**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff and Physician Assistant interviews, the facility failed to ensure an as needed (PRN) psychotropic medication, Lorazepam, prescribed for anxiety had a stop date 14 days or less for 1 or 5 residents (Resident #17) reviewed for unnecessary medications. Findings included: Resident #17 was admitted to the facility on [DATE] with diagnoses which included anxiety. A Physician's order dated 1/07/25 read in part for Lorazepam (antianxiety medication) 0.5 milligrams (mg) by mouth every 12 hours as needed for anxiety. Review of the Psychotherapy Comprehensive Clinical Reassessment dated [DATE] read in part current medications included Ativan 0.5 mg by mouth every 12 hours as needed. Resident #17's annual Minimum Data Set assessment dated [DATE] revealed she was moderately cognitively impaired. She was independent with most activities of daily living. She was coded as receiving antianxiety medication. Resident #17's care plan, last revised on 4/21/25 read in part; Resident #17 had the potential for fluctuations in mood related to anxiety with frequent crying. Interventions included to administer medications as ordered, observe and report acute changes in mood or behavior to physician as indicated. Review of Resident #17's Medication Administration records revealed she received Lorazepam 0.5 mg as follows: January 2025 - 8, 9, 14, 16, 18, 20, 21, 23, 29, & 30 - total of 10 doses February 2025 - 1, 2, 4, 5, 8, 9, 11, 12, 13, & 23 - total of 10 doses March 2025 - 5, 10, 11, 16, 21, 22, 23, 27 & 30 - total of 9 doses April 1- 23, 2025 - 4, 12, 18, 19, & 20 - total of 5 doses An interview on 4/22/25 at 4:03 PM with the Physician's Assistant (PA) revealed he was aware of the PRN psychotropic medication stop date requirement. He had no explanation for why there was no stop date included in the order. He stated he believed it was an order entry error that the stop date was not added due to recent changes in the electronic health software. An interview on 4/23/25 at 10:30 AM with the Administrator revealed he was aware of the requirement for PRN psychotropic medications to have a stop date and did not know why Resident #17's PRN Lorazepam did not have a stop date.

Based on observations and staff interviews, the facility failed to discard food items that were beyond the manufacturer's expiration date in 2 of 2 walk-in coolers (cooler #1 and cooler #2) in the kitchen and 1 of 1 dry food storage areas. These deficient practices had the potential to affect food served to residents. The findings included: 1. An initial tour of the kitchen occurred on 4/21/25 at 9:30 AM with the Dietary Manager. The initial observation of the walk-in cooler and dry food storage areas revealed the following: a. The cold food storage had food items that were stored for use beyond the manufacturer's expiration date. - two bags of shredded lettuce with a manufacturer expiration date of 4/20/25 was observed in cooler #1 - one box of mixed lettuce with a manufacturer expiration date of 4/13/25 was observed in cooler #1. - two containers of egg salad with a manufacturer expiration date of 4/14/25 was observed in cooler #2 b.The dry food storage area had food items that were stored for use beyond the manufacturer's expiration date. -three packs of hotdog buns with a manufacturer expiration date of 4/10/25. An interview was conducted with the Dietary Manager (DM) on 4/21/25 at 9:45 AM. The DM stated food items should be discarded if they were expired, and food storage areas should be checked daily for expired food items. She reported she checked the dry food storage and cold food storage areas daily for expired food items when she was at the facility. The DM said the Cooks should be responsible for checking the food storage areas for expired items on the weekends and when she was not at the facility. The DM explained she had just hired two new Cooks, and they had been working this past weekend. She stated she had not told the new cooks specifically they needed to check the food storage areas, and they had not known they needed to check the food storage areas for expired items. The DM reported she had been out of town last week and the two new Cooks had been working over the weekend and thought that was why the food storage areas had not been checked and had expired food items. An interview was conducted with the Administrator on 4/24/25 at 10:49 AM. The Administrator stated food storage areas should be checked daily for expired items and if there was something expired it should be discarded. He reported the DM had been out of town last week and there had been new kitchen staff working and said he thought that was why the food storage areas had not been checked and had expired food times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, staff, Physician Assistant and Medical Director interviews, the facility failed to clarify and update medical records to reflect the desired advanced directives for 2 of 3 residents reviewed for code status (Resident #30 and Resident #75). The findings included: 1. Resident #30 was re-admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #30 was cognitively intact. Review of Resident #30's Care Plan, which was last reviewed on [DATE], revealed no information regarding the resident advanced directives. Review of the facility advanced directive/ code book located at the nurses' station revealed a physician signed Do Not Resuscitate (DNR) form on goldenrod colored paper dated [DATE] and an Emergency Response Directive-NC (North Carolina) form dated [DATE] signed by both the physician and Resident #30 that indicated to do not attempt resuscitation if Resident #30 had no pulse and was not breathing. Further review of Resident #30's electronic medical record revealed a physician order dated [DATE] and signed by the Medical Director on [DATE] for No CPR/DNR (cardiopulmonary resuscitation/ do not resuscitate). Review of Resident #30's admission Nursing assessment dated [DATE] revealed Resident #30 did want CPR. This was indicated by yes being marked on the admission Nursing Assessment for the question titled Does the resident want CPR. Additional review of Resident #30's electronic medical record revealed an updated Emergency Response Directive-NC form had been completed by Resident #30 and scanned into the electronic medical record on [DATE]. The updated form was signed by Resident #30 on [DATE] and indicated her desire for resuscitation if her heart or breathing stopped. The form was signed by the facility Medical Director on [DATE]. An interview was conducted with Resident #30 on [DATE] at 3:12 PM. Resident #30 stated she remembered changing her code status when she was readmitted to the facility after her hospitalization. She said she wanted CPR and resuscitation if her heart stopped, or she stopped breathing. Resident #30 stated, I know they say it is horrible and can be painful for someone my age, but it is how I feel right now. An interview was performed on [DATE] at 3:28 PM with Nurse #3. She stated resident code status was located in the electronic medical record and in the advanced directive/ code book located at the nurse's station. She explained the advanced directive/ code book contained the resident emergency response directive-NC form, original DNR (Do Not Resuscitate) form, and original MOST (Medical Orders for Scope of Treatment) form. She stated she was unsure who updated code status orders in the electronic medical record or advance directive forms if a resident's code status changed. Nurse #3 reviewed Resident #30's electronic medical record revealing No CPR/DNR as her code status. Nurse #3 checked the advance directive/ code book at the nurses' station further revealing a physician signed DNR form and resident emergency response directive- NC form both dated [DATE] for Resident #30. Nurse #3 explained if Resident #30 had an acute episode, was not breathing, or did not have a heart beat she would not perform CPR. An interview was performed on [DATE] at 5:05 PM with the Unit Manager (UM) #2. UM #2 stated education on advance directives was included in the admission packet for the resident and family. She stated code status was discussed with the resident or resident representative (RR) on admission, and the resident or RR chose their desired code status. She stated a resident's code status should always be addressed on admission in case the resident or RR changed their mind. UM #2 explained an emergency response directive- NC form is signed by the physician and the resident or RR indicating their desired code status. She explained the physician completed advance directive DNR/MOST forms when needed. She stated after advance directive forms were completed, the forms were scanned into the electronic medical record by Medical Records. She explained a copy of the advance directive forms were made for the advance directive/ code book until the original forms returned from medical records. UM #2 stated when the original advanced directive forms returned from medical records the copied forms were removed from the advanced directive/ code book and replaced with the original form. She verbalized the process was the same if a resident changed their mind and wanted to change their code status. She said all old advance directive paperwork should be removed from the advanced directive/ code book and replaced with new forms if a resident changed their code status. UM #2 reviewed Resident #30's electronic medical record and stated Resident #30 has a No CPR/ DNR order. UM #2 reviewed the most recent emergency response directive- NC form scanned into Resident #30 electronic medical record on [DATE] revealing Resident #30's desire for resuscitation/ full code. UM #2 was unable to locate any additional updated advanced directive forms for Resident #30 since [DATE]. She stated she was not sure why Resident #30's code status had not been changed in her electronic health record or in the advanced directive/ code book. UM #2 stated if Resident #30 had an acute episode, was not breathing, or did not have a heartbeat she would not have received CPR and the outcome for Resident #30 would likely be death. An interview was conducted on [DATE] at 5:48 PM with the Medical Director. The Medical Director stated he did not specifically remember completing Resident #30's updated emergency response directive- NC form but he completed and signed a lot of paperwork. He stated if Resident #30 wanted to change her status to be resuscitated and he signed the form, then Resident #30 should be a full code. He stated when Resident #30 returned from the hospital the facility should have updated her code status. He explained if Resident #30 wanted to change her code status to be resuscitated her medical record and orders should have been updated. An interview was performed on [DATE] at 3:45 PM with the Director of Nursing (DON). The DON explained the inaccuracy of Resident #30's advance directives was complicated by multiple hospitalizations. She stated Resident #30's electronic health record, orders, and the advance directive/ code book should have been updated to reflect Resident #30's desired code status. The DON explained the facility's process for updating advance directives. She stated nurses had the physician complete/ sign the residents advance directives, then a copy was made for the advance directive/ code book, and the original form was given to Medical Records. She said Medical Records scanned the original advance directive forms into the resident's electronic health record. Then they replaced the copied forms in the advance directive/ code book with the original advance directive forms. She stated the advance directive/ code books at the nurses' station are updated by the nurses and nurse managers. She explained the code status order in the electronic health record was updated by the Nurse Manager when there is a change. The DON stated conversations were held with residents or RR about updating advanced directives on admission, quarterly during care plans, and when there was a change in a resident's condition. She voiced the facility needed to perform audits on all advance directives to ensure they are correct. An interview with the Administrator was performed on [DATE] at 4:55 PM. The Administrator stated Resident #30's advance directives should have been changed in the electronic medical record, orders, and in the advance directive/ code book to reflect her desire for full code. She explained a resident's advance directive order in the electronic medical record and in the advance directive/ code book should be exactly the same and reflect the resident's wishes. 2. Resident #75 was admitted to the facility on [DATE]. A review of Resident #75's electronic medical record indicated a physician's order dated [DATE] for no cardiopulmonary resuscitation (CPR)/do not resuscitate (DNR). A copy of the Emergency Response Directive dated [DATE] was in Resident #75's electronic medical record and it indicated that if his heart or his breathing stopped, he understood that no CPR would be initiated. This form was signed by Resident #75 and the Nurse Practitioner on [DATE]. A review of the advance directive binder at the nurses' station revealed a paper copy of Resident #75's emergency response directive dated [DATE] that indicated no CPR. In addition, a Medical Orders for Scope of Treatment (MOST) form dated [DATE] was also in the binder and it indicated to attempt resuscitation with limited additional interventions. The MOST form was signed by Resident #75 and the Physician Assistant (PA) on [DATE]. A progress note in Resident #75's medical record dated [DATE] by the PA indicated Resident #75 agreed to discuss his advance directive. Resident #75 agreed to CPR but do not intubate. Resident #75 agreed to limited additional interventions which included hospitalization, antibiotics if indicated, intravenous fluids for defined trial period, and no feeding tube. Resident #75 was alert and oriented x 3 (to time, place and person). The most recent quarterly Minimum Data Set assessment dated [DATE] indicated Resident #75's cognitive patterns were not assessed. An interview with Unit Manager (UM) #1 on [DATE] at 4:53 PM revealed she did not know that Resident #75 had two conflicting advance directives in the advance directive binder. UM #1 stated the PA should have notified her or the nurses so they could have changed Resident #75's advance directive order in his chart and she could have forwarded the most recent MOST form to Medical Records to get it scanned into his electronic medical record. An interview with the Physician Assistant (PA) on [DATE] at 4:28 PM revealed he did not specifically remember the conversation with Resident #75 on [DATE] but he did express to him that he wanted CPR. The PA stated after Resident #75 signed and after he signed the MOST form on [DATE], he went ahead and filed it in the advance directive book which was at the nurses' station. The PA stated he thought he was being helpful, and he was not aware of the facility's systems at that time. The PA shared that he didn't know the most current advance directive had to be scanned into the electronic medical record. An interview with the Director of Nursing (DON) on [DATE] at 5:20 PM revealed she and UM #1 went back and talked to Resident #75 and he told them that he wanted to be DNR. The DON stated the PA did not notify them of the change in Resident #75's advance directive on [DATE]. The DON further stated they recently identified an issue with the correct advance directives not being scanned into the medical record and had talked to their providers, but they didn't go back and check the previous advance directives for all residents. The DON shared that this was a concern because if a resident had conflicting advance directive, they would follow the one that was most recently signed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff and Detective interviews, the facility failed to protect a resident's right to be free from misappropriation of property when a staff member (Nurse Aide #1) used Resident #283's personal credit card to make multiple purchases without the resident's consent. The deficient practice was for 1 of 3 residents reviewed for misappropriation of resident property (Resident #283). The findings included: A review of the facility's Abuse Prohibition Policy dated 9/22/22 indicated each guest/resident shall be free from abuse, neglect, mistreatment, exploitation and misappropriation of property. It defined misappropriation of guest/resident property as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of guest's/resident's belongings or money without the guest's/resident's consent. Resident #283 was admitted to the facility on [DATE] and was cognitively intact. He was at the facility for short-term rehabilitation and discharged home on 9/10/23. The Facility Reportable Incident (FRI) was reviewed. On 9/6/23 staff notified the Director of Nursing (DON) and Administrator that Resident #283 was missing his credit card. The unit manager spoke to Resident #283 and asked when the last time he saw the card or remembered using it. Resident #283 stated on 9/4/23 he went to the vending machine in the evening to get a few candy bars. Resident #283 stated it was dark in the dining room so he used the flashlight on his phone to follow the instructions to use his credit card. Resident #283 stated that somewhere between getting the candy bars on 9/4/23 and 9/6/23 was when the card went missing. On 9/6/23 the Resident noticed that there were charges on his credit card for that were not his. Resident #283 froze his account by calling the credit card company. Resident #283 reported the charges to the unit manager. Resident #283 showed the unit manager that there were several food locations all over Asheville area and a spa where his credit card was used. On 9/6/23 at 8:30 PM the local Police Department was notified. An interview with the Director of Nursing (DON) on 2/22/24 at 3:31 PM revealed that the facility had found online that Resident #283's credit card had been used. Resident #283 could not remember where he had lost the credit card. As soon as the facility was made aware of the missing credit card the police were called. Both DON and the Administrator called all the businesses the card was used to try and find who had the stolen card. The DON stated that the detective was able to find a video with a matching time stamp of the missing card being used. The police showed the DON the still picture of the person and the DON recognized the person to be an employee who worked in the facility as Nurse Aide (NA) #1. The DON stated that NA #1 had only worked at their facility a few times. The police told the DON that they were going to make an arrest. The DON stated they had not heard anything more about the case. The DON stated that NA #1 was terminated right after they identified him on the video. An interview with the Administrator on 2/22/24 at 4:33 PM revealed the facility wasn't sure if Resident #283 had left his credit card in the vending machine or dropped it. Resident #283 checked his credit card statements and noticed charges on his card that were not his. The local police department was called, and the Administrator started calling the businesses that the credit card had been used at. One of the local businesses stated they did have a video of a person using the card but could only release the video to the police. The police officer showed the Administrator the picture of the person and recognized him as NA #1. The police officer stated they were going to charge him. The Administrator stated the facility never got a police report regarding if he was charged or not so they did not report to the nurse aide registry. On 2/27/24 at 8:30 AM received by email a copy of a police report. The name of the suspect on the police report was the same name as NA #1 which was given by the facility. No information was in the report regarding an arrest. On 2/27/24 at 9:45 AM a phone interview with the assigned Detective revealed that NA #1 was arrested for fraud.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to submit an initial and 5-day investigation report to the State Survey Agency after confirming Nurse Aide #1 had used a resident's credit card for personal purchases for 1 of 3 residents reviewed for misappropriation of resident property (Resident #283). The findings included: Resident #283 was admitted to the facility on [DATE] and was cognitively intact. He was at the facility for short-term rehabilitation and discharged home on 9/10/23. The Facility Reportable Incident (FRI) was reviewed. On 9/6/23 staff notified the Director of Nursing (DON) and Administrator that Resident #283 was missing his credit card. Resident #283 stated that somewhere between getting the candy bars on 9/4/23 and 9/6/23 was when the card went missing. On 9/6/23 the Resident noticed that there were charges on his credit card for that were not his. Resident #283 froze his account by calling the credit card company. Resident #283 reported the charges to the unit manager. Resident #283 showed the unit manager that there were several food locations all over Asheville area and a spa where his credit card was used. On 9/6/23 at 8:30 PM the local Police Department was notified. An interview with the Director of Nursing (DON) on 2/22/24 at 3:31 PM revealed that the facility had found online that Resident #283's credit card had been used. Resident #283 could not remember where he had lost the credit card. As soon as the facility was made aware of the missing credit card the police were called. Both DON and the Administrator called all the businesses where the card was used to try and find who had the stolen card. The DON stated that the detective was able to find a video with a matching time stamp of the missing card being used. The police showed the DON the still picture of the person and the DON recognized the person to be an employee who worked in the facility as Nurse Aide (NA) #1. The police told the DON that they were going to make an arrest. The DON stated that NA #1 had only worked at their facility a few times. The DON stated they had not heard anything more about the case. The DON stated that NA #1 was terminated right after they identified him on the video. An interview with the Administrator on 2/22/24 at 4:33 PM revealed the facility wasn't sure if Resident #283 had left his credit card in the vending machine or dropped it. Resident #283 checked his credit card statements and noticed charges on his card that were not his. The local police department was called, and the Administrator started calling the businesses that the credit card had been used at. One of the local businesses stated they did have a video of a person using the card but could only release the video to the police. The police officer showed the Administrator the picture of the person and recognized him as NA #1. The police officer stated they were going to charge him. The Administrator stated the facility never got a police report regarding if he was charged or not so they did not report to the nurse aide registry. The Administrator also stated she did not know what she needed to do because she had already completed her 5-day investigation report on 9/8/23 which is when the investigation was complete. On 9/11/23 the Administrator submitted the report to the State Survey Agency wherein she unsubstantiated the misappropriation of resident property because at that time, she did not know what had happened to Resident #283's credit card. The Administrator added that without having the official police report, she could not substantiate the allegation against NA #1 even though they had identified him on the video. On 2/27/24 at 8:30 AM received by email a copy of a police report. The name of the suspect on the police report was the same name as NA #1 which was given by the facility. No information was in the report regarding an arrest. On 2/27/24 at 9:45 AM a phone interview with the assigned Detective revealed that NA #1 was arrested for fraud.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed for residents with new mental health diagnoses for 1 of 3 residents (Resident #55) reviewed for PASRR. The findings include: Review of Resident #55's medical record revealed the resident had a PASRR level I completed prior to admission dated 07/21/21 and was admitted to the facility on [DATE]. The resident was diagnosed with anxiety disorder on 08/11/23 and major depressive disorder and vascular dementia, moderate, with psychotic disturbance on 10/24/23. No PASRR level II had been completed per Resident #55 medical records. During an interview on 02/22/24 at 11:27AM with the part-time and full-time social worker (SW) revealed the part-time SW had worked at the facility since April 2023 3 days a week but had never been made responsible for applying for PASRR or trained on when or how to apply for them. The full-time SW stated she had only worked at the facility for 1 month and was currently receiving training on PASRR to include when to apply for one, which PASRR required reviews, and how to send in requested information for PASRR. Both SWs revealed they were not aware of any residents in the facility requiring a level II PASRR but believed if a resident had a mental health diagnosis on admission, a significant change in their behavior, or was given a new diagnosis a PASRR should be completed. During an interview on 02/22/24 at 4:37 PM with the Administrator revealed a PASRR level II should be completed in a timely manner upon admission for a resident with a mental health diagnosis or anytime a resident has had a change of condition or a newly added mental health diagnosis. She stated based on Resident #55 added diagnosis of anxiety disorder, major depressive disorder, and vascular dementia, moderate, with psychotic disturbance a PASRR level II should have been completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews with resident, staff and the Nurse Practitioner, the facility failed to follow a resident's care plan and allowed a resident who was assessed as unsafe to self-administer medications for 1 of 1 resident observed with medication at the bedside (Residents #22). The findings included: Resident #22 was admitted to the facility on [DATE] with diagnoses that included end-stage renal disease. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #22 was moderately cognitively impaired, and was dependent on staff assistance with most activities of daily living. A review of Resident #22's medical record indicated no physician's order for self-administration of medications. Resident #22's care plan last revised on 1/6/24 indicated Resident #22 had history of not consuming all medications provided to him during his medication administration and at times pills were found in his jacket or shorts pockets, in his bedside table, or in the trash can. Due to decreased dexterity, increased weakness at times, and inability to steadily hold the medication cup, medications were often spilled when/if he attempted to administer the medications to himself from a medication cup. Resident #22 was at risk for increased medication non-compliance. Interventions included to administer medications by spoon whole as he preferred, and reinforce with Resident #22 as needed that medications could not be left at bedside for him to take. A review of Resident #22's Medication Administration Record for February 2024 indicated an active physician's order for Sevelamer Carbonate 800 milligrams - give 2 tablets by mouth four times a day for dialysis. (Sevelamer is used to lower the amount of phosphorus in the blood of patients receiving kidney dialysis.) There was also an order which started on 1/7/24 for medications to be administered by nurse with spoon due to loss of dexterity causing medications to spill from cup and history of hiding pills. An observation of Resident #22 on 2/20/24 at 1:02 PM during the lunch meal in his room revealed a medication cup containing two large white pills on his bedside table right next to his meal tray. An interview with Resident #22 during this observation revealed he had forgotten what those two pills were for but that he was supposed to take them with meals. Resident #22 stated that the nurse left it at his bedside because he was still eating his lunch. An interview with Medication Aide (MA) #1 on 2/20/24 at 1:19 PM revealed he handed the medication cup to Resident #22 but didn't watch him take his pills because the Nurse Practitioner was in the room at that time. MA #1 stated he usually handed the medication cup to Resident #22 and watched him take his medications. MA #1 further stated that he had not used a spoon to administer Resident #22's medications to him and he was not sure if Resident #22 had been assessed to self-administer his medications. An interview with Nurse #1 on 2/20/24 at 2:46 PM revealed he was assigned to Resident #22 and oversaw MA #1. Nurse #1 stated that Resident #22 could take his medications whole, but he was not sure if he needed some apple sauce to help him swallow his bigger pills. Nurse #1 stated he was not sure why there was an order to spoon Resident #22's medications to his mouth when administering medications to him because he would usually hand him the medication cup and he could take his medications by himself. Nurse #1 stated that he knew they were supposed to observe Resident #22 take his medications and not leave them at the bedside, and that no resident had been assessed that they could take medications on their own. A phone interview with the Nurse Practitioner (NP) on 2/21/24 at 6:05 PM revealed when she visited Resident #22 on 2/20/24 he did not have a lunch tray on his bedside table, and she did not see a medication cup at the bedside. The NP stated that if she saw the nursing staff leave Resident #22's pills at the bedside, she would have said something to them because this could be an issue. The NP stated that leaving medications at the bedside was not acceptable because they would not know whether Resident #22 would take his medications or not. An interview with Unit Manager (UM) #1 on 2/22/24 at 12:13 PM revealed Resident #22 had an order to use a spoon to administer his medications because he had a history of dropping and spilling his pills whenever he was handed the medication cup. UM #1 stated that sometimes Resident #22 refused to take his medications or often requested to leave his medications at the bedside to take later but they should not have left his medications at the bedside. An interview with the Director of Nursing (DON) on 2/22/24 at 3:40 PM revealed Resident #22 would not be a candidate to safely administer medications to himself. The DON stated Resident #22 probably persuaded MA #1 to leave his medications at the bedside, but he should have followed the facility policy which was not to leave medications at the bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #12 was admitted to the facility on [DATE] with diagnoses including Parkinson disease, Huntington disease, dysphagia and dementia with mood disturbance. The Minimum Data Set (MDS) quarterly assessment dated [DATE] for Resident #12 revealed that she was cognitively intact. She would lose liquids and solids from her mouth when eating. She coughed and choked during meals. She would complain of difficulty or pain when swallowing. She had lost 5% or more weight in the last month. She was on a mechanically altered diet and had no dental issues. A physician's order dated 2/14/23 for Resident #12 was on a pureed texture, regular consistency diet, frozen nutritional supplement at lunch, 2 handled cup and divided plate. Observations of Resident #12's lunch tray was observed on 2/19/24 at 1:07 PM, 2/20/24 at 12:54 PM and 2/21/24 at 12:49 PM and no frozen nutritional supplement was on the tray. The frozen nutritional supplement was listed on the tray ticket. The Medication Administration Record (MAR) showed that on 2/21/24 at 12:00 PM Nurse #5 signed that the frozen nutritional supplement was on the lunch tray. During an interview on 2/21/24 at 2:20 PM with Nurse #5 it was revealed that the nurse did sign off that Resident #12 received the frozen nutritional supplement on her lunch tray. The nurse did not check to ensure the Resident #12 received the frozen nutritional supplement and stated the Resident #12 usually got it and thought she did on 2/21/24. During an interview on 2/21/24 at 3:03 PM with the Dietary Manager revealed that he was aware of the frozen nutritional supplement not being on the trays. The Dietary Manager stated that the staff did not know there was any frozen nutritional supplement in the freezer. The staff thought they only had ice cream. He stated the kitchen received a delivery on 2/20/24 at 11 AM, the products did not get offloaded till after lunch. The Dietary Manager stated he places an order for product every 1 or 2 weeks and tries to always keep 2 cases of the frozen nutritional supplement. During an interview on 2/21/24 at 3:17 PM with the Registered Dietician revealed that she did not think that the missing frozen nutritional supplement is a routine missed item. The registered Dietician stated that Resident #12 is on palliative care and is heading towards failure to thrive, so her weight loss was expected. During an interview on 2/21/24 at 3:40 PM with the Medical Director revealed that the Resident #12 should have been getting the frozen nutritional supplement as ordered. The Medical Director did not feel the missing item would make a difference to her weight loss, but if an item is ordered it should be available. During an interview on 2/22/24 at 3:40 PM with the Director of Nursing (DON) revealed that the nurse aide that is setting up the tray for Resident #12 should be checking the ticket on the tray to ensure it was correct. During an interview on 2/22/24 at 4:49 PM with the Administrator revealed that she had been made aware of Resident #12 not receiving the frozen nutritional supplement. The Administrator said that there were several staff who should be checking the ticket. The first being the kitchen staff and Dietary Manager. Then the nurse aide should also be checking the ticket to make sure it was correct. Based on record review, observations, and interviews with resident, staff, and the Medical Director, the facility failed to provide a nutritional supplement ordered by the physician for 2 of 4 residents (Resident #19 and Resident #12) reviewed for nutrition. The findings included: 1. Resident #19 was admitted to the facility on [DATE] with diagnoses that included diabetes, chronic kidney disease, anemia (condition in which the blood doesn't have enough healthy red blood cells and hemoglobin), vitamin D deficiency and dysphagia (difficulty swallowing). The significant change in status Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #19 was cognitively intact, required partial/moderate assistance with eating and had the following signs and symptoms of possible swallowing disorder: holding food in mouth/cheeks or residual food in mouth after meals, coughing or choking during meals or when swallowing medications, and complaints of pain when swallowing. The MDS further indicated that Resident #19's height was 63 inches and weight was 146 pounds during the assessment period, and she had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and was not on a physician-prescribed weight loss regimen. A review of Resident #19's medical record indicated a physician's order dated 1/17/24 for a frozen nutritional supplement for weight loss two times a day with lunch and dinner. Resident #19's care plan last revised on 2/6/24 indicated Resident #19 was at nutritional and/or dehydration risk related to impaired mobility, required assistance with meal set-up, history of weight loss, poor intake, vitamin D deficiency, and increased swallowing difficulty. Continued decline was expected related to medical condition. Interventions included to provide diet as ordered: regular diet, mechanical soft texture, thin consistency liquids, and (frozen nutritional supplement) with lunch and dinner, and to provide supplements as ordered for weight loss. Resident #19's Medication Administration Record (MAR) for February 2024 indicated documentation through initials that the (frozen nutritional supplement) was given two times a day for weight loss at 12:00 PM and at 5:00 PM on 2/19/24 and 2/20/24. An observation on 2/19/24 at 1:22 PM of Resident #19 during the lunch meal revealed her lunch tray on a bedside table in front of her while Resident #19 was sitting up in bed. She was observed talking on her phone and was not eating her food. There was no frozen nutritional supplement on her lunch tray. A second observation of Resident #19 on 2/20/24 at 1:25 PM revealed her lunch tray on her bedside table in front of her. A review of the meal ticket on the tray revealed a frozen nutritional supplement was supposed to be served with lunch and dinner. The food was untouched and there was no frozen nutritional supplement on the lunch tray. Resident #19 reported that she felt sick to her stomach, and was nauseated. Resident #19 declined to answer any questions about her supplements. A third observation of Resident #19 on 2/21/24 at 12:45 PM revealed no frozen nutritional supplement on her lunch tray. An interview with Resident #19 during this observation revealed that she was trying to figure out what the frozen nutritional supplement was that was listed on her meal ticket because she didn't get any at lunch or dinner this week. Resident #19 reported that she felt better today and would try to eat some. An interview with Nurse #1 on 2/21/24 at 1:04 PM revealed Resident #19's frozen nutritional supplement was supposed to come with her meal tray from the kitchen but was not sure why it had not been there. Nurse #1 stated that he had documented on Resident #19's MAR on 2/19/24 at 5:00 PM and 2/20/24 at 12:00 PM without visualizing if the frozen nutritional supplement was on the tray. Nurse #1 further stated he just assumed that it was on Resident #19's meal tray. Nurse #1 added that he was going to check with the kitchen if there were some available. A phone interview with Nurse #2 on 2/22/24 at 10:38 AM revealed Nurse #1 told him that the frozen nutritional supplement came from the kitchen and to go ahead and sign for it on 2/20/24 at 5:00 PM without checking if it came on her supper tray. Nurse #2 stated he wasn't sure if Resident #19 received the frozen nutritional supplement on her supper tray on 2/20/24 and he did not go back to see how much was consumed. Nurse #2 also shared that Nurse #1 was orienting him on 2/20/24 and he was also assigned to Resident #19, but he did not see her at lunch time because he was busy administering medications. An interview with the Dietary Manager (DM) on 2/21/24 at 3:03 PM revealed there was miscommunication with his dietary staff when they failed to put the frozen nutritional supplement on Resident #19's tray. The DM stated a dietary aide told him that they didn't know that the shipment had come in and that they thought the frozen nutritional supplement was just regular ice cream which was why they didn't put it on Resident #19's tray. The DM further stated that they have had issues in the past with obtaining the frozen nutritional supplement and he could understand why there was confusion. He shared that they received the shipment on 2/20/24 right before lunch time but his staff assumed there were none available. The DM also stated he usually placed an order for the frozen nutritional supplement at least once a week or every two weeks whenever they were down to half a case. An interview with the Registered Dietician (RD) on 2/21/24 at 3:17 PM revealed Resident #19 has had a significant weight loss due to several acute and chronic medical issues including nausea and dementia. The RD stated that Resident #19's weight loss might be unavoidable due to these superimposed medical issues. The RD also stated that she had recommended for Resident #19 to receive a frozen nutritional supplement with lunch and dinner, and this was included in the meal ticket for staff to make sure it was placed on her meal tray. The RD stated that she knew the nurses were supposed to make sure that she received it, but this was not realistic and practical for the nurses to be following up on the supplement. The RD also shared that she came to the building once a week and she looked at trays on the hall, and she didn't think the supplements were omitted routinely. The RD further stated that she heard there was a communication issue in the kitchen and if they were not available, they could have called her, and she would have recommended something else. A phone interview with the Medical Director (MD) on 2/21/24 at 5:51 PM revealed Resident #19 should have received the frozen nutritional supplement as ordered and this order was in place to help with her weight loss. The MD stated that he did not think Resident #19's not receiving the frozen nutritional supplement would contribute to further weight loss. An interview with the Director of Nursing (DON) on 2/22/24 at 3:40 PM revealed the nurses typically should look at Resident #19's meal tray to make sure she was receiving her frozen nutritional supplement. The staff member who serves the meal tray should do the last check ideally, but they usually did not always look for complete accuracy. The DON stated the tray check was focused more on making sure the right food consistency was served, adaptive equipment was on the tray and food preferences were honored. The DON added that they could do better with making sure the ordered supplements were served according to the meal ticket. An interview with the Administrator on 2/22/24 at 4:48 PM revealed the meal trays should be checked by the DM but everybody was responsible for making sure the ordered supplements were placed on the meal tray. The Administrator stated that the dietary aides should put them on the tray and then the nursing staff who deliver the tray to the residents should make the last check to make sure the residents receive the ordered supplements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff and Medical Director interviews, the facility failed to obtain orders for the use of supplemental oxygen for 1 of 1 resident reviewed for oxygen (Resident # 30). The findings included: Resident #30 was re-admitted to the facility on [DATE] after hospitalization with diagnoses which included acute and chronic respiratory failure (the respiratory system cannot adequately provide oxygen to the body), pneumonia (an infection of the lungs), and congestive heart failure (a condition in which the heart does not pump blood as efficiently as it should). Review of Resident # 30 quarterly Minimum Data Set, dated [DATE] indicated she was cognitively intact and received oxygen while she was at the facility. Review of Resident # 30 care plan dated 12/17/23 revealed resident was on oxygen at 1-5 liters per minute via nasal cannula as needed for shortness of breath. The care plan interventions included to monitor for respiratory distress and report any shortness of breath, encourage frequent position changes for optimal breathing, observe for difficulty breathing (Dyspnea) on exertion, remind resident not to push beyond endurance and provide rest periods, observe for signs and symptoms of acute respiratory insufficiency: anxiety, confusion, restlessness, shortness of breath at rest, cyanosis, somnolence, and report abnormal findings to the physician. Review of Resident #30's physician orders revealed no order for supplemental oxygen use. Record review was completed of Resident #30's skilled nursing notes and oxygen saturation levels from 1/3/24 to 2/20/24. The oxygen saturation entries indicated Resident #30 wore oxygen. Skilled nursing note documentation revealed Resident #30 wore oxygen and had shortness of breath when lying flat. An observation made on 2/20/24 at 3:12 PM revealed Resident #30 wearing oxygen at 2 liters per minute via nasal cannula administered by an oxygen concentrator unit. An interview on 2/20/24 at 3:49 PM with Nurse #3 confirmed Resident #30 wore supplemental oxygen. Nurse #3 stated orders for oxygen show up on the electronic medical administration record (e-MAR) and oxygen orders included how many liters of oxygen a resident was supposed to have or if the oxygen could be titrated. Nurse #3 reviewed the e-MAR for Resident #30 and was unable to locate oxygen orders for Resident #30. On 2/20/24 at 5:05 PM an interview was completed with Unit Manager (UM) #2. UM #2 stated if a resident wears oxygen and has oxygen in use there should be an order in place for oxygen. She explained the flow rate for oxygen liters would be part of the oxygen order. She stated she checked, and Resident #30 did not have an order for supplemental oxygen. She explained the order did not get carried over from a hospitalization. She stated Resident #30 was supposed to wear oxygen and she was unsure why the order did not get carried over. A follow-up interview was completed on 2/21/24 at 9:41 AM with UM #2. She stated the facility did not have standing orders. She explained if an oxygen order was needed, the nurse would contact the medical provider to obtain an order. UM #2 stated residents receiving supplemental oxygen had an oxygen saturation checked twice daily. She verified there was not an order in place to check Resident #30's oxygen saturation level. A telephone interview was completed on 2/21/24 at 5:29 PM with Nurse #4. He verified Resident #30 wore supplemental oxygen. Nurse #4 stated he had not noticed that Resident #30 did not have an order for oxygen on her e-MAR prior to last night. He explained he was used to Resident #30 wearing oxygen because she had always worn supplemental oxygen. He stated Resident #30's oxygen was typically set at 2 liters per minute but was titrated based on her oxygen saturation level. He said if a resident was wearing oxygen and did not have an order, he would call the medical provider to obtain an order. A phone interview was completed on 2/21/24 at 5:48 PM with the Medical Director. The Medical Director stated if a resident required oxygen there should be an order for oxygen and documentation of oxygen saturation level. He explained the liters of oxygen to be administered would be part of the oxygen order. An interview was conducted on 2/22/24 at 3:45 PM with the Director of Nursing (DON). The DON stated the facility did not have standing orders. She explained the facility failed to carry over the oxygen order when Resident #30 returned from the hospital. She stated anyone with supplemental oxygen needed to have an order. An interview was performed with the Administrator on 2/22/24 at 4:55 PM. The Administrator stated there should be an order in place for oxygen if a resident was using supplemental oxygen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and Resident, Physician Assistant, Psychologist, Health Care Personnel Investigator and staff interviews, the facility failed to protect a vulnerable female resident (Resident #1) from inappropriate intimacy from an employee (Medication Aide #1) for 1 of 3 residents reviewed for abuse. On or around 09/27/23, Resident #1 alleged Medication Aide #1 kissed her on her mouth. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus, anxiety, depression and post-traumatic stress disorder. Source of this information. Resident #1 was her own responsible party. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #1 was cognitively intact. The Resident was able to understand others and be understood. She had no behaviors such as rejection of care, physical or verbal aggression and no hallucinations or delusions during the MDS assessment period. A review of Resident #1's care plan initiated on 09/26/19 and revised on 05/12/23 addressed the area of: Resident #1 was having irrational thoughts regarding a therapist and physician having an affair and was upset because she had been in love with the physician since she had been in the community. The goals that Resident #1 would participate in decision making regarding care to enhance sense of control and she would be free of inappropriate behaviors through the next review would be attained by interventions which included referring to psychiatry. On 12/04/23 at 9:55 AM an interview was conducted with the Health Care Personnel Investigator (HCPI) who reported she went to the facility on [DATE] to review the personnel files of Medication Aide (Med Aide) #1 and interview the staff in relation to a current investigation at a sister facility. She explained that she interviewed the Administrator, Director of Nursing (DON), and Unit Manager (UM) #1 at the facility and from the interviews she felt there could have been an inappropriate relationship between Med Aide #1 and Resident #1. The HCPI continued to explain that the Administrator reported Med Aide #1 was transferred to the sister facility because he had gotten close to a resident by being an active listener because she was going through some family dynamics and there were rumors circulating about him with the staff and he had not gotten a fair shake. The DON explained that she was in the middle of a Performance Improvement Plan (PIP) with Med Aide #1 because of inappropriate interactions with female staff and she had to go out on sick leave on 10/03/23 and found out during her leave that Med Aide #1 was no longer with the facility which she assumed he had been terminated due to the PIP. The DON later found out he was transferred to a sister facility. The HCPI continued to report that Unit Manager #1 informed her that one day, she did not know the day, she noticed Resident #1 was sad and tearful and had a change in her behavior. When she spoke with the Resident about it, she would only say that he didn't say goodbye and that it was consensual but would not elaborate on what she meant. During an interview and observation made with Resident #1 on 12/05/23 at 10:10 AM the Resident who was lying on her bed fully dressed in street clothes and well-groomed explained she performed her own care without the assistance of the staff. The Resident indicated she had been at the facility for about 5 years and had to come to the facility because of her diabetes and had to have insulin injections. Resident #1 was calm and displayed no apprehension and stated she felt safe at the facility. Resident #1 inquired about the reason for the visit, in which she was asked if she had had a recent encounter with a staff member? The Resident responded, why does everybody keep asking me about him? When asked about who? The Resident replied, the name of Med Aide #1. The Resident reported what we had was consensual and it did not involve sex. When asked what was consensual the Resident explained, we kissed on the lips, I kissed him and he kissed me back, it wasn't all him. She stated, it wasn't all him because she wanted it just as much as he did. She described the kiss as lasting about 3 seconds and there was no tongue involved, just a kiss on the lips. When asked how it made her feel she indicated good, because he must have known that I needed it. When asked how he knew she needed it, she explained that she had been very worried for weeks about her family situation and she confided in him. She stated that the Med Aide worked 7:00 PM to 7:00 AM and when he brought her nighttime medications to her, they would visit and talk about her family problems, that they became close, and he would hold her hand. Resident #1 reported the Med Aide #1 could see that she needed a friend in her life, and he was there for her. She stated when she was down, he brought a smile to her face. The Resident explained that the last night Med Aide #1 worked, he told her that he had another job that needed him to work more hours for them and she would not be seeing him for a few days. She stated the kiss happened when he tucked her in bed that night first by tucking the covers up over her legs and moving up the sides of her body then as he raised up to her face they just kissed on the lips. She stated it only happened one time and it was not planned. The Resident repeated it was consensual. The Resident reported that happened about 2 months ago and she has not seen him since. She stated when she asked staff about him, she was told that he was not allowed back in the facility. She stated she cried over him for 3 weeks because she did not get closure. The Resident stated if Med Aide #1 walked through the door right now she would give him a big hug and ask him where he had been. The Resident stated she had discussed her feelings with the Administrator and Nurse #1. On 12/05/23 at 12:00 PM during a conversation with Nurse #1 she explained that she worked with Resident #1 on day shift. She continued to explain that one day (she could not remember when) Resident #1 called her into the Resident's room and relayed to her that she knew Nurse #1's husband had gone to work at the other facility where Med Aide #1 transferred to. The Resident wrote her phone number on a piece of paper and asked the Nurse if she would give the number to her husband to give to Med Aide #1 because she needed closure and if she did not pass the number along then she understood. The Nurse stated she did not ask the Resident what she meant by closure because she felt that if the Resident wanted her to know then she would have told her. Nurse #1 reported that she did not give the Resident's number to her husband but threw it away instead. The Nurse stated a few weeks later Resident #1 asked her if she passed her number to Med Aide #1 and she told her that she didn't because her husband worked a different shift and did not see the Med Aide. The Nurse reported she never informed the facility administration about Resident #1's request. During an interview with Nurse Aide (NA) #1 on 12/06/23 at 7:50 AM the NA explained that one day (he could not remember when) he went to visit Resident #1 at the facility because he used to work at the facility. The NA reported that Resident #1 told him that she knew that he worked with Med Aide #1 and made the statement nothing happened between us, we just kissed. The NA stated her comment took him aback and he did not ask her to elaborate on the comment, but he reported it to Nurse #1 who was on duty at the time. The NA continued to explain that sometime later Resident #1 asked Nurse #1 to give her phone number to NA #1 to pass along to Med Aide #1, but they threw the Resident's phone number away and did not pass it along to Med Aide #1. A follow up interview with Nurse #1 on 12/06/23 at 11:10 AM revealed that she did not remember NA #1 telling her that Resident #1 had reported that the Resident and Med Aide #1 kissed, and nothing happened between them. The Nurse stated had she been notified of that; she would have reported it to the Administrator. On 12/05/23 at 1:55 PM during a conversation with Unit Manager (UM) #1, she reported that one day, she did not recall the exact date, she noticed Resident #1 had walked by her office and did not stop to talk as she normally did but instead went to the other side of the facility to speak with Unit Manager #2. UM #1 stated she did not know what the conversation between Resident #1 and UM #2 was about, but knew it was upsetting to Resident #1. UM #1 continued to explain that shortly after that Resident #1 had a change in her behavior and was tearful which the UM thought was related to her family dynamics. The UM went to talk with Resident #1 and the Resident reported that she was upset because someone needed to apologize to her but when the UM asked the Resident what she was referring to the Resident stated, he just left and didn't give her an explanation. The Resident made the comment it was consensual but would not say what was consensual. The UM stated she was blindsided by the comment and when she asked what was consensual and who she was referring to, again the Resident would not continue the conversation. The UM explained that although she did not state it was Med Aide #1, she put two and two together and felt it was the Med Aide she was referring to because it was right around the time Med Aide #1 left the facility. UM #1 stated she made the Administrator aware of the conversation via telephone that day or the next, she could not remember which. The UM reported Med Aide #1 no longer worked at the facility, so she thought the situation was handled. An interview was conducted with Unit Manager #2 on 12/05/23 at 2:35 PM. The UM explained that one day about a month or so ago Resident #1 came to her side of the building and the UM could tell by the look on her face that the Resident was upset about something, so she asked her to come into her office. When they went into the UM's office Resident #1 asked her if she was Med Aide #1's girlfriend? The Resident explained that she heard the staff talking about the Med Aide seeing someone who worked at the facility and thought it was UM #2. The UM stated she ensured the Resident that she was not Med Aide's girlfriend and Resident #1 began to explain that he owed her an apology because the Med Aide told her that he would be gone for a while and would keep in contact with her, but she had not seen the Med Aide since he left. UM #2 explained that she asked the Resident if there was something she needed from Med Aide #1 and the Resident stated no, they had moments together that was not sexual and would not elaborate on what the moments were. The UM stated the Resident's statements were so concerning to her that she went straight to the Administrator and informed her of the conversation between her and the Resident. The UM stated she asked the Administrator if she needed to write a statement about the conversation and the Administrator told the UM to hold off until they could figure out what was going to happen. During an interview with Nurse Aide #2 on 12/05/23 at 3:05 PM the NA stated she went to work at the facility in early June 2023, and discovered Med Aide #1 also worked at the facility. The NA explained that she felt like she needed to inform the Director of Nursing (DON) that there had been rumors at the other facility that Med Aide #1 was intimate with a resident on third shift, so she reported it to the DON. An interview was made with Medication Aide #1 on 12/06/23 at 9:50 AM. The Med Aide explained that he worked the 7:00 PM to 7:00 AM shift for about 3.5 months and the last day he worked at the facility was October 22nd or 23rd. He stated it was hard to remember because he tried to put it out of his mind (would not elaborate on what was hard to put out of his mind). When asked how often he took care of Resident #1 the Med Aide stated that he would give her medications to her and obtain her blood sugar. When asked if he had ever kissed Resident #1 the Med Aide replied, absolutely not, not if she is the one, I am thinking of. He stated, I have not ever kissed her, not once, are you kidding with COVID in the building. The Med Aide continued to report I remember her now, she gets insulin, very sweet lady and we have talked but no, I have never kissed her. We talked about nothing significant because I haven't spent a lot of time with her. When the Med Aide was asked if it was reported that he and Resident #1 had kissed in the mouth, what would he say to that and the Med Aide stated, it would be a lie because I have never kissed her in the mouth or anywhere else, not even on the forehead. Med Aide #1 stated I know myself pretty well and I know that I would not do that. The Med Aide explained that they had joked around a lot but that was it. When the Med Aide was asked if he ever referred to Resident #1 as being his girlfriend the Med Aide replied No, I have a girlfriend. The Med Aide was asked if an inappropriate relationship between a resident and a staff member occurred, should it be reported and the Med Aide stated, if it was unwanted and bothered her then yes ma'am but I never seemed to bother Resident #1 when I was around, and she seemed to always be glad to see me'. When asked if he thought the Resident was in her right mind and could make good decisions the Med Aide replied he never interacted with her enough to make that assumption. The Med Aide denied that he ever spoke to Resident #1 about leaving the facility. A review of Resident #1's Psychotherapy progress notes dated 11/10/23 and 11/24/23 revealed that Resident #1's speech was clear and coherent and seemed to be less stressed. They discussed personal issues that were distressing the Resident, and the Psychotherapist positively reinforced the use of reframing to reduce the Resident's distress. An interview was conducted with the Psychotherapist on 12/06/23 at 12:00 PM. The Psychotherapist explained that the personal issues that were discussed between she and Resident #1 were the Resident's personal feelings that she felt for someone, and the Resident felt that the someone had those feelings for her as well, but then he left. The Resident explained that she and the staff member would spend time with her, having kind things to say to her. She liked him and was happy to have him but was struggling with her feelings because she was married. She said he had another part-time job and he left but she did not say if he left because of what they had (between them) or if he had to leave (for another reason). The Resident was sad that he left and did not come back to say goodbye. The Psychotherapist stated that she did not know anything about Resident #1 and the staff member kissing. She stated if it happened, and was consensual, it was poor judgement on the part of the staff member. She stated she did not find Resident #1 to have poor judgement and in general she seemed to have pretty good judgement. She stated she was focused and loved the time they had to talk. The Resident wasn't upset that she had spent time with the staff member and was happy about it. She enjoyed having him come and see her. The Psychotherapist stated that Resident #1 told her that she had already discussed the situation with someone, so she thought the facility was aware of it. The Psychotherapist explained that if the staff member was still there and Resident #1 was distressed about it, she would have asked her permission to discuss it with the facility. She was sad and had her feelings hurt but the next visit she had with her; the Resident was over it. The Psychotherapist reported that she thought Resident #1 understood her situation with the staff member and if the kiss happened the Resident could give her consent to the kiss. During an interview with the Supervisor on 12/06/23 at 1:20 PM, the Supervisor stated that he had worked as the weekend Supervisor since June 2023. The Supervisor explained that he had worked with Medication Aide #1 at a different facility and was surprised to see that the Med Aide worked at this facility as well. He continued to explain that before he left the previous facility, he was aware of the facility investigating the Med Aide because there were reports of him having sexual misconduct or abuse toward a resident. The Supervisor stated he did not know the outcome of the investigation because he left before the investigation was complete. The Supervisor continued to explain that he had heard rumors about the Med Aide and Resident #1 having an inappropriate relationship and thought that he should report what he knew about the Med Aide from the other facility to the DON and the Assistant Director of Nursing which he did. The Assistant Director of Nursing could not be interviewed because she was out of the country. An interview was conducted with Nurse Aide #3 on 12/06/23 at 3:35 PM who explained that she worked as a treatment aide at the facility and one day she was talking with Resident #1 when the Resident remarked that she missed Med Aide #1, and they were really close. She stated she could not understand why he left and wasn't reaching out to her. The NA stated Resident #1 mentioned it being consensual but did not elaborate on what she meant by consensual. The NA stated she did not report the conversation to the Administrator because the Resident did not indicate the relationship was inappropriate. On 12/07/23 at 10:30 AM during an interview with the Physician Assistant (PA), he reported he did not know Resident #1 very well because he had only been coming to the facility since early October 2023. The PA explained that he had only seen the Resident a few times but his day-to-day interaction with her was she was alert and oriented but had poor insight into her medical needs. The PA continued to explain that Resident #1 was able to understand what was going on with her on a short-term basis and was one of the more alert residents but had underlying anxiety issues. He stated her insight in judgement was questionable but was understanding in the moment. The PA stated if there was known dialog between Resident #1 and Med Aide #1, she could be misinterpreting it, but he assumed that if she did not want to kiss the Med Aide then she would say no. Resident #1 could be easily manipulated. When the PA was asked if Resident #1 could give consent to the kiss, the PA stated she was alert enough to say yes or no in the moment, but her judgement might not be appropriate. An interview was conducted with the Director of Nursing (DON) on 12/05/23 at 4:00 PM. The DON explained that she had several disciplinary issues with Med Aide #1, but none were about inappropriate behaviors toward the residents. The DON continued to explain that she was in the middle of a disciplinary process with the Med Aide when she became ill and had to be out of work. While she was out, she heard from a coworker that he was transferred to a sister facility. The DON reported that she and the Administrator had a conversation, but could not remember when, about the rumors going around between Resident #1 and Med Aide #1. The Administrator told the DON that the Resident had a situation in the past where she fabricated a relationship between herself, and a previous physician and the Administrator thought it was the same thing. The Administrator told the DON that she had asked Resident #1 about the Med Aide, and the Resident told the Administrator that the Med Aide was tucking her in at night and giving her kisses and the Resident was asking when the Med Aide would be back to work. The Administrator told the DON it was the same situation that happened with a previous physician a few years earlier because apparently Resident #1 had fabricated that she was in a relationship with a physician. The DON stated the Administrator described the kiss like it was a good night kiss on the forehead. She stated she did not ask the Administrator what was done about it because the Administrator was the Abuse Coordinator, and she was under the impression that it was resolved. On 12/05/23 at 4:40 PM and 12/07/23 at 4:15 PM during interviews with the Administrator she stated that Med Aide #1 was hired at the facility on 05/11/23 to work the 7:00 PM to 7:00 AM shift as a Medication Aide and Nurse Aide. He was transferred to a sister facility because the DON and ADON informed her that there were rumors that Med Aide #1 had been arrested because of some sort of allegation from a previous facility where he was employed. The Administrator stated she advised the ADON that they should not be spreading rumors and she spoke with the Med Aide later that day and told him that they had been spreading rumors. The Med Aide then asked the Administrator about transferring to a sister facility and the Administrator was in agreement and was able to provide the Med Aide with the information to the other facility. The Administrator continued to explain that it was sometime after the Med Aide had transferred to the other facility that Unit Manager #2 informed her that Resident #1 had asked her if she was dating Med Aide #1. The Administrator explained she went to talk with the Resident and the Resident was crying and stated she was sad and maybe a little mad because someone had left her. When the Administrator asked her to explain the Resident refused to talk about it, so she left the Resident alone. The Administrator stated she asked Unit Manager #1 to go talk with Resident #1, but the conversation did not go any further with Unit Manager #1. The Administrator explained that on the following Monday she went back to talk with Resident #1 and this time the Resident opened up and told her that she was upset Friday because she was dealing with family issues and Med Aide #1 would come into her room at night and would sit and listen to her so she kind of got to the point where she relied on him to be there for a shoulder to cry on. The Resident explained that the last night the Med Aide worked he told her that he would see her in a couple of days, and he never came back. The Resident stated she was sad and angry so when she heard the staff talking about Med Aide #1 having an affair the Resident thought it was with Unit Manager #2. The Administrator stated that the Resident stated she understood why the Med Aide decided to leave but was mad that he did not say goodbye. During the second conversation with the Resident, she stated she did not want to get the Med Aide into trouble because he would tuck her in at night, kiss her on the forehead and would tell the Resident that he loved her. The Administrator stated that it gave her pause when the Resident reported that Med Aide #1 kissed her on the forehead because the Resident fixated on any kind of male attention. She explained that a kiss on the forehead being acceptable depended on the circumstances. She stated we all kiss residents on the forehead because we take care of the residents and get close to them and if they were okay to hug or show affection then she thought a kiss on the forehead was a minimal way to do so but a kiss in the mouth was not. The Administrator stated she did not think a kiss on the forehead was appropriate between Resident #1 and Med Aide #1 because knowing what she knows now, the Med Aide seemed to groom the Resident and it was not acceptable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility record review and staff interviews the facility failed to implement their abuse policy and procedure in the area of investigation when the facility became aware of a previous employee (Med Aide #1) being investigated for inappropriate sexual behavior with a resident at a sister facility for 1 of 3 residents reviewed for abuse (Resident #1). The findings include: The facility policy titled Abuse Prohibition Policy with a revised date of 09/09/22, read in part: Each resident shall be free from abuse, neglect, mistreatment, exploitation and misappropriation of property. Abuse shall include freedom from verbal, mental, sexual, physical abuse, corporal punishment, and involuntary seclusion. To assure residents are free from abuse, the facility shall monitor residents care and treatments on an on-going basis. It is the responsibility of all staff to provide a safe environment for the residents. Allegations of resident abuse shall be thoroughly investigated and documented by the Administrator. On 12/04/23 at 9:55 AM an interview was conducted with the Health Care Personnel Investigator (HCPI) who reported she went to the facility on [DATE] to review the personnel files of Medication Aide (Med Aide) #1 and interview the staff in relation to a current investigation at a sister facility. She explained that she interviewed the Administrator, Director of Nursing (DON), and Unit Manager (UM) #1 at the facility and from the interviews she felt there could have been an inappropriate relationship between Med Aide #1 and Resident #1. The HCPI continued to explain that the Administrator reported Med Aide #1 was transferred to the sister facility because he had gotten close to a resident by being an active listener because she was going through some family dynamics and there were rumors circulating about him with the staff and he had not gotten a fair shake. The HCPI continued to report that Unit Manager #1 informed her that one day, she did not know the day, she noticed Resident #1 was sad and tearful and had a change in her behavior. When she spoke with the Resident about it, she would only say that he didn't say goodbye and that it was consensual but would not elaborate on what she meant. Resident #1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #1 was cognitively intact. An interview was conducted with Resident #1 on 12/05/23 at 10:10 AM. The Resident reported that she and Med Aide #1 had a consensual relationship that did not involve sex, it was a kiss on the lips. The Resident described the Med Aide as caring and would hold her hand and would be there for her when she needed a friend to discuss her family problems with. Resident #1 explained that she was sad when the Med Aide left but then the sadness turned to anger when he did not come back after a few weeks before she was told that Med Aide #1 could not come back to the facility. During an interview with Nurse Aide #2 on 12/05/23 at 3:05 PM the NA stated she went to work at the facility in early June 2023, and discovered Med Aide #1 also worked at the facility. The NA explained that she felt like she needed to inform the Director of Nursing (DON) that there had been rumors at the other facility that Med Aide #1 was intimate with a resident on third shift, so she reported it to the DON. During an interview with the Supervisor on 12/06/23 at 1:20 PM, the Supervisor stated he went to work at the facility in June 2023 and explained that he had worked with Med Aide #1 at a different facility and was surprised to see that the Med Aide worked at this facility as well. The Supervisor continued to explain that he was aware of Med Aide #1 being investigated at another facility for sexual misconduct or abuse of a resident. The Supervisor stated that he had heard rumors about the Med Aide and Resident #1 having an inappropriate relationship and thought he should report what he knew about the Med Aide from the other facility to the DON and the Assistant Director of Nursing which he did. An interview was conducted with the Director of Nursing (DON) on 12/05/23 at 4:00 PM. The DON explained that she was in the middle of a disciplinary process with Med Aide #1 when she became ill and had to be out of work therefore, she could not personally complete the process. While she was out, she heard from a coworker that the Med Aide was transferred to a sister facility. The DON reported that she and the Administrator had a conversation about the rumors going around between Resident #1 and Med Aide #1. The Administrator told the DON that she had asked Resident #1 about the Med Aide, and the Resident told the Administrator that the Med Aide was tucking her in at night and giving her kisses and the Resident was asking when the Med Aide would be back to work. The DON stated the Administrator described the kiss like it was a good night kiss on the forehead. On 12/05/23 at 4:40 PM and 12/07/23 at 4:15 PM interviews were conducted with the Administrator. The Administrator explained that Med Aide #1 was transferred to a sister facility because she was informed that there were rumors that the Med Aide had been arrested because of some sort of allegation from a different facility where he was employed, and the rumors were going around this facility. She stated it was after Med Aide #1 was transferred that she received reports from staff about concerning comments that Resident #1 had made. The Administrator went to interview Resident #1 twice and the Resident reported she was sad because Med Aide #1 had left her, but the Resident would not explain what she meant until she visited the Resident again on a different day. The Administrator explained that on the second visit, Resident #1 reported that when she would be upset about her family issues, Med Aide #1 would go into her room at night and spend time with her and listen to her, so she got to the point where she relied on the Med Aide to be there for a shoulder to cry on. The Resident reported that the Med Aide told her he would see her in a few days, and he had not been back and that made her sad and angry since he did not say goodbye to her. The Administrator stated that Resident #1 continued to inform her that she did not want to get the Med Aide into trouble because when he would tuck her into bed at night, he would kiss her on the forehead and tell her that he loved her. The Administrator explained that a kiss on the forehead was a minimal way to show affection toward the residents if they allowed it. The Administrator explained that when she found out that Med Aide #1 was being investigated at their sister facility for inappropriate behaviors with a resident it should have sparked her to interview Resident #1 again, but she felt that the Resident's interview would stay the same. She stated if she had opened up an investigation then she would have followed the facility's abuse policy that would include interviewing more residents other than Resident #1. She stated they had a conference call with the corporate staff after it was known their sister facility received a jeopardy citation related to Med Aide #1's inappropriate behavior with a resident and she was not given any direction to reinvestigate the situation Resident #1 and the Medication Aide. She stated since she was made aware of Resident #1 reporting that Med Aide #1 had kissed her in the mouth, she reopened the investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to provide notification for discharge for 1 of 1 sampled resident (Resident #1) for notification requirements before transfer/discharge. Findings included: Resident #1 was admitted to the facility on [DATE] and discharged on 01/13/23 to an assisted living facility. Diagnoses included type 2 diabetes, stage 4 pressure ulcer of right buttock, and hypertensive heart disease without heart failure. Review of revised facility discharge/transfer policy dated 08/31/22 read in part: when an anticipated discharge is scheduled, the post-discharge plan of care and summary is developed prior to discharge. Social services/ designee reviews the plan with the resident at least 24-hours prior to discharge. Review of the discharge Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact. Review of the Nurse Practitioner (NP) note dated 01/13/23 revealed Resident #1's potassium level was stabilized, and she was safe for discharge with recommendations of physical therapy, occupational therapy, nursing assistance and services for disease and medication management as ordered. Resident #1 was unable to leave home without assistance and follow up with medical doctor in one week, sooner if needed. Hard scripts provided. Review of the nursing note written by Nurse #1 dated 01/13/23 revealed Resident #1 discharged home at 10:00 AM by car with caseworker/friend. Paperwork was signed by Resident #1 and prescriptions were given to the resident. An interview conducted with Nurse #1 on 02/01/23 at 12:47 PM revealed she was familiar with Resident #1 and had been responsible for completing her discharge paperwork on 01/13/23. She stated Resident #1 had labs completed on 01/12/23 and results showed her bloodwork to be stable and she was able to be discharged on 01/13/23. Nurse #1 revealed she was informed of Resident #1's discharge around 9:00 AM on 01/13/23 and completed and reviewed the facility discharge/transfer summary with Resident #1 and provided her with a copy along with a hard script for medication to be given to the assisted living facility. She stated no knowledge of Resident #1 being notified of discharge prior to 01/13/23. An interview conducted with the Unit Manager on 02/01/23 at 01:21 PM revealed she was familiar with Resident #1 and her discharge on [DATE]. She stated she was informed around 9:00 AM on 01/13/23 during morning meeting, Resident #1 was being discharged back to the assisted living facility due to her labs taken day before being normal. She revealed nursing completed and reviewed the discharge summary with Resident #1 and provided her with a copy along with a hard script for medications to be given to the assisted living facility. She stated no knowledge of Resident #1 being notified prior to the morning of 01/13/23 of discharge to assisted living facility. An interview conducted with the Business Office Manager on 02/01/23 at 2:02 PM revealed she was out of the facility on 01/13/23 when Resident #1 was discharged and had not been made aware of possible discharge prior and to her knowledge Resident #1 had not discussed or received notification of discharge prior to the morning of 01/13/23. An interview conducted with the Social Worker on 02/01/23 at 2:18 PM revealed she was familiar with Resident #1. She stated she was normally responsible for resident discharge which would include speaking with residents about their upcoming discharge prior to being discharged and reviewing a discharge plan, but Resident #1's discharge was done quickly the morning of 01/13/23 and to her knowledge was being handled by the business office and the administrator. The social worker stated Resident #1 did not have a scheduled discharge and she did not notify Resident #1 about her discharge and to her knowledge notification was not given to Resident #1 about her discharge until the morning of 01/13/23. An interview with the Administrator on 02/01/23 at 4:00 PM revealed she was familiar with Resident #1 and her discharge to assisted living facility. She stated they did not have set date for Resident #1's discharge until the morning of 01/13/23 although discharge back to assisted living facility had been the plan since her admission. She revealed to her knowledge Resident #1 had not been notified of discharge or possible discharge until the morning of 01/13/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and Director of Assisted Living Facility interviews, the facility failed to notify and provide discharge paperwork to the assisted living facility and to schedule a Home Health referral to provide wound care for 1 of 1 sampled resident (Resident #1) for safe and orderly discharge to an assisted living facility. Findings included: Resident #1 was admitted to the facility on [DATE] and discharged on 01/13/23 to an assisted living facility. Diagnoses included type 2 diabetes, stage 4 pressure ulcer of right buttock, and hypertensive heart disease without heart failure. Review of the discharge Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact. An interview conducted with Nurse #1 on 02/01/23 at 12:47 PM revealed she was familiar with Resident #1 and had been responsible for completing her discharge paperwork on 01/13/23. She stated she was informed of Resident #1's discharge on [DATE] and completed and reviewed the facility discharge/transfer summary with Resident #1 and provided her with a copy along with a hard script for medication to be given to the assisted living facility. She revealed that she did not complete a referral for home health to provide wound care at the assisted living and did not speak to anyone at the assisted living facility about Resident #1 being discharged . She stated when she tried to call later that day to give report on Resident #1, she was placed on hold and hung up before speaking with anyone. Nurse #1 stated the Social Worker or Unit Manager was responsible for scheduling resident discharges and speaking with the receiving facility and she was not aware the assisted living facility had not been told about Resident #1's discharge. An interview conducted with the Unit Manager on 02/01/23 at 01:21 PM revealed she was familiar with Resident #1 and her discharge on [DATE]. She stated she was informed around 9:00 AM on 01/13/23 during morning meeting, Resident #1 was being discharged back to the assisted living facility. She revealed nursing completed and reviewed discharge summary with Resident #1 and provided her with a copy along with a hard script for medications to be given to the assisted living facility and she was not aware of anyone making a referral for Home Health to provide wound care at the assisted living facility. The Unit Manager stated prior to Resident #1's discharge the business office had spoken with assisted living facility about payment and they had requested to speak with someone from nursing for an update on Resident #1 and she attempted to call the assisted living facility and was sent to wrong department and placed on hold and hung up without speaking to anyone. She revealed to her knowledge she believed the assisted living facility had been notified of Resident #1's discharge and paperwork had been faxed by Social Worker who was responsible for resident discharge. An interview conducted with Business Office Manager on 02/01/23 at 2:02 PM revealed she was familiar with Resident #1. She stated she had spoken with assisted living facility either on 01/04/23 or 01/11/23 about Resident #1's payee status and payment due to her Medicare days ending. She revealed the assisted living facility agreed to take Resident #1 back once she was ready for discharge and had asked for a status update. The Business Office Manager stated she informed the assisted living facility that she was not knowledgeable of Resident #1's clinical status, and she could only read off her current orders and the assisted living facility asked if someone from clinical could contact them to update them on Resident #1's status. She revealed there was no discharge date s discussed with the assisted living facility and she informed the Unit Manager and Social Worker of the phone call with the assisted living facility and their request for someone from clinical to update them on Resident #1's status. She stated she was out of the facility on 01/13/23 when Resident #1 was discharged and had not been made aware of possible discharge prior and had not informed the assisted living facility of possible discharge on [DATE]. An interview conducted with the Social Worker on 02/01/23 at 2:18 PM revealed she was familiar with Resident #1. She stated she was normally responsible for resident discharge which would include speaking with receiving facility prior to date of discharge, faxing over all paperwork, making referrals for any services or appointments needed, and confirming the facility had received the fax. She revealed Resident #1's discharge was done quickly the morning of 01/13/23 and to her knowledge, was being handled by the business office and the Administrator. The Social Worker stated she did not speak with anyone from the assisted living facility about Resident #1's discharge and did not fax over any paperwork until after Resident #1 had been discharged and assisted living facility had called stating they were not aware of the discharge and had no paperwork for Resident #1 to include referral for home health to provide wound care. She revealed she believed issues with Resident #1's discharge was due to miscommunication and believing other staff had spoken with the assisted living facility and taken care of discharge details. Telephone interview conducted with Director of the Assisted Living Facility on 02/01/23 at 2:54 PM revealed she was familiar with Resident #1. She stated she had received a telephone call from the Business Office Manager at the skilled nursing facility a week or two weeks prior to Resident #1's discharge discussing her payee status and asking if they would take her back when she was ready for discharge. She revealed she asked about a discharge date and the Business Office Manager did not have a discharge date available and she then asked for an update on her status and requested someone from clinical staff contact her with a status update. The Director of the Assisted Living Facility stated she heard nothing back from the facility and received no paperwork. She revealed on 01/13/23 she received a telephone call from Resident #1 stating she had been discharged from the skilled nursing facility and was in the parking lot and needed someone to bring her some shoes because she only had socks to wear. She stated she immediately called the skilled nursing facility and spoke with the Administrator about not being notified of Resident #1's discharge and not having any paperwork for Resident #1 to include a current FL2, medication administration record, medication orders, progress notes, information on wound care, and no referral for home health to provide wound care. The Director of the Assisted Living Facility revealed the Administrator stated the assisted living facility had spoken with their Business Office Manager a week or two ago about finances and she believed their facility had tried to contact the assisted living facility yesterday about the discharge yesterday and was unable to speak with anyone. She stated the Administrator offered to fax over all the needed paperwork and then hung up before receiving correct fax number and she had to call back and give correct fax number. She revealed her facility was able to provide medications for Resident #1 by using their back-up pharmacy until her medications could be filled and delivered from pharmacy and her nursing staff provided wound care for Resident #1 until a referral for home health could be scheduled for the following Monday. The Director of the Assisted Living stated Resident #1's discharge was unsafe and they should have been notified of her pending discharge date prior to her discharge and been able to discuss her status, medications, and treatments needed. An interview with the Administrator on 02/01/23 at 4:00 PM revealed she was familiar with Resident #1 and her discharge to the assisted living facility. She stated to her knowledge the Business Office Manager had spoken with the assisted living facility prior to Resident #1's discharge on [DATE] and discussed if they would be willing to take Resident #1 back when ready for discharge to which they agreed and payment status. She revealed they did not have a set date for Resident #1's discharge until the morning of 01/13/23 and to her knowledge she believed staff had attempted to contact the assisted living facility and was unable to speak with anyone. The administrator stated she was not aware the assisted living facility had not received discharge paperwork for Resident #1 until after she was discharged , and the assisted living facility called, and she offered to fax needed paperwork to them immediately. She revealed the Social Worker was responsible for discharges and she assumed all details for discharge had been taken care of and was not aware the assisted living facility had not been notified of discharge. The Administrator stated discharge protocol should have been followed and the assisted living facility should have been notified and discharge paperwork sent prior to discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews the facility failed to date and label a tube feeding bag for 1 of 1 resident reviewed for tube feeding management (Resident #24). Findings included: Resident #24 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis and dysphagia. A review of the significant Minimal Data Set (MDS) dated [DATE] indicated Resident #24 was unable to be interviewed and was coded for receiving 51% or greater of her caloric needs and greater than 501 mL of her fluid intake. Resident #24's care plan dated 11/14/22 indicated she was unable to tolerate nutritionally adequate food and/or fluids by mouth requiring the use of a feeding tube and at risk for nutritional decline and dehydration. Interventions included administer tube feeding and supplements as ordered. Resident #24's physician's order dated 11/10/22 indicated she received Perative (tube feeding formula) 1.3 calorie at 50 mL per hour with 30 mL water flush every hour. The tube feeding on at 10:00 AM and off at 6:00 AM. An observation of Resident #24 conducted on 12/5/22 at 3:01 PM revealed the Resident's continuous tube feeding was running at 50 mL per hour with 30 mL water flush every hour. The tube feeding formula bag did not contain a date, time, or label indicating when the bag of tube feeding was started, or the type of feeding formula. Nurse # 1 stated in an interview on 12/5/22 at 3:03 PM he had started Resident #24's tube feeding that morning at 11:00 AM. He said he forgot to place the label on the tube feeding formula bag and the label was supposed to have the date, time, and the type of tube feeding formula. An observation of Resident #24 conducted on 12/6/22 at 2:11 PM revealed the Resident's continuous tube feeding was running at 50 mL per hour with 30 mL water flush every hour. The tube feeding formula bag did not contain a date, time, or label indicating when the bag of tube feeding was started, or the type of feeding formula. Nurse # 2 was assigned to Resident #24 on 12/6/22 and was interviewed at 2:41 PM. She stated she started Resident #24's tube feeding at 10:30 AM and the tube feeding bag should have been dated and labeled when it was placed earlier in the day. Nurse # 2 said normally she did place the date, time, and the type of tube feeding formula. The Director of Nursing (DON) stated on 12/8/22 that nurses should have dated and labeled the tube feeding bag when it was hung for use per the facilities policy.

Based on observations and staff interviews the facility failed to date, label, and remove expired foods from 3 of 3 facility refrigerators (walk-in refrigerator, the 100/200-unit nourishment room refrigerator, and the 300/400-unit nourishment room refrigerator) This practice had the potential to affect all residents in the facility. The findings included: On 12/7/22 at 10:10 AM an inspection of the kitchen walk-in refrigerator with the Dietary Manager (DM) revealed a covered container of leftover meat dated 12/3/22 with use by date of 12/6/22. The expired meat was removed for disposal by the DM. An inspection of the 100-200 nourishment room refrigerator on 12/7/22 at 10:20 AM revealed an opened 1-gallon jug of chocolate milk belonging to a resident with an expiration date of 11/28/22. The refrigerator contained two 8 oz carton's of fortified nutritional supplement opened with no open date indicated. Based on state regulation, an opened fortified nutritional supplement is safe for use for 24 hours after it has been opened. The DM removed the items. An inspection of the 300-400 nourishment room on 12/7/22 at 10:27 AM revealed one opened box fried chicken belonging to a resident with the date of 11/28/22 written on it. The DM removed the box of chicken. An interview with the DM on 12/7/22 at 10:40 AM the DM stated the [NAME] checks the walk-in refrigerator daily in the morning and he overlooked the expired meat. The nourishment rooms should be checked by the dietary staff every day and they should throw out any expired or unlabeled items. The [NAME] stated on 12/07/22 at 10:54 AM that he had checked the walk-in refrigerator earlier and had overlooked the expired meat. The Administrator stated on 12/8/22 at 4:27 PM the dietary department should have checked dates daily and thrown out any out of date or unlabeled food items.