containers. CMA #4 observed Resident #10 reach with bare fingers to obtain food from Resident #43's container/plate. Staff did not attempt to provide fresh plates/food to the residents affected by the cross contamination of other residents eating from food containers not assigned to them. On 08/22/22 at 12:25 p.m., Resident #45 ambulated into the nurse work area/meal service area, and reached into individual dessert container that had remained uncovered on the counter. CMA #4 stop serving meal containers to residents waiting for meal service to re-direct Resident #45 to return to the meal container that had been placed for Resident #45. On 08/22/22 at 12:30 p.m., CMA #4 began to serve dessert to several residents that remained seated at the table for meal service. Many residents had completed the meal, left the table and paced in the common area of the unit. On 08/22/22 at 12:41 p.m., LPN #1 and CMA #4 were overheard to discuss work not completed and if there would be any help available if they made a call. CMA #4 stated no one available, LPN #1 agreed with CMA #4. After hearing the conversation, LPN #1 was asked if they had been discussing the need for additional assistance. LPN #1 stated CMA #4 had called earlier to request additional assistance and was told state is in the building and there is no one to send. LPN #1 stated a text and call were made to discuss with supervisors if memory care unit had others coming to cover the memory care unit due to a large staff meeting. LPN #1 stated the memory care staff were instructed to keep working. On 08/22/22 at 12:48 p.m., Resident #52 was served tray in a private room. Resident #52 was seated in a recliner, semi-reclined. Resident #52 was positioned to lean to the right with her head resting on the right arm rest of the recliner. Resident #52 had a container of food placed in her lap. The food container included: sliced meat, French-fries, and green beans. Nursing staff were not available to supervise or assist Resident #52. On 08/22/22 at 1:10 p.m., observe Resident #40 open /exit resident room [ROOM NUMBER], followed by Resident #28. Resident #40 was dressed with a long sleeved sweat shirt that was up-side down and on the lower body. One leg was through the bottom of the shirt and a sleeve. The other leg through the bottom of the shirt then through the neck. Residents #40 and #28 walked through the common area of the memory care unit then entered resident room [ROOM NUMBER] and closed the door. LPN #1 and CMA #4 had been with other residents/tasks and did not observe Resident #40 and #28. CMA #4 was asked if there had ever been issues with Resident #28 being sexually inappropriate with other residents. CMA #4 stated, Sometimes. While the surveyor informed CMA #4 of the observation of resident #40 and resident #28, both residents exited room [ROOM NUMBER] and entered the common area. CMA #4 stated Resident #40 is very inappropriate and has to be watched closely and is hard to keep Resident #40 supervised when there is only one aide on the memory care unit. On 08/22/22 at 1:17 p.m., LPN #1 looked into the private room of Resident #52, while passing by to administer medications to a different resident. On 08/22/22 at 1:18 p.m., LPN #1 was asked if Resident #52 had just did look in on. LPN #1 stated, Yes. LPN #1 was asked how long was it from the time Resident #52 had been served her noon meal to the time any staff checked on Resident #52 according to the aspiration precautions. LPN #1 stated, It was too long. LPN #1 was asked if there was a reason Resident #52 had not been supervised/checked on earlier. LPN #1 stated, It is just the two of us. There is not enough staff to do all that we need to do. LPN #1 was asked if there were any concerns regarding residents putting their hands into other resident's food or touching the desserts that were to be served. LPN #1 state that caused cross contamination of the food. LPN #1 stated it is difficult to monitor the residents and keep them out of the food during meal service. LPN #1 was asked if there was a reason staff were unable to prevent cross contamination of foods to be served. LPN #1 stated. There is not enough staff to redirect residents. We try to catch them but not always enough to stay ahead of the residents. 6. On 08/24/22 at 8:21 a.m., an interview was conducted with the administrator, administrator assistant and the Interim DON. They were asked if the facility had assessed, identified and placed adequate staffing to meet the needs of the residents. The Interim DON stated a second aide was added the memory care/locked unit this week and the facility is starting to look at staffing patterns. They were asked if the QA reviewed the staffing issues. The administrator assistant stated we did discuss staffing and tried to think outside the box. We did identify more help was needed. They were asked if the facility QA committee had been effective to assess, identify issues and place interventions in order meet the needs of the residents with adequate staffing. The administrator assistant stated, the facility needs to have good leadership for the QA to be the most effective. The Interim DON stated the facility continues to find systems and process that are lacking. They stated the lack of stable management/leadership in the facility resulted in the failure to identify and placed corrective measures in an appropriate time frame.

Based on observation and interview the facility failed to provide adequate supervision to prevent cross contamination of food on the memory care/locked unit during meal service. This affected six (#10, 38, 39, 43, 45, and #67) of 16 residents that resided on the memory care unit. The Resident Roster documented the census on the memory care/locked unit was 16. Findings: On 08/22/22 at 11:41 a.m., on the memory care/locked unit, LPN #1 stated that two nursing staff were working the memory care unit today. On 08/22/22 at 12:12 p.m., the first container was served for the noon meal in the common area of the memory care/locked unit. On 08/22/22 at 12:18 p.m., Resident #39 was observed to ambulate in common areas. Resident #39 ambulated past the area several residents were seated, eating the noon meal. Resident #38 used fingers to obtain food items and eat from the plate Resident #67 was eating from. This was unwitnessed by LPN #1 while working on medication pass and CMA #4 that was serving the plate/containers to residents. After Resident #39 stood several minutes and continued to eat multiple items from Resident #67's plate, the surveyor alerted staff of Resident #39 eating from other resident's food containers. CMA #4 observed Resident #10 reach with bare fingers to obtain food from Resident #43's container/plate. Staff did not attempt to provide fresh plates/food to the residents affected by the cross contamination of other residents eating from food containers not assigned to them. On 08/22/22 at 12:25 p.m., Resident #45 ambulated into the nurse work area/meal service area, and reached into individual dessert container that had remained uncovered on the counter. CMA #4 stop serving meal containers to residents waiting for meal service to re-direct Resident #45 to return to the meal container that had been placed for Resident #45. On 08/22/22 at 12:30 p.m., CMA #4 began to serve dessert to several residents that remained seated at the table for meal service. Many residents had completed the meal, left the table and paced in the common area of the unit. On 08/22/22 at 1:18 p.m., LPN #1 was asked if there were any concerns regarding residents putting their hands into other resident's food or touching the desserts that were to be served. LPN #1 state that caused cross contamination of the food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the facility risk assessment was fully updated annually to accurately reflected the needs of the residents. The administrator identified the facility census was 82. Findings: 1. The facility risk assessment contained a Resident's Census and Condition of Residents form, dated 02/04/2020, to identify the needs of the residents. The Resident Census and Condition of Residents documented the census was 114. The facility risk assessment documented the risk assessment had been updated on 08/01/22. The risk assessment documented the average daily census was 107. On 08/24/22 at 11:57 a.m., the administrator and administrator assistant were asked if the date, 08/01/22, documented on the risk assessment was accurate, if portion for identifying resident needs had not updated since 02/04/20. The administrator and administrator assistant stated we thought we updated that. At 12:05 p.m., the administrator provided a Resident Census and Condition of Residents form completed on 08/15/22. On 08/24/22 at 12:27 p.m., the Resident Census and Condition of Residents form, dated 08/15/22, was shown to the administrator and Interim DON. They verified the Resident Census and Condition of Residents dated 08/15/22 was the most current portion of the Facility Risk Assessment to identify resident's needs. The administrator and Interim DON were asked to review the dates of the Resident Census and Condition of Residents provided as the new assessment reviewed on 08/01/22. The administrator and Interim DON were asked how often should the risk assessment tool be fully reviewed and updated. The Interim DON stated the Facility Risk Assessment should be updated annually and as needed. The Interim DON was asked if the risk assessment tool had been fully updated as required. They stated, No. 2. Resident #23 had diagnosis of dysphagia following cerebral infarction. A physician's order, original order date 10/22/16, read in part, .Aspiration Precautions . A physician's order, original order date 10/22/16, read in part, .Sit up 90 degrees .Eat Slow Rate .Small Sips/bites .Close Supervision .Check for Pocketing on the Right side .Double Swallow .Assist/Feed . Resident #23's care plan, dated 11/27/16, read in part, .[Resident #23] .is at risk for aspiration .Related to .Needs Supervision/cues .Swallowing difficulty . Resident #23's care plan interventions, dated 09/19/17, read in part, .Aspiration precautions. Needs supervision with meal . Resident #23's care plan interventions, dated 03/08/22, read in part, .Provide necessary assistance at meal time . Resident #23's assessment, dated 06/07/22, documented the resident had severely impaired cognition with daily decision making, and required supervision with eating. Resident #23's speech therapy evaluation and plan of treatment report, dated 06/11/22, read in part, .Recommendations .Assist pt achieve 90 degree posture for PO intake. Pt has difficulty maintaining posture. Cue for alternating liquids and solids to encourage liquid intake and assist with clearing residue from oral cavity . On 08/19/22 at 8:40 a.m., dietary aide #1 was observed to deliver Resident #23's breakfast tray to their room. Resident #23 was observed lying in bed, with the head of the bed elevated at approximately 30 degrees. Resident #23 was pointing at the tray. Dietary aide #1 gave the resident the toast while the resident was lying in bed. Dietary aide #1 was observed to leave the resident's room. Resident #23 was observed taking big, fast, bites of toast and coughing between bites. Resident #23 was observed to finish eating the toast and began to transfer self out of the bed. LPN #2 was observed to come into the resident's room and assist the resident up and into their wheelchair. LPN #2 was observed to set resident up in front of the breakfast tray, uncovered the tray, and left the room. Resident #23 was observed eating oatmeal unsupervised in their room. On 08/19/22 at 9:20 a.m., the administrator was asked how staff ensured residents' dietary needs and restrictions were met. They stated they review this in their meetings and the nurses observed. On 08/19/22 at 12:05 p.m., LPN #2 was asked what assistance with meals did Resident #23 required. They stated it depended on the day. They stated sometimes the resident required set up assistance and sometimes they required more assistance. On 08/19/22 at 12:15 p.m., CMA #5 was asked how staff knew which residents were on aspiration precautions. They stated, I don't. They were asked to describe a situation where a resident would be fed lying down in bed. They stated, I would not feed a resident lying down because of aspiration risk. An undated meal sticker/label was observed for Resident #23. It did not identify the resident was on aspiration precautions. Other than a physician order, there was no system in place to notify staff of the residents with aspiration precautions. On 08/19/22 at 12:52 p.m., the administrator assistant stated they did not have an aspiration precaution policy. On 08/19/22 at 1:22 p.m. the administrator was asked who served meal trays to the residents. They stated dietary and CNAs. They were asked who all can serve trays to the residents. They stated they have seen nursing staff help. The administrator assistant was asked who assisted the residents with the meals. They stated CNAs and staff, such as dietary and some office staff, that have been through training with the previous dietician. The administrator and administrator assistant were asked what were aspiration precautions. The administrator stated the resident needed to sit up for 30 minutes after eating. The administrator assistant stated they need to sit up while they eat and if the resident needed assistance, they would receive the assistance. The administrator and administrator assistant were asked what resident had aspiration precautions. The administrator assistant stated they would have to go through and look at each chart or ask the nurse. The administrator stated the nurses would know who had aspiration precautions. The administrator assistant stated the dietary, and staff who were working with residents would know. The administrator assistant stated CNA/CMAs have section sheets with diets on them. The administrator assistant was asked to describe the section sheets. They stated the section sheet was something to describe the care the resident needed. They were asked how often the section sheets were updated. They stated weekly and with every change. The administrator assistant was asked if all staff who served and assisted the residents with food have access to residents' precautions. They stated they can look on the food container label. They stated the label consisted of the resident's name, room number, diet order, any specialized order, and allergy. The administrator and administrator assistant were asked how the trained staff were aware of the residents with aspiration precautions. The administrator stated the staff were aware if the resident was getting assistance with feeding, through report, or the section sheet. The administrator assistant stated if the resident was on a specialized diet, such as thickened liquid, pureed, mechanical soft diet, the resident was automatically on aspiration precautions. The administrator assistant was asked how staff would know the resident was on aspiration precautions with a regular diet and thin liquids. They stated the staff still needed to make sure the resident was sitting up. They stated that was universal precautions to prevent anyone from choking. The administrator was asked how did staff ensure aspiration precautions were followed. They stated when the resident received their food, ensure the resident was sitting up and ensured resident was up for 30 minutes after eating. The administrator was asked if it was safe to serve a resident, who had physician ordered aspiration precautions, a piece of toast while in bed with the head of the bed up at approximately 30 degrees. They stated no it wasn't safe. The administrator was asked what risk was to the resident. They stated the resident would be at high risk for aspiration. The administrator was asked what it could indicate if the resident was coughing between bites of the toast. They stated possible aspiration. On 08/19/22 at 1:52 p.m., the dietary manager stated aspiration precautions were not on the residents' dietary food label. The administrator was observed looking at the printed label for Resident #23 and confirmed aspiration precautions were not on the label. On 08/23/22 at 8:55 a.m., LPN #2 was asked if there were new interventions placed for residents dining in their rooms. LPN #2 stated there are more people in place watching and assisting residents during dining. LPN #2 was asked if staffing was an issue prior to today during dining. LPN #2 stated, Yes. On 08/23/22 at 9:46 a.m., The IP nurse was asked if new dining interventions were in place. The IP nurse stated, aspiration precautions were in place. If a resident has orders to be supervised, staff are to ensure the resident at risk is provided supervision. The IP nurse was asked, prior to today, how were you supervising residents. The IP nurse stated, we keep checking in the rooms or we try and bring them to desk. The IP nurse was asked what does supervised feeding mean. The IP nurse stated the resident is supervised as long as you can see the resident in your vision and eye sight. On 08/24/22 at 3:29 p.m., the administrator was asked what the policies regarding staffing based upon census. The administrator stated, The DON was responsible for staffing until 4 day ago and we are fixing the schedule. The administrator was asked if there was a policy regarding minimum staffing. The administrator stated, we have a staffing form, called a flip sheet, which is a daily staffing form. I'm sure we have a staffing policy. On 08/24/22 a.m., 3:29 p.m., the Interim DON stated she is not from Oklahoma and thinks the staffing requirement will be different. The Surveyor requested staffing for sheets for each shift for those not in compliance and provided a list of dates in 08/2022. On 08/24/22 at 3:30 p.m., the administrative assistance stated that she had nurse managers come in and did not provide all time sheets for over the weekend. Surveyor asked to provide all staffing time sheets. 3. Resident #52 had diagnoses to include dementia, cerebral infarction with hemiplegia, Parkinson's Disease, auditory/visual hallucinations, ataxia; dysphagia; and abnormal posture. A physician's order, dated 10/15/21, documented the resident was to receive liquids with a thin consistency. A physician order, dated 5/17/22, documented Resident #52 was to be served a diet consistency of soft bite size pieces and finger foods as tolerated with staff supervision. The ADL Focus care plan, dated 04/01/21, documented Resident #52 required supervision for eating. Interventions included staff would assist with ADL's as needed. The Nutrition Risk Focus care plan, dated 04/01/21, documented Resident #52 was at nutritional risk related to the need for assistance/cues, swallowing difficulty and Parkinson's disease. The Nutritional care plan interventions included: provide diet as prescribed; allow eating/drinking at own pace, and assist the resident as needed. The Nutritional Risk Focus care plan was last updated on 07/14/22. The interventions did not address the resident's assessment status and/or the physician orders regarding Resident #52 required supervision with meals. The Resident CNA Documentation History Detail, for 06/2022 documented Resident #52 was independent had not received supervision for 21 meals. Resident #52 had required limited assistance of staff for 2 meals. A quarterly assessment, dated 07/08/22, documented Resident #52 had severe cognitive impairment for daily decision making, and required supervision of one staff for eating. The Resident CNA Documentation History Detail, for 07/2022, documented the resident had not received supervision for 35 meals. Resident #52 required limited assistance for two meals. The Resident CNA Documentation History Detail, from 08/01/22 through 08/22/22, documented the resident did not receive supervision for 23 of 66 meals. On 08/16/22 at 8:45a.m., resident #52 was observed in a private room, seated in a recliner. Resident #52 was leaned to the right arm rest of the chair. On 08/17/22 at 1:19 p.m., Resident #52 was seated in a recliner in her room, a meal container was in front of the on an over-bed table. Staff were not available. On 08/22/22 at 11:40 a.m., LPN #1 was asked how many staff were assigned to the memory care unit. LPN #1 stated only her and 1 aide had been assigned to the memory care unit today. On 08/22/22 at 12:48 p.m., Resident #52 was served the noon meal while seated in a recliner inside a private room. The food container included sliced meat, French-fried potatoes and green beans. The food container was placed on the resident's lap. Resident #52 remained seated semi-reclined in a recliner. Resident #52 was leaned to the right, positioned in a manner with her head on the right arm rest of the recliner. Staff remained in the common areas and other resident rooms. On 08/22/22 at 1:17 p.m., LPN #1 was observed to glance into Resident #52's room while the LPN passed by the doorway. The LPN did not stop or call for assistance for the resident. Resident #52 was not provided meal supervision from 12:48 p.m., until after 1:18 p.m. On 08/22/22 at 1:18 p.m., LPN #1 was asked if the LPN had just did look in on Resident #52. LPN #1 stated yes. LPN #1 was asked how much time had passed from when Resident #52 was served the noon meal and a staff member checked on the resident. LPN #1 stated, It was too long. LPN #1 was asked if Resident #52 had been identified as at risk for aspiration and/or required supervision for meals. LPN #1 stated Resident #52 was identified at risk for aspiration but likes to eat in a private room. LPN #1 stated Resident #52 should have been monitored closer. LPN #1 was asked if there was a specific reason Resident #52 was not provided supervision for the meal. LPN #1 stated there are only two staff assigned and working the memory care unit. 4. On 08/16/22 at 9:10 a.m., on the memory care/locked unit, strong gaseous odors were identified outside the door of Resident #39. Resident #39 was inside the room with the door closed. On 08/16/22 at 9:58 a.m., a maintenance man entered the memory care unit to work on a sink. LPN #1 was heard to inform the maintenance man the nursing staff needed to clean the room before the sink would be looked at but had not had time to clean the room. LPN #1 was observed to obtain cleaning supplies and enter Resident #39's room. The floor of the resident room had large amounts of fecal smears across most of the floor of the room. LPN #1 stated I can't get this up, I am calling housekeeping to see if there is something different to clean with. LPN #1 was attempting to clean the laminate floor with a pad designed mop and liquid substance in a spray bottle. The feces was so dry that no changes were made when LPN #1 made attempts to scrub the floor. On 08/16/22 at 10:35 a.m., LPN #1 was asked how many residents were on the memory care unit. LPN #1 state 16 residents are on the unit at this time. LPN #11 was asked how many staff were working on the locked memory care unit. LPN #1 stated there were two nursing staff on the memory care unit. LPN #1 was asked if that was the planned schedule for staffing on this day or if there had been an unforeseen event that resulted in two staff on the memory care unit. LPN #1 stated there are usually only two nursing staff scheduled on the memory care unit. On 08/18/22 at 7:40 a.m., LPN #1 and CMA #6 were observed to work on the memory care unit. CMA #6 was asked if there were other nursing staff working the memory care unit today. CMA #6 stated, Not today. CMA #6 stated the schedule usually is for two or three each day shift. CMA #6 was asked if the schedule is for three nursing staff, and there are two nursing staff working, was this due to the facility having staff to call-in or if the schedule had two scheduled to work. CMA #6 stated the schedule will only show two nursing staff to work the memory care unit. LPN #1 approached the area when CMA #6 was asked if the nursing staff were able to toilet residents per the resident needs and/or the residents bathed as scheduled. LPN #1 stated the medications are not always administered on time as ordered by the physician if there are only two staff scheduled/working. 5. On 08/22/22 at 11:41 a.m., on the memory care/locked unit, LPN #1 was observed to return to the common area from a resident room. LPN #1 stated that two nursing staff were working the memory care unit today. LPN #1 stated the facility had a new admission to the memory care unit but there had not been enough time to complete the admission On 08/22/22 at12:12 p.m., the first container was served for the noon meal in the common area. On 08/22/22 at 12:18 p.m., Resident #39 was observed to ambulate in common areas. Resident #39 ambulated past the area several residents were seated, eating the noon meal. Resident #38 used fingers to obtain food items and eat from the plate Resident #67 was eating from. This was unwitnessed by LPN #1 while working on medication pass and CMA #4 that was serving the plate/containers to residents. After Resident #39 stood several minutes and continued to eat multiple items from Resident #67's plate, the surveyor alerted staff of Resident #39 eating from other resident's food containers. CMA #4 observed Resident #10 reach with bare fingers to obtain food from Resident #43's container/plate. Staff did not attempt to provide fresh plates/food to the residents affected by the cross contamination of other residents eating from food containers not assigned to them. On 08/22/22 at 12:25 p.m., Resident #45 ambulated into the nurse work area/meal service area, and reached into individual dessert container that had remained uncovered on the counter. CMA #4 stop serving meal containers to residents waiting for meal service to re-direct Resident #45 to return to the meal container that had been placed for Resident #45. On 08/22/22 at 12:30 p.m., CMA #4 began to serve dessert to several residents that remained seated at the table for meal service. Many residents had completed the meal, left the table and paced in the common area of the unit. On 08/22/22 at 12:41 p.m., LPN #1 and CMA #4 were overheard to discuss work not completed and if there would be any help available if they made a call. CMA #4 stated no one available, LPN #1 agreed with CMA #4. After hearing the conversation, LPN #1 was asked if they had been discussing the need for additional assistance. LPN #1 stated CMA #4 had called earlier to request additional assistance and was told state is in the building and there is no one to send. LPN #1 stated a text and call were made to discuss with supervisors if memory care unit had others coming to cover the memory care unit due to a large staff meeting. LPN #1 stated the memory care staff were instructed to keep working. On 08/22/22 at 12:48 p.m., Resident #52 was served tray in a private room. Resident #52 was seated in a recliner, semi-reclined. Resident #52 was positioned to lean to the right with her head resting on the right arm rest of the recliner. Resident #52 had a container of food placed in her lap. The food container included: sliced meat, French-fries, and green beans. Nursing staff were not available to supervise or assist Resident #52. On 08/22/22 at 1:10 p.m., observe Resident #40 open /exit resident room [ROOM NUMBER], followed by Resident #28. Resident #40 was dressed with a long sleeved sweat shirt that was up-side down and on the lower body. One leg was through the bottom of the shirt and a sleeve. The other leg through the bottom of the shirt then through the neck. Residents #40 and #28 walked through the common area of the memory care unit then entered resident room [ROOM NUMBER] and closed the door. LPN #1 and CMA #4 had been with other residents/tasks and did not observe Resident #40 and #28. CMA #4 was asked if there had ever been issues with Resident #28 being sexually inappropriate with other residents. CMA #4 stated, Sometimes. While the surveyor informed CMA #4 of the observation of resident #40 and resident #28, both residents exited room [ROOM NUMBER] and entered the common area. CMA #4 stated Resident #40 is very inappropriate and has to be watched closely and is hard to keep Resident #40 supervised when there is only one aide on the memory care unit. On 08/22/22 at 1:17 p.m., LPN #1 looked into the private room of Resident #52, while passing by to administer medications to a different resident. On 08/22/22 at 1:18 p.m., LPN #1 was asked if Resident #52 had just did look in on. LPN #1 stated, Yes. LPN #1 was asked how long was it from the time Resident #52 had been served her noon meal to the time any staff checked on Resident #52 according to the aspiration precautions. LPN #1 stated, It was too long. LPN #1 was asked if there was a reason Resident #52 had not been supervised/checked on earlier. LPN #1 stated, It is just the two of us. There is not enough staff to do all that we need to do. LPN #1 was asked if there were any concerns regarding residents putting their hands into other resident's food or touching the desserts that were to be served. LPN #1 state that caused cross contamination of the food. LPN #1 stated it is difficult to monitor the residents and keep them out of the food during meal service. LPN #1 was asked if there was a reason staff were unable to prevent cross contamination of foods to be served. LPN #1 stated. There is not enough staff to redirect residents. We try to catch them but not always enough to stay ahead of the residents. 6. On 08/24/22 at 8:21 a.m., an interview was conducted with the administrator, administrator assistant and the Interim DON. They were asked if the facility had assessed, identified and placed adequate staffing to meet the needs of the residents. The Interim DON stated a second aide was added the memory care/locked unit this week and the facility is starting to look at staffing patterns. They were asked if the QA reviewed the staffing issues. The administrator assistant stated we did discuss staffing and tried to think outside the box. We did identify more help was needed. They were asked if the facility QA committee had been effective to assess, identify issues and place interventions in order meet the needs of the residents with adequate staffing. The administrator assistant stated, the facility needs to have good leadership for the QA to be the most effective. The Interim DON stated the facility continues to find systems and process that are lacking. They stated the lack of stable management/leadership in the facility resulted in the failure to identify and placed corrective measures in an appropriate time frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to maintain a QA program to identify/assess, develop and implement appropriate plans of action to ensure there was adequate staffing to meet the residents' needs. This affected two (#23 and #52) of two sampled residents reviewed for aspiration precautions, and 16 of 16 residents that resided on the memory care/locked unit. The administrator identified 82 residents resided in the facility. Findings: 1. The facility risk assessment, updated 08/01/22, contained a Resident's Census and Condition of Residents form, dated 02/04/20, to identify the needs of the residents. The Resident Census and Condition of Residents documented the census was 114. The facility risk assessment, last updated on 08/01/22, documented the average daily census was 107. On 08/15/22, the administrator identified 82 residents resided in the facility. On 08/24/22 at 11:57 a.m., the administrator and administrator assistant were asked if the date documented risk assessment was accurate on 08/01/22, if portion for identifying resident needs had not been updated since 02/04/20. The administrator and administrator assistant stated we thought we updated that. At 12:05 p.m., the administrator provided a Resident Census and Condition form completed on 08/15/22. On 08/24/22 at 12:27 p.m., an updated Resident Census and Condition of Residents form dated 08/15/22 was provided and identified as the current portion of the Facility Risk Assessment to identify resident's needs. The administrator and Interim DON were asked to review the dates of the Resident Census and Condition of Residents provided as the new assessment reviewed on 08/01/22. The administrator and Interim DON were asked how often should the risk assessment tool be fully reviewed and updated. The Interim DON stated the Facility Risk Assessment should be updated annually and as needed. The Interim DON was asked if the risk assessment tool had been fully updated as required. They stated, No. 2. Resident #23 had diagnosis of dysphagia following cerebral infarction. A physician's order, original order date 10/22/16, read in part, .Aspiration Precautions . A physician's order, original order date 10/22/16, read in part, .Sit up 90 degrees .Eat Slow Rate .Small Sips/bites .Close Supervision .Check for Pocketing on the Right side .Double Swallow .Assist/Feed . Resident #23's care plan, dated 11/27/16, read in part, .[Resident #23] .is at risk for aspiration .Related to .Needs Supervision/cues .Swallowing difficulty . Resident #23's care plan interventions, dated 09/19/17, read in part, .Aspiration precautions. Needs supervision with meal . Resident #23's care plan interventions, dated 03/08/22, read in part, .Provide necessary assistance at meal time . Resident #23's assessment, dated 06/07/22, documented the resident had severely impaired cognition with daily decision making, and required supervision with eating. Resident #23's speech therapy evaluation and plan of treatment report, dated 06/11/22, read in part, .Recommendations .Assist pt achieve 90 degree posture for PO intake. Pt has difficulty maintaining posture. Cue for alternating liquids and solids to encourage liquid intake and assist with clearing residue from oral cavity . On 08/19/22 at 8:40 a.m., dietary aide #1 was observed to deliver Resident #23's breakfast tray to their room. Resident #23 was observed lying in bed, with the head of the bed elevated at approximately 30 degrees. Resident #23 was pointing at the tray. Dietary aide #1 gave the resident the toast while the resident was lying in bed. Dietary aide #1 was observed to leave the resident's room. Resident #23 was observed taking big, fast, bites of toast and coughing between bites. Resident #23 was observed to finish eating the toast and began to transfer self out of the bed. LPN #2 was observed to come into the resident's room and assist the resident up and into their wheelchair. LPN #2 was observed to set resident up in front of the breakfast tray, uncovered the tray, and left the room. Resident #23 was observed eating oatmeal unsupervised in their room. On 08/19/22 at 9:20 a.m., the administrator was asked how staff ensured residents' dietary needs and restrictions were met. They stated they review this in their meetings and the nurses observed. On 08/19/22 at 12:05 p.m., LPN #2 was asked what assistance with meals did Resident #23 required. They stated it depended on the day. They stated sometimes the resident required set up assistance and sometimes they required more assistance. LPN #2 was asked how staff ensured aspiration precautions were followed. They stated to make sure the resident was sitting up with the correct diet and liquid consistency. They were asked how staff knew which residents were on aspiration precautions. They stated it was in the computer and on their section/report sheet. LPN #2 was asked if Resident #23 was on aspiration precautions. They stated they needed to look in the computer. After LPN #2 was observed looking in the computer, they stated the resident was. On 08/19/22 at 12:52 p.m., the administrator assistant stated they did not have an aspiration precaution policy. On 08/19/22 at 1:22 p.m. the administrator was asked who served meal trays to the residents. They stated dietary and CNAs. They were asked who all can serve trays to the residents. They stated they have seen nursing staff help. The administrator assistant was asked who assisted the residents with the meals. They stated CNAs and staff, such as dietary and some office staff, that have been through training with the previous dietician. On 08/23/22 at 8:55 a.m., LPN #2 was asked if there were new interventions placed for residents dining in their rooms. LPN #2 stated there are more people in place watching and assisting residents during dining. LPN #2 was asked if staffing was an issue prior to today during dining. LPN #2 stated, Yes. On 08/23/22 at 9:46 a.m., The IP nurse was asked if new dining interventions were in place. The IP nurse stated, aspiration precautions were in place. If a resident has orders to be supervised, staff are to ensure the resident at risk is provided supervision. The IP nurse was asked, prior to today, how were you supervising residents. The IP nurse stated, we keep checking in the rooms or we try and bring them to desk. The IP nurse was asked what does supervised feeding mean. The IP nurse stated the resident is supervised as long as you can see the resident in your vision and eye sight. On 08/24/22 at 3:29 p.m., the administrator was asked what the policies regarding staffing based upon census. The administrator stated, The DON was responsible for staffing until 4 day ago and we are fixing the schedule. The administrator was asked if there was a policy regarding minimum staffing. The administrator stated, we have a staffing form, called a flip sheet, which is a daily staffing form. I'm sure we have a staffing policy. The Interim DON stated she is not from Oklahoma and thinks the staffing requirement will be different. 3. Resident #52 had diagnoses to include dementia, cerebral infarction with hemiplegia, Parkinson's Disease, auditory/visual hallucinations, ataxia; dysphagia; and abnormal posture. A physician order, dated 05/17/22, documented Resident #52 was to be served a diet consistency of soft bite size pieces and finger foods as tolerated with staff supervision to decrease loss of bolus with patient feeding attempts. The ADL Focus care plan, dated 04/01/21, documented Resident #52 required supervision for eating. Interventions included staff would assist with ADL's as needed. The ADL Focus care plan was last reviewed on 06/30/22. The ADL Focus care plan did not include interventions to ensure supervision for meals/eating. The Nutrition Risk Focus care plan, dated 04/01/21, documented Resident #52 was at nutritional risk related to the need for assistance/cues, swallowing difficulty and Parkinson's disease. The care plan documented a recent weight loss as evidence the Resident #52 was at nutritional risk. The Nutritional care plan interventions included: provide diet as prescribed; allow eating/drinking at own pace, and assist the resident as needed. The Nutritional Risk Focus care plan was last updated on 07/14/22. The interventions did not address the resident's assessment status and/or the physician orders regarding Resident #52 required supervision with meals. The Resident CNA Documentation History Detail, for 06/2022 documented Resident #52 was independent had not received supervision for 21 meals. Resident #52 had required limited assistance of staff for 2 meals. Seven meals had been refused and one meal did not contain documentation. A quarterly assessment, dated 07/08/22, documented Resident #52 had severe cognitive impairment for daily decision making, and required supervision of one staff for eating. The Resident CNA Documentation History Detail, for 07/2022, documented the resident had not received supervision for 35 meals. Resident #52 required limited assistance for two meals. Four meals documented the resident refused. Nineteen meals contained no documentation. The Resident CNA Documentation History Detail, from 08/01/22 through 08/22/22, documented the resident did not receive supervision for 23 of 66 meals. One meal documented the meal did not occur. Fifteen meals contained no documentation. On 08/17/22 at 1:19 p.m., Resident #52 was seated in a recliner in her room, a meal container was in front of the on an over-bed table. Staff were not available. On 08/22/22 at 11:40 a.m., LPN #1 was asked how many staff were assigned to the memory care unit. LPN #1 stated only her and 1 aide had been assigned to the memory care unit today. On 08/22/22 at 12:48 p.m., Resident #52 was served the noon meal while seated in a recliner inside a private room. The food container included sliced meat, French-fried potatoes and green beans. The food container was placed on the resident's lap. Resident #52 remained seated semi-reclined in a recliner. Resident #52 was leaned to the right, positioned in a manner with her head on the right arm rest of the recliner. Staff remained in the common areas and other resident rooms. On 08/22/22 at 1:17 p.m., LPN #1 was observed to glance into Resident #52's room while the LPN passed by the doorway. The LPN did not stop or call for assistance for the resident. Resident #52 was not provided meal supervision from 12:48 p.m., until after 1:18 p.m. On 08/22/22 at 1:18 p.m., LPN #1 was asked if the LPN had just did look in on Resident #52. LPN #1 stated yes. LPN #1 was asked how much time had passed from when Resident #52 was served the noon meal and a staff member checked on the resident. LPN #1 stated, It was too long. LPN #1 was asked if Resident #52 had been identified as at risk for aspiration and/or required supervision for meals. LPN #1 stated Resident #52 was identified at risk for aspiration but likes to eat in a private room. LPN #1 stated Resident #52 should have been monitored closer. LPN #1 was asked if there was a specific reason Resident #52 was not provided supervision for the meal. LPN #1 stated there are only two staff assigned and working the memory care unit. 4. On 08/16/22 at 9:10 a.m., on the memory care/locked unit, strong gaseous odors were identified outside the door of Resident #39. Resident #39 was inside the room with the door closed. On 08/16/22 at 9:58 a.m., a maintenance man entered the memory care unit to work on a sink. LPN #1 was heard to inform the maintenance man the nursing staff needed to clean the room before the sink would be looked at but had not had time to clean the room. LPN #1 was observed to obtain cleaning supplies and enter Resident #39's room. The floor of the resident room had large amounts of fecal smears across most of the floor of the room. LPN #1 stated I can't get this up, I am calling housekeeping to see if there is something different to clean with. LPN #1 was attempting to clean the laminate floor with a pad designed mop and liquid substance in a spray bottle. The feces was so dry that no changes were made when LPN #1 made attempts to scrub the floor. On 08/16/22 at 10:35 a.m., LPN #1 was asked how many residents were on the memory care unit. LPN #1 state 16 residents are on the unit at this time. LPN #11 was asked how many staff were working on the locked memory care unit. LPN #1 stated there were two nursing staff on the memory care unit. LPN #1 was asked if that was the planned schedule for staffing on this day or if there had been an unforeseen event that resulted in two staff on the memory care unit. LPN #1 stated there are usually only two nursing staff scheduled on the memory care unit. On 08/18/22 at 7:40 a.m., LPN #1 and CMA #6 were observed to work on the memory care unit. CMA #6 was asked if there were other nursing staff working the memory care unit today. CMA #6 stated, Not today. CMA #6 stated the schedule usually is for two or three each day shift. CMA #6 was asked if the schedule is for three nursing staff, and there are two nursing staff working, was this due to the facility having staff to call-in or if the schedule had two scheduled to work. CMA #6 stated the schedule will only show two nursing staff to work the memory care unit. LPN #1 approached the area when CMA #6 was asked if the nursing staff were able to toilet residents per the resident needs and/or the residents bathed as scheduled. LPN #1 stated the medications are not always administered on time as ordered by the physician if there are only two staff scheduled/working. 5. On 08/22/22 at 11:41 a.m., on the memory care/locked unit, LPN #1 was observed to return to the common area from a resident room. LPN #1 stated that two nursing staff were working the memory care unit today. On 08/22/22 at 12:12 p.m., the first container was served for the noon meal in the common area of the memory care/locked unit. On 08/22/22 at 12:18 p.m., Resident #39 was observed to ambulate in common areas. Resident #39 ambulated past the area several residents were seated, eating the noon meal. Resident #38 used fingers to obtain food items and eat from the plate Resident #67 was eating from. This was unwitnessed by LPN #1 while working on medication pass and CMA #4 that was serving the plate/containers to residents. After Resident #39 stood several minutes and continued to eat multiple items from Resident #67's plate, the surveyor alerted staff of Resident #39 eating from other resident's food containers. CMA #4 observed Resident #10 reach with bare fingers to obtain food from Resident #43's container/plate. Staff did not attempt to provide fresh plates/food to the residents affected by the cross contamination of other residents eating from food containers not assigned to them. On 08/22/22 at 12:25 p.m., Resident #45 ambulated into the nurse work area/meal service area, and reached into individual dessert container that had remained uncovered on the counter. CMA #4 stop serving meal containers to residents waiting for meal service to re-direct Resident #45 to return to the meal container that had been placed for Resident #45. On 08/22/22 at 12:30 p.m., CMA #4 began to serve dessert to several residents that remained seated at the table for meal service. Many residents had completed the meal, left the table and paced in the common area of the unit. On 08/22/22 at 12:41 p.m., LPN #1 and CMA #4 were overheard to discuss work not completed and if there would be any help available if they made a call. CMA #4 stated no one available, LPN #1 agreed with CMA #4. After hearing the conversation, LPN #1 was asked if they had been discussing the need for additional assistance. LPN #1 stated CMA #4 had called earlier to request additional assistance and was told state is in the building and there is no one to send. LPN #1 stated a text and call were made to discuss with supervisors if memory care unit had others coming to cover the memory care unit due to a large staff meeting. LPN #1 stated the memory care staff were instructed to keep working. On 08/22/22 at 12:48 p.m., Resident #52 was served tray in a private room. Resident #52 was seated in a recliner, semi-reclined. Resident #52 was positioned to lean to the right with her head resting on the right arm rest of the recliner. Resident #52 had a container of food placed in her lap. The food container included: sliced meat, French-fries, and green beans. Nursing staff were not available to supervise or assist Resident #52. On 08/22/22 at 1:10 p.m., observe Resident #40 open /exit resident room [ROOM NUMBER], followed by Resident #28. Resident #40 was dressed with a long sleeved sweat shirt that was up-side down and on the lower body. One leg was through the bottom of the shirt and a sleeve. The other leg through the bottom of the shirt then through the neck. Residents #40 and #28 walked through the common area of the memory care unit then entered resident room [ROOM NUMBER] and closed the door. LPN #1 and CMA #4 had been with other residents/tasks and did not observe Resident #40 and #28. CMA #4 was asked if there had ever been issues with Resident #28 being sexually inappropriate with other residents. CMA #4 stated, Sometimes. While the surveyor informed CMA #4 of the observation of resident #40 and resident #28, both residents exited room [ROOM NUMBER] and entered the common area. CMA #4 stated Resident #40 is very inappropriate and has to be watched closely and is hard to keep Resident #40 supervised when there is only one aide on the memory care unit. On 08/22/22 at 1:17 p.m., LPN #1 looked into the private room of Resident #52, while passing by to administer medications to a different resident. On 08/22/22 at 1:18 p.m., LPN #1 was asked if Resident #52 had just did look in on. LPN #1 stated, Yes. LPN #1 was asked how long was it from the time Resident #52 had been served her noon meal to the time any staff checked on Resident #52 according to the aspiration precautions. LPN #1 stated, It was too long. LPN #1 was asked if there was a reason Resident #52 had not been supervised/checked on earlier. LPN #1 stated, It is just the two of us. There is not enough staff to do all that we need to do. LPN #1 was asked if there were any concerns regarding residents putting their hands into other resident's food or touching the desserts that were to be served. LPN #1 state that caused cross contamination of the food. LPN #1 stated it is difficult to monitor the residents and keep them out of the food during meal service. LPN #1 was asked if there was a reason staff were unable to prevent cross contamination of foods to be served. LPN #1 stated. There is not enough staff to redirect residents. We try to catch them but not always enough to stay ahead of the residents. On 08/24/22 at 8:21 a.m., an interview was conducted with the administrator, administrator assistant and the Interim DON. They were asked if the facility had assessed, identified and placed adequate staffing to meet the needs of the residents. The Interim DON stated a second aide was added the memory care/locked unit this week and the facility is starting to look at staffing patterns. They were asked if the QA reviewed the staffing issues. The administrator assistant stated we did discuss staffing and tried to think outside the box. We did identify more help was needed. They were asked if the facility QA committee had been effective to assess, identify issues and place interventions in order meet the needs of the residents with adequate staffing. The administrator assistant stated, the facility needs to have good leadership for the QA to be the most effective. The Interim DON stated the facility continues to find systems and process that are lacking. They stated the lack of stable management/leadership in the facility resulted in the failure to identify and placed corrective measures in an appropriate time frame. 6. On 08/24/22 at 8:21 a.m., an interview was conducted with the administrator, administrator assistant and the Interim DON. They were asked if the facility had assessed, identified and placed adequate staffing to meet the needs of the residents. The Interim DON stated a second aide was added the memory care/locked unit this week and the facility is starting to look at staffing patterns. They were asked if the QA reviewed the staffing issues. The administrator assistant stated we did discuss staffing and tried to think outside the box. We did identify more help was needed. They were asked if the facility QA committee had been effective to assess, identify issues and place interventions in order meet the needs of the residents with adequate staffing. The administrator assistant stated, the facility needs to have good leadership for the QA to be the most effective. The Interim DON stated the facility continues to find systems and process that are lacking. They stated the lack of stable management/leadership in the facility resulted in the failure to identify and placed corrective measures in an appropriate time frame.