**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, residents record review, review of a facility policy titled ABUSE POLICY, review of Facility Reported Incidents (FRI), and review of the facility's investigative files, the facility failed to ensure residents in the facility were free from abuse perpetrated by employees of the facility and other facility residents. Specifically, 1) On 09/20/2024 Certified Nursing Assistant (CNA) #4, who was assigned to provide care for Resident Identifier (RI) #10, verbally and mentally abused RI #10 when other facility staff witnessed CNA #4 tell RI #10 not to shit in his/her brief or she would leave his/her big ass to sit in it. This deficiency was cited as the result of the investigation of complaint/report number AL00049007. 2) On 11/04/2024 RI #10 was verbally abused by RI #13, a resident with a history of verbally aggressive behaviors, when RI #13 asked RI #10 if he/she could play with RI #10's titties. The facility failed to ensure RI #13 had a plan of care to address the level of supervision RI #13 required for facility staff to manage RI #13's behaviors for abuse prevention. This deficiency was cited as the result of the investigation of complaint/report number AL00049525. 3) On 11/29/2024 RI #32 was physically abused by RI #33, a resident with a history of verbally aggressive behavior, when RI #33 slapped RI #32 multiple times on the right upper chest area. This was witnessed by facility staff who said this was physical abuse and it may have hurt or caused the resident to be distraught. RI #32 did not have any evidence of physical injury identified by the facility. The facility failed to ensure RI #33 had a plan of care to address the level of supervision RI #33 required for facility staff to manage RI #33's behaviors for abuse prevention. This deficiency was cited as the result of the investigation of complaint/report number AL00049664. 4) On 12/11/2024 RI #21 was verbally abused by RI #22 who told RI #21 to get the f**k out of his/her room. This was witnessed by staff and substantiated by the facility as verbal abuse. The facility failed to protect RI #21 from verbal abuse when RI #21 was placed in the room with RI #22, a resident who the Administrator said, was constantly cursing. This deficiency was cited as the result of the investigation of complaint/report number AL00049752. These deficient practices affected RI #32, #33, #10, #13 and RI #21, five of 18 residents sampled for abuse concerns. Findings include: A facility policy titled ABUSE POLICY dated December 2024, revealed the following: . IT IS THE POLICY . TO ENSURE THAT EACH RESIDENT IS FREE FROM VERBAL, SEXUAL, PHYSICAL AND MENTAL ABUSE, MISAPPROPRIATION OF RESIDENT PROPERTY AND EXPLOITATION. Resident's Rights . Residents shall not be subjected to abuse by anyone, including facility staff, other residents . Definitions . Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Verbal Abuse is the use of oral . or gestured language that includes disparaging and derogatory terms to residents . Physical abuse includes, but is not limited to, hitting, slapping, . or kicking . Mental abuse includes, but is not limited to, humiliation, . threats of punishment or deprivation . 1) RI #10 was originally admitted to the facility on [DATE] and had diagnoses to include Memory Deficit following Cerebral Infarction. RI #10's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Data (ARD) of 09/10/2024 documented a Brief Interview for Mental Status (BIMS) score of 9 of 15 which indicated RI #10 had moderately impaired cognition. On 09/20/2024 the State Agency received an Online Incident Report (FRI) from the facility alleging CNA #4 verbally abused RI #10 when CNA #5 and CNA #6 heard CNA #4 tell RI #10 if he/she had a bowel movement in his/her pants, she would leave his/her big ass there. The report also documented the perpetrator was questioned, placed on suspension, and removed from facility; the Physician and CRNP (Certified Registered Nurse Practitioner), Ombudsman and APS (Adult Protective Services)/DHR (Department of Human Services) were notified; and a full investigation was to follow within five working days. Contained within the facility's investigative file was a written statement given by CNA #5 dated 09/20/2024, which documented the following: . (1) Were you present or know of an incident where (CNA #4) spoke inappropriately to (RI #10)? If so, what was said? A. Yes, IF (He/She) boo boo (stool) on (him/herself) she was gonna leave (his/her) big ass there (meaning in soil brief) . (3) what care was being providing @ (at) the time of incident? A. check & change . On 12/18/2024 at 7:36 AM, an interview was conducted with CNA #5. CNA #5 said the incident between CNA #4 and RI #10 occurred in the shower room. CNA #5 said, she and CNA #6 were in the shower room with another resident and the wound nurse when CNA #4 brought RI #10 into the shower room to change him/her. CNA #5 said RI #10 passed gas and CNA #4 told RI #10 if he/she boo booed on him/herself, she (CNA #4) would leave him/her (RI #10) in it. When asked how she thought a reasonable person would feel to be told if they had a bowel movement they would be left in it, CNA #5 said it would make the person feel bad about not being able to take care of themselves and what she witnessed CNA #4 say to RI #10 was verbal abuse. Within the facility's investigative file was a written statement given by CNA #6 dated 09/20/2024, which documented the following: . Q) Did you witness (CNA #4) providing care to (RI #10) today? A) yes, I did Q) If yes, give details as to what you heard? A) Resident was passing gas. I heard her (CNA #4) tell (RI #10) if you shit that (he/she) would have to sit in it and that she (CNA #4) was not going to change (him/her). On 12/18/2024 at 1:01 PM, an interview was conducted with CNA #6. CNA #6 said CNA #4 told RI #10 if he/she shit on him/herself he/she would have to sit in it and she (CNA #4) was not going to change him/her. CNA #6 said a reasonable person would not feel good about having to sit in their bowel movement. CNA #6 said this comment would be considered verbal and mental abuse. On 12/18/2024 at 10:39 AM, the surveyor conducted a telephone interview with CNA #4. CNA #4 said RI #10 passed gas and she told RI #10 not to shit in the diaper and not to shit in the chair. CNA #4 said RI #10 never had a bowel movement. CNA #4 said she should have said not to boo boo in the diaper. When asked what type abuse she would consider her comment to be, CNA #4 said verbal. CNA #4 said she made the comment in a joking manner. When asked did she think it was appropriate to joke with RI #10 that way, CNA #4 said no. Review of the facility's five day summary, dated 09/27/2024, and signed by the Administrator (ADM) revealed the following: . Conclusion: Our conclusion in this investigation is that we will substantiate the allegation of verbal abuse. Although C.N.A. (CNA #4) admits that she did make the comment to (RI #10), she states she was joking with (RI #10) . There were . witnesses who heard (CNA #4) make the inappropriate comment . (CNA #4) will be terminated from our employment . On 12/19/2024 at 12:18 PM during an interview with the facility ADM, the ADM said, the facility substantiated the incident of verbal abuse that occurred on 09/20/2024 when CNA #4 told RI #10 not to shit in his/her brief and if he/she did he/she would have to sit in it. The ADM said, it would be demoralizing to be told that. The ADM said, CNA #4 was suspended, sent home, and later terminated. 2) RI #13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Dementia, Severe with Psychotic Disturbances. RI #13's annual MDS assessment with an ARD of 07/30/2024 documented a BIMS score of 12 of 15 which indicated RI #13 had moderately impaired cognition. On 11/04/2024 the State Agency received an Online Incident Report from the facility alleging RI #13 verbally abused RI #10 when RI #13 said to RI #10 Let me play with your titties. The report also alleged RI #10 was assessed, RI #13 did not approach or touch RI #10, RI #13 was monitored 1:1, and would be visited by the Psychologist for verbally inappropriate comments/suggestions. Contained within the facility's investigative file was a typed statement given by CNA #7 dated 11/04/2024, which revealed the following: . I (CNA #7) was sitting in the Dayroom on TCU (Transitional Care Unit). Resident (RI #13) walked in and looked at resident (RI #10) and made the comment, Can I play with your titties. I explained to (RI #13) that (he/she) could not make those comments. (He/She) denied that (he/she) said it. (He/She) said that (he/she) was speaking to (him/her). I notified the Nurse (Licensed Practical Nurse (LPN) #8), and she removed (RI #10) to another table, out of (RI #13's) presence . On 12/17/2024 at 11:46 AM, an interview was conducted with CNA #7 who was sitting in the dayroom when RI #13 walked down the hall and came into the dayroom. CNA #7 said RI #10 was already sitting in the dayroom, and RI #13 walked up to RI #10 and asked RI #10 if he/she could play with his/her titties. CNA #7 said she told RI #13 he/she could not say those types of words. CNA #7 said RI #13 denied saying what he/she did and said he/she was just speaking to RI #10. When asked did RI #13 touch RI #10 in an inappropriate sexual manner, CNA #7 said no. CNA #7 said she informed LPN #8 of what RI #13 said to RI #10. On 12/17/2024 at 2:08 PM, the surveyor conducted an interview with LPN #8. LPN #8 said she too heard RI #13 ask RI #10 if he/she could touch his/her titties. LPN #8 said when she heard the comment RI #10 was moved to a different area in the dayroom and RI #13 went to his/her room and was placed on one-on-one then behavioral tracking was started. LPN #8 said she informed the supervisor and the Social Worker (SW) of the inappropriate comment RI #13 made to RI #10. When asked what type of comment would she consider the comment RI #13 made to RI #10 to be, LPN #8 said it was an inappropriate sexual comment. Review of the facility's five day summary, dated 11/11/2024, and signed by the ADM revealed the following: . Conclusion: Our conclusion in this investigation is that we will substantiate the allegation of verbal abuse. Although (RI #13) denies having made the statement, a staff member heard (him/her) make the sexually inappropriate comment to (RI #10) . (RI #13) was placed on behavior tracking for making socially/sexually inappropriate behaviors. (RI #10) could not recall the statement being made and laughed when asked about the allegation . Care plans will be reviewed and revised as necessary . On 12/18/2024 at 4:19 PM the SW was asked about RI #13 and the incident that occurred on 11/04/2024. The SW said, RI #13 had impaired cognition, had Dementia, was forgetful, and had a history of verbally aggressive behavior. The SW said, what RI #13 said to RI #10 was verbal abuse, it was inappropriate and someone in that situation would not like being asked the question about their titties being touched. On 12/19/2024 at 6:22 PM a follow-up interview was conducted with the SW. When asked how residents with newly identified behaviors were assessed for their level of supervision, the SW said she did not know. The SW said she did not see anything on RI #13's behavior care plan that addressed the level of supervision RI #13 required, before and after, RI #13 made the sexual inappropriate comment to RI #10 on 11/04/2024. The SW said the level of supervision should be on the resident's care plan and she could not say why it was not. 3) RI #32 was admitted to the facility on [DATE] and had diagnoses to include Dementia. RI #32's admission MDS assessment with an ARD of 09/16/2024 documented a BIMS score of 6 of 15 which indicated RI #32 had severely cognitive impairment. RI #33 was readmitted to the facility on [DATE] and had diagnoses to include Paranoid Schizophrenia, Major Depressive Disorder and Bipolar Disorder. RI #33's quarterly MDS assessment with an ARD of 09/23/2024 documented a BIMS score of 13 of 15 indicated RI #33 had intact cognition. On 11/29/2024 the State Agency received an Online Incident Report from the facility alleging RI #33 physically abused RI #32 when RI #32 was sitting in a recliner in the dayroom and RI #32 reached over and gently patted RI #33 on the leg and in response RI #33 slapped RI #32 with his/her open hand. The report alleged RI #32 was assessed and found to be without injury, did not recall details of events due to cognitive deficits, RI #33 was placed on 1:1 monitoring until receiving orders to send for an evaluation/treatment when the physician, Nurse Practitioner, Resident representatives, Ombudsman and Adult Protective Services (APS) were notified of the resident-on-resident contact. Review of the facility's five-day summary, dated 12/05/2024, and signed by the ADM revealed the following: . Conclusion: Our conclusion in this investigation is that since there were witnesses to the slap, we will substantiate the allegation of physical abuse. Although (RI #33) states (RI #32) hit (him/her) first, there were no witnesses. (RI #33) was placed on 1:1 monitoring until he/she was discharged to the ER/Geri Psych (Emergency Room/Geriatric Psychiatric Care) for evaluation and treatment as necessary. (RI #33) had already been care-planned for verbal aggression. RI #33 had a care plan initiated on 10/30/2024 for behavior symptoms of cursing and verbal aggression toward staff with a 10/30/2024 approach documented as follows: Remove me from noisy or congested areas. The care plan did not include the level of supervision RI #33 needed. The facility investigative file contained a witness statement dated 12/03/2024 signed by LPN #13 that documented: . yes I saw (RI #33) hit (RI #32) multiple times open handed to the right arm/shoulder . (LPN #13) made sure residents were separated, assessed (RI #32) for injuries, notified (the ADM) . I have heard (RI #33) be verbally abusive to other residents . LPN #13's witness statement also documented LPN #13 was only about five feet away from the residents when she witnessed the abuse. On 12/17/2024 at 12:10 PM an interview was conducted with LPN #13. She said at the time of the incident between RI #33 and RI #32 she was sitting at the nurses' station, RI #32 was in a recliner across from nurses' station and RI #33 came down the hall and sat on his/her rollator next to RI #32. LPN #13 said, she was documenting and looked up from the desk and saw RI #33 hit RI #32 with an open hand to RI #32's right upper chest about three to five times. LPN #13 said, someone in that situation would feel confused and hurt. LPN #13 stated she considered the incident to be physical abuse. Contained within the facility's investigative file was a statement given by CNA #14, dated 12/03/2024, which revealed the following: . I was standing in the dayroom and (RI #33) hit (RI #32) three times in the upper chest area on the right side . CNA #14's witness statement also documented CNA #14 was only about three to five feet away from the residents when she witnessed the abuse. On 12/17/2024 at 12:27 PM an interview was conducted with CNA #14 who said, she was in the dayroom and saw RI #32 sitting down and RI #33 hit RI #32 three times in the right upper chest area. CNA #14 said, she did not witness RI #32 hit RI #33. CNA #14 said, what she witnessed was physical abuse and someone in that situation would not feel good about it. Contained within the facility's investigative file was a statement given by CNA #15 dated 12/04/2024, which revealed the following: . (RI #33) and (RI #32) were both sitting in the dayroom, (RI #32) lightly touched (RI #33), that's when (RI #33) slapped (RI #32's) chest about three times real hard and loud. it was open handed. On 12/17/2024 at 2:42 PM an interview was conducted with CNA #15. CNA #15 said, RI #32 and RI #33 were sitting side by side in the dayroom when RI #33 hit RI #32 three to five times with his/her open hand. CNA #15 said the slapping sound was loud. CNA #15 said, what she witnessed was physical abuse. On 12/17/2024 at 3:04 PM RI #33's responsible party was asked about the incident involving RI #33 and RI #32. RI #33's responsible party said RI #33 did not like people in his/her personal space. An interview was conducted on 12/18/2024 at 5:35 PM with the SW. The SW stated she was responsible for initiating behavior tracking on residents and she was responsible for all behavior care plans. The SW said RI #33 had exhibited abusive behaviors prior to the incident and RI #33 was care planned for behaviors. The SW said behavior care plans for RI #33 were initiated on 10/30/2024. The SW said, if she had been slapped in the chest she would be upset, angry or confused and what happened to RI #32 was physical abuse. On 12/19/2024 at 5:30 PM a follow-up interview was conducted with the SW and she was asked about RI #33 not wanting people in his/her personal space. The SW responded, RI #33 stayed to himself/herself and only interacted with a few residents. When asked why RI #33's care plan did not specify RI #33 not wanting people in his/her personal space, the SW stated, she did not realize it. The SW was asked about the reason RI #33 was not removed from the congested area on 11/29/2024, as specified in RI #33's plan of care. The SW said she could not answer that question. The SW said, RI #33 could have been monitored more closely to prevent the abuse from occurring. The SW said, the level of supervision required should be listed on the plan of care and the multidisciplinary team would discuss what level of supervision was needed. An interview was conducted on 12/19/2024 at 3:30 PM with the Administrator (ADM). The ADM said following the incident RI #32 was assessed and found to be without injuries and did not recall the events and RI #33 was placed on 1:1 monitoring until an order was received from the Nurse Practitioner to send RI #33 to the hospital for evaluation and possible geriatric psychiatric treatment. The ADM was asked for what type of behaviors RI #33 was being monitored. The ADM said, verbal aggression toward staff and another resident. The ADM said the situation with RI #33 and RI #32 was substantiated as physical abuse and someone in that situation might feel hurt and possibly distraught. 4) RI #21 was admitted to the facility on [DATE] and had a diagnosis to include Adjustment Disorder with Depressed Mood. RI #21's admission MDS assessment with an ARD of 09/24/2024 documented RI #21's BIMS was 12 of 15 which indicated that RI #21 had moderately impaired cognition. RI #22 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis to include Adjustment Disorder with Mixed Anxiety and Depressed Mood. RI #22's admission MDS assessment with an ARD of 08/26/2024 documented that RI #22 had a BIMS of 15 of 15 which indicated that RI #22 was cognitively intact. On 12/11/2024 the State Agency received an Online Incident Report from the facility revealing the following: . Incident Type . Abuse - Verbal . Incident Detail . Name(s) of resident(s) involved: (RI #21 and RI #22) . Name of alleged perpetrator(s): (RI #22) . Narrative summary of incident: (RI #21) reported that (his/her) roommate, (RI #22) cursed (him/her) out today . Action(s) taken by the facility in response to the incident. (RI #21) was assessed and found to be without injury. (RI #21) wanted a room change and that is being done now . Contained within the facility's investigative file was a statement given by RI #21 to Social Service Designee (SSD) #10, dated 12/11/2024, which revealed the following: . Summoned to (room number) by resident. (RI #21) said (he/she) no longer wants to be in (his/her) current room because (his/her) roommate cursed (him/her) out. (RI #21) said (RI #22) asked (him/her) to leave the room but (he/she) did not want to leave . Resident said (RI #22) told (him/her) to get then F*** out of this room and if you don't I'll have you put out. Resident reports (CNA #9) and (CNA #11) being present during altercation . On 12/18/2024 at 2:38 PM, the surveyor conducted an interview with RI #21 who said he/she had to move to a different room because his/her roommate cursed him/her out. RI #21 said his/her roommate called him/her M*F* and things like that. RI #21 said staff were in the room and heard this. Contained within the facility's investigative file was a written statement by SSD #12, dated 12/11/2024, which documented the following: . (CNA #9) said that (RI #22) told (RI #21) to get the F*** out. During the survey unsuccessful telephone attempts were made to contact CNA #9. On 12/19/2024 at 9:15 AM, the surveyor conducted an interview with SSD #10 and SW #12. SW #10 said RI #21 said RI #22 cursed him/her and told him/her to get the f*** out of this room. When asked what type of abuse this would be considered, both SW #10 and SW #12 said verbal. Review of the facility's five-day summary, dated 11/17/2024, and signed by the ADM revealed the following: . Conclusion: Our conclusion in this investigation is that we will substantiate the allegation of verbal abuse. After following up with (RI #21), (he/she) feels that the language used by (RI #22) was abusive to (him/her) . The five-day summary also documented that RI #21 was only in the room with RI #22 for about three hours before RI #21 was verbally abused. On 12/19/2024 at 12:18 PM during an interview with the ADM, the ADM said, the incident was investigated, RI #21 was removed from the room, RI #21 was assessed, and assigned a new room. The ADM said, since there was a witness, the abuse was substantiated. The ADM said, RI #22 was constantly cursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of a facility policy titled, ABUSE POLICY, review of the facility's investigative file and review of a Facility Reported Incident (FRI) received by the State Agency, the facility failed to ensure an allegation of verbal abuse involving Certified Nursing Assistant (CNA) #4 and Resident Identifier (RI) #10 was reported to the Administrator (ADM) immediately and within two hours of the incident after the incident occurred on 09/20/2024. This deficient practiced affected one of 11 FRIs reviewed, and one of 18 residents sampled for abuse. This deficiency was cited as a result of the investigation of complaint/report number AL00049007. Findings include: Review of a facility policy titled, ABUSE POLICY, dated 12/2024, revealed the following: . Procedure for Documentation and Investigation of Resident Abuse . 4. Notify . Administrator . immediately . RI #10 was admitted to the facility on [DATE]. The Alabama Department of Public Health Online Incident Reporting System form, submitted on 09/20/2024 documented: . Incident Type . Abuse - Verbal . Incident Detail: Name(s) of resident(s) involved: (RI #10) . Name of alleged perpetrators): (CNA #4) . time of when administrator was notified of the incident: Time: 02:30 PM . Date and time of alleged incident: 09/20/2024 Time: 10:45 AM . Narrative summary of incident: Narrative summary of incident: (CNA #4) took Resident (RI #10) to shower to change (him/her). (CNA #5) & (and) (CNA #6) were in the shower room with another resident. (CNA #5) reports that (CNA #4) told resident (RI #10) that if (he/she) boo [NAME] in (his/her) pants, she would leave (his/her) big ass there . Contained within the facility's investigative file was an EMPLOYEE CORRECTIVE ACTION REPORT dated 09/30/2024, signed by CNA #5, which revealed the following: . (CNA #5) is given this verbal Reprimand in regards to failure to report suspected abuse timely . On 12/18/2024 at 7:36 AM an interview was conducted with CNA #5 who said after the incident occurred she went to lunch and informed the supervisor of the incident after she returned from lunch. When asked when she should have reported the incident, CNA #5 said immediately. Another EMPLOYEE CORRECTIVE ACTION REPORT in the facility's investigative file, dated 09/30/2024, and signed by CNA #6 revealed the following: . (CNA #6) is given this verbal reprimand in regards to failure to report suspected abuse timely . On 12/18/2024 at 1:01 PM an interview was conducted with CNA #6 who said she did not report the incident to anyone. CNA #6 said she should have reported the incident to the ADM immediately after she heard what was said. On 12/19/2024 at 12:18 PM, an interview was conducted with the ADM. The ADM said the CNAs should have immediately reported the incident to their supervisor and the supervisor would have immediately informed her of the incident. ************************************************ After retrospective Quality Assurance review it was determined that the facility took immediate action to correct the noncompliance by: CNA #5 and CNA #6 were reprimanded for failure to report suspected abuse on 09/30/2024. The facility Administrator was educated by the Regional Consultant on the reporting requirement in accordance with the regulatory requirement and facility policies and procedures on 10/09/2024. An audit of all allegations of abuse/neglect/misappropriation that have occurred since 09/20/2024 was completed on 10/11/2024 to ensure that all allegations of abuse/neglect/misappropriation have been reported timely as applicable. Training for all facility staff to include contracted staff on F 609, the facility Abuse Policy and Procedure, with special emphasis on timely reporting beginning on was completed on 10/15/2024. A new system will be implemented by the facility on 10/11/2024 to ensure accessibility and timeliness of reporting of all allegations of abuse/neglect/misappropriation within the proper timeframe to the State Agency. The Administrator will have a designated electronic device that has Wi-Fi/cellular connection and access to the State Agency portal with appropriate passwords to report any allegations timely. The DON will serve as the designee in the absence of the Administrator/Abuse Coordinator. If after hours, once the allegation is submitted, the confirmation will be emailed to the reporter to print when a printer is accessible for facility records. The Regional Consultant monitored to ensure reporting requirements were followed by reviewing all allegations of abuse/neglect/misappropriation weekly x 4 weeks then monthly x 5 months to ensure timely reporting by the facility. This will be documented on a monitoring tool by the Regional Consultant and provided to the facility Administrator, responsible for implementing the acceptable plan of correction and will be placed in the plan of correction binder located in Administrator's office. Monitoring to began on 10/15/2024. **************************************************************** After review and verification of the information provided in the facility's corrective action plan, inservice/education records, monitoring tools and the facility's investigation, as well as staff interviews, the survey team determined the facility implemented corrective actions from 09/20/2024 through 10/18/2024 with ongoing monitoring implemented; thus, past noncompliance was cited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record reviews, interviews, review of facility investigative files, and a facility policy titled Abuse Prevention Policy, the facility failed to report allegations of abuse within two hours to the State Agency. 1) On 07/30/2024 at 6:00 PM Certified Nursing Assistant (CNA) #17 heard a slap in Resident Identifier (RI) #1 and RI #3's room and the alleged physical abuse was not reported to the State Agency until 07/30/2024 at 8:30 PM, two and a half hours later. 2) On 08/20/2024 at 9:45 PM RI #1 was found to have injuries as a result of a tussle with roommate (RI #2). The incident of alleged physical abuse was reported to the State Agency the next morning on 08/21/2024 at 10:42 AM, over 12 hours later. 3) On 09/13/2024 at 3:00 PM RI #20 alleged physical abuse of being hit in the back by RI #1. The allegation of abuse was not reported to the State Agency until 09/18/2024, five days later. This deficient practice was cited a result of the investigation of complaint/report numbers AL00048506 and AL00048629, and an allegation of abuse received during the survey and had the potential to affect RI #1, RI #2, RI #3, and RI #20, four of 12 residents reviewed for abuse concerns. Findings include: A facility policy titled Abuse Prevention Policy with an effective date of October 2022 documented: Procedure for Documentation and Investigation of Resident Abuse . 8. The facility will ensure that all alleged violations involving abuse, neglect . are reported immediately, but not later than 2 hours after the allegation is made . 1) RI #1 was readmitted to the facility on [DATE]. RI #3 was admitted to the facility on [DATE]. On 07/30/2024 at 8:30 PM the State Agency received an Online Incident Report (FRI) from the facility alleging physical abuse after CNA #17 heard a slapping sound and RI #1 had a pink area on his/her face and RI #3 was near RI #1. The alleged time of the incident was 6:00 PM. The facility's investigative file was reviewed and contained a document dated 08/06/2024, signed by the Administrator, summarizing the incident as follows: . On 07/30/2024, at approximately 06:00 PM, residents/roommates, (RI #3 and RI #1) were in their room . She (CNA #17) heard a slap and turned around. (RI #1) was holding (his/her) cheek standing near (RI #3). (RI #3) said, I did what I had to do. The investigative file indicated the residents were seperated and RI #3 was placed on one-on-one monitoring. On 09/20/2024 at 11:47 AM the Administrator (ADM) was asked about the alleged physical abuse reported on 07/30/2024. The ADM said she became aware of the incident on 07/30/2024 at 6:19 PM. The ADM said, it was reported because there could have been a slap even though no one actually witnessed the slap. On a follow up interview on 09/20/2024 at 5:15 PM, the ADM said, the timeframe to report alleged physical abuse allegations was within two hours and the allegation on 07/30/2024 was reported late. 2) RI #1 was readmitted to the facility on [DATE]. RI #2 was readmitted to the facility on [DATE]. On 08/21/2024 at 10:42 AM the State Agency received an Online Incident Report (FRI) from the facility alleging physical abuse after staff became aware of the incident the night before, on 08/20/2024 at 9:45 PM and the ADM became aware of the incident on 08/20/2024 at 9:50 PM. The Narrative Summary of the incident reported to the State Agency alleged RI #2 and RI #1 began a tussle over a reach extender tool (reacher) resulting in RI #1 had a hematoma inside his/her ear, two small bruises on his/her left forearm, a small scratch on his/her scalp, both residents had broken fingernails, and both were separated immediately for the rest of the night. The facility's investigative file was reviewed and contained a document dated 08/26/2024 summarizing the incident as follows: . On 08/20/2024, at approximately 09:45 PM, residents (RI #1 and RI #2) were possibly involved in an altercation. The staff reported that (RI #1) had some scratches and a minor hematoma to (his/her) ear. They reported that while no one witnessed the event, (RI #2) said that (RI #1) was on (RI #2's) side of the room messing with (RI #2's) items and when (RI #1) took (RI #2's) reacher, the two residents started tussling with the reacher and that's how the scratches and bruise occurred. The incident was reported by the nurse to the Administrator but was not determined to be physical abuse as (RI #2) had denied hitting (RI #1) and there only minor injury that would be expected with a tussle of a reacher. the residents were separated for the night. Review of RI #1's departmental notes documented the following injuries found after the event: . 8/20/2024 11:38 PM . Resident obtained injuries from tussling over (his/her) roommate's reacher according to (his/her) roommate. Roommate denies hitting resident. Resident has three bruises to inside of right forearm with an open area to one of them. Cleaned with normal saline pat dry and applied dressing. Blood filled blister to top inner of left ear. A scratch to left side of face and left side of neck. Laceration to top of left side of head. Review of RI #2's departmental notes documented the following account of the event: . 8/20/2024 11:28 PM . Resident states that (his/her) roommate went over to (his/her) bed and grabbed (his/her) reacher and they started tussling over the reacher. Resident stated it happen so fast that (he/she) don't know what happen. Resident states (he/she) broke a couple of finger nails. On 09/20/2024 at 11:47 the ADM was asked about the alleged abuse on 08/20/2024. The ADM said, she was notified of the incident with RI #1 and RI #2 on 08/20/2024 at 9:50 PM. The ADM said, she was notified of a possible resident to resident physical abuse allegation where RI #1 and RI #2, who were roommates, were involved in a tussle over a reacher. ADM said, she was notified of the incident the night of 08/20/2024 of a possible scratch from the tussle. On 09/20/2024 at 5:15 PM in a follow up interview with the ADM she was asked to clarify when she was notified of the incident. The ADM said, on 08/20/2024 at 9:50 PM it was reported to her of a resident-to-resident physical abuse in which there was a tussle between RI #1 and RI #2 over a reacher. The ADM said, she was notified of an injury including a scratch. The ADM said, the incident was reported to the State Agency the next morning on 08/21/2024 at 10:42 AM. The ADM said, the time frame for reporting physical abuse was within two hours. 3) RI #1 was readmitted to the facility on [DATE]. RI #20 was admitted to the facility on [DATE]. On 09/18/2024 at 12:15 PM during observations of the lunch meal, RI #20 approached Activity Coordinator (AC) and said, I want to know if an incident report was done about the (man/woman) who hit me in the back. On 09/18/2024 at 12:23 PM RI #20 was asked about the incident and said he/she did not remember who or when it was, but it happened last week and he/she reported it. On 09/18/2024 at 12:34 PM the surveyor informed the Administrator of the allegation. On 09/18/2024 at 4:43 PM the State Agency received an Online Incident Report (FRI) from the facility alleging physical abuse occurred, five days before, on 09/13/2024 at 3:00 PM, and the Administrator was made aware of the incident on 09/13/2024 at 3:15 PM after RI #1 entered RI #20's room, RI #20 told RI #1 to leave and guided RI #1 to the door and when RI #1 walked past RI #20 in the doorway, RI #1 hit RI #20 in the back. The facility's investigative file was reviewed and contained a handwritten statement dated 09/13/2024, signed by the AC, that documented: . Friday September 13, 2024 3:30 - (RI #1) . was in (RI #20's) Room, and (RI #20) yell for someone to come and get (RI #1). I . (AC) went to get (RI #1) and (RI #20) stated (RI #1) had hit (him/her) in the Back . On 09/23/2024 at 2:07 PM a telephone interview was conducted with the ADM to further question the incident of 09/13/2024. The ADM said, she became aware of the incident between RI #1 and RI #20 on 09/13/2024 at 3:15 PM but did not report it at that time because there was conflicting information as to whether the resident was hit or pushed by the other resident. The ADM was asked when it was reported to the State Agency. The ADM replied, on 09/18/2024 after resident (RI #20) had said something again about it to the nurses and to the surveyor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, medical record review, review of facility policies titled Discharge and Transfer Policy and DOCUMENTATION GUIDELINES, and review of a facility handbook titled A Matter of RIGHTS, the facility failed to ensure: (1) RI #1 was allowed to remain in the facility when a letter of NOTICE OF APPEAL was presented to facility staff on 07/10/2023. (2) Resident Identifier (RI) #1's medical records provided evidence RI #1 had been discharged from the facility on 07/07/2023, (3) RI #1 received written notice of his/her emergent discharge notice in a timely manner to ensure an orderly discharge; and This deficient practice affected RI #1, one of two residents sampled for transfers and discharges. Finding Include: Review of a facility policy titled Discharge and Transfer Policy, dated 01/2020, revealed the following: 1. G. The facility may not transfer or discharge a resident while a appeal is pending, when a resident exercises his/her right to appeal a transfer or discharge notice from the facility, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individual's in the facility . 2. When the facility initiates a resident transfer/discharge a 30 day notice will be executed. The Administrator . will be responsible to notify the resident, resident representative or legal representative, in writing, in a language and manner that they understand . 3. C. Documentation upon discharge must include contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, Advance Directive information, all special instructions or precautions for ongoing care, discharge comprehensive care plan goals, if applicable, resident's discharge summary and any other documentation to ensure a safe and effective transition of care. Review of another facility policy titled DOCUMENTATION GUIDELINES, with a reviewed/revised date of 07/2020, revealed the following: PURPOSE Provide an account of the resident's care, treatment, response to care, signs, symptoms as well as progress of the resident's acre to all disciplines . GUIDELINES: . 2. NURSING Many events occur in a resident's stay that require specific documentation in the nurses notes. Suggestions for content in documenting these events are as follows: . b. Episodic/Acute Charting Date and time/shift, document the resident status as it relates to the acute condition or document the applicable sections of the skilled nursing assessment, include document notification of the MD (Medical Doctor)/resident representative that pertains to the acute event . e. Transfer to Hospital: Date, time, events leading to transfer, reason for transfer, transfer assessment . f. Discharge Home, NNH (New Nursing Home), or Assisted Living Facility: Date and time of discharge, physician orders and instructions for discharge, medications instructions, follow-up appointments and care. Discharge assessment, nursing discharge instructions for follow-up care, follow-up appointments, medication, accompanied by, mode of transportation. Resident and/or responsible party signs off on discharge instructions, medication instructions and receives the original . Review of an undated facility's booklet titled A Matter of RIGHTS, pages 22-24, revealed the following: . Our policies and procedures on admissions, transfer, and discharge are: 1 We will not transfer or discharge a resident without first providing written notice in a language and manner you understand. We will notify the resident and, if known, a family member or legal representative of the resident, of the transfer or discharge and the reasons. Our notice will be given at least thirty days before transfer or discharge. 2 We reserved the right to transfer or discharge a resident on shorter notice when: . an immediate transfer or discharge is required by the resident's urgent medical needs . 4 We will provide preparation and orientation to residents prior to transfer and discharge in order to ensure a safe and orderly transition from our facility . RI #1 was admitted to the facility on [DATE] with diagnoses to include Schizoaffective Disorder, Bipolar Type, Bipolar Disorder, Unspecified and Unspecified Depression. A review of RI #1's Physician's Orders dated 07/07/2023, documented the following: Send to ER (emergency room) MCB (abbreviations of local hospital) C/O (complaint of) evaluation R/T (related to) combativeness and aggression . RI #1's Discharge Minimum Data Set assessment, dated 07/07/2023, revealed this was an unplanned discharge to an acute hospital and RI #1's .return anticipated . to the facility. A review of an immediate discharge notice, dated 07/07/2023, which was sent to RI #1's representative revealed the following: . Re (Regarding): (RI #1's name) Dear (RI #1's son's name) . You have the right to appeal to Alabama Medicaid . This letter was signed by Employee Identifier (EI) #1, the facility's Administrator. A review of RI #1's Departmental Notes (nursing notes) did not provide evidence of documentation of events leading up to why RI #7 was transferred to a local hospital on [DATE]; nor did RI #1's nurses note document RI #1 was being discharged from the facility and where RI #1 was being discharged to. Also, further review of RI #1's Physician's Order for July 2023 did not identified RI #1 had a Physician's Order to be discharged from the facility. A fax cover sheet dated 07/10/2023, along with a copy of the immediate discharge notice from the facility was reviewed. This sheet was addressed to a psychiatric staff member at the psychiatric health care facility (name) where RI #1 went, with the following documented: . ATTENTION: (name of staff member) & (and) (RI #1) COMMENTS: (name of staff member) could you please hand deliver to (RI #1) if possible. If not I understand and will hand deliver to (RI #1) at the court hearing . This fax was sent to the psychiatric health care center by EI #1. Review of a faxed letter from the psychiatric health facility, dated 07/10/2023, documented the following: . To Whom It May Concern: Upon discharge from (name of psychiatric facility) the following patient (name of RI #1) is not a danger to herself/himself or others . Review of an appeal letter from RI #1's attorney dated 07/10/2023, revealed the following: . RE: NOTICE OF APPEAL (Name of RI #1) Crowne Healthcare LTC (Long Term Care) resident Dear Sir or Madame: I represent (name of RI #1) who is being wrongly discharged from Crowne Healthcare of Eufaula. (Name of RI #1) had not been given proper notice of Crowne's intent to discharged as required . (Name of RI #1) is exercising (his/her) right to appeal the decision to refuse to allow (him/her) to return to Crowne Healthcare of Eufaula . On 07/13/2022, the Survey State Agency received a complaint that RI #1 had been unsafely discharged from the nursing home. Review of a facility form titled Discharge Instructions/Post Discharge Plan of Care, revealed a discharge plan was not completed for RI #1 until 07/14/2023, seven days after RI #1 was transferred from the nursing home. This form was completed by EI #3, the facility's Director of Social Services. On 07/26/2023 at 8:30 AM, an interview was conducted with RI #1. The resident (RI #1) said, he/she was given a discharge notice on the day of court (07/10/2023) from EI #1 (Administrator). RI #1 said no one from the nursing home discussed with him/her about where he/she would be going since he/she would not be going back to the nursing home. RI #1 said she ended up staying with family members until she could go back to where she lived. On 07/26/2023 at 10:15 AM, a telephone interview was conducted with RI #1's court appointed lawyer. RI #1's lawyer said he became aware RI #1 had been discharged from the nursing home when he spoke to EI #3 (on 07/10/2023) and was told RI #1 would not be coming back to the nursing home. RI #1's lawyer said at RI #1's court hearing, EI #1 said RI #1 was a threat to him/herself and others and would not be allowed to come back to the nursing home. RI #1's lawyer said he explained EI #1 that he had no problem with that, but they needed to take RI #1 back and discharge him/her properly. RI #1's lawyer said he felt it was an unsafe discharge from the nursing home because RI #1 was not given adequate notice about the discharge. RI #1's lawyer said the letter of discharge for RI #1 was dated 07/07/2023 but was not faxed to the facility where RI #1 was admitted until 07/10/2023. RI #1's lawyer said RI #1 had already been picked up for his/her court hearing when the letter arrived at the other facility. RI #1's lawyer said he presented a letter of appeal to EI #1 at RI #1's hearing. RI #1's lawyer said EI #1 kept saying RI #1 could not come back to the facility because of his/her behaviors. On 07/26/2023 at 3:16 PM, an interview was conducted with EI #3, the facility's Director of Social Services. EI #3 said, a discharge letter was given to RI #1 in person at court on 07/10/2023. EI #3 said discharge was initiated by facility. EI #3 said she did not know the time frame to which the resident's discharge notice was given to them. EI #3 said when a resident is discharged from the facility you discuss with the resident or family which home health they want, if needed, any medical equipment needed, transportation to receiving facility, or how they will be transported home. EI #3 said when RI #1 did not come back to the facility after his/her hearing, she and EI #1 was going through RI #1's chart and discussing RI #1 and saw where a discharge summary had not been done so she (EI #3) completed one on 07/14/2023. EI #3 said RI #1 should have been given a 30-day discharge notice if the facility was planning to discharge RI #1. Also, EI #3 said it would be important to give the resident a 30-day discharge notice so that the facility could prepare and have resources in place. On 07/27/2023 at 8:12 AM, an interview was conducted with EI #4, the RN (Registered Nurse) unit manager of the unit where RI #1 resided when he/she was transferred out of the facility on 07/07/2023. EI #4 said, when or if a resident is discharged from the facility to home or another facility, excluding the hospital, a physician's order should be written for the discharge. EI #4 said some information that would be contained in the physician's order would be if the resident was going home; it would be written the day they were going home, how they were going to be transported, like to the care of family, a listing of medications and instructions, if resident require home health/equipment and any therapy orders would be included in the order as well. EI #4 said if the resident was going to another facility, or another nursing home, the order would be written the same way minus services for home health and equipment. EI #4 said looking at RI #1's physician's orders there was no order written for RI #1 to be discharged from the facility to home or another facility, just to the hospital where RI #1 was sent out for an evaluation. EI #4 said discharge summaries are written the day the resident is being discharged from the facility and on 07/07/2023, she did not remember if one had been completed, but she knew she had not completed one. EI #4 said she did not see a discharge nurse's note for that day the resident was sent out of the facility. EI #4 said if an emergent transfer was done, there may not have been a skilled note but there should had been something in the progress notes about RI #1 being sent to the ER and the reason for sending the resident out. EI #4 said RI #1 did not return to the facility after he/she was sent out on 07/07/2023. When asked what she would consider a safe and orderly discharge, EI #4 said a clear and concise order from the doctor; and the facility would know where the resident was going and how they were being transported. On 07/27/2023 at 10:20 AM, an interview with EI #5, the facility's Nurse Practitioner. EI #5 said she did give an order to send RI #1 out for behaviors and his/her aggressiveness on 07/07/2023. EI #5 said the reason for sending RI #1 out was for an evaluation and hopefully psychiatric placement. EI #5 said she did not write an order for RI #1 to be discharged from the facility. EI #5 said included in a physician's discharge order for a resident to be discharged from the facility would be, where the resident was going, who they were to being discharged to, what services were needed, and what medications they would be receiving. On 07/27/2023 at 3:11 PM, a telephone interview was conducted with the Ombudsman. The Ombudsman said she had not reviewed any information about RI #1 being discharged from the facility. The Ombudsman said the only thing she received from the facility was about RI #1's behaviors and what to do about them. When asked was she aware RI #1 had been given an emergent discharge notice from the facility on 07/07/2023, the Ombudsman said no. When asked should a 30-day discharge notice had been given if RI #1 was being discharged permanently from the facility due to his/her behaviors, the Ombudsman said she thought one should have been given. The Ombudsman said the 30-day discharge gives the resident time to prepare for the discharge, time to get community services if needed, home health if needed, set up for physician appointments and basically gives instructions for care to whoever or wherever the resident was being discharged to. On 07/27/2023 at 6:06 PM, an interview was conducted with EI #2, the DON (Director of Nursing). EI #2 said you have to have a physician's order for discharge permanently from the facility. EI #2 said the order would identify where the person was being discharged , who they are being discharge with, what the discharge transportation would be required, any orders for home health or therapy treatments if ordered and the day the resident was being discharged . EI #2 said she was not sure if RI #1 had a physician's order for discharge like she has identified. On 07/28/2023 at 9:15 AM, a telephone interview was conducted with the judge presiding over RI #'1 committal hearing on 07/10/2023. The judge said from what she recalled; RI #1 was under emergent care to (name of psychiatric facility). The judge said the courts found out RI #1 was not going back to the nursing home at the hearing, and that was when RI #1 was given the notice of the immediate discharge from the nursing home. The judge said she asked the Administrator, EI #1, was there any way the nursing home could take RI #1 back and EI #1 said no. The judge said her concern was the nursing home needed to have given RI #1 a few days' notice that he/she was not coming back and not just let RI #1 know that on the day of the court hearing. On 07/28/2023 at 10:48 AM, a telephone interview was conducted with a social worker at the psychiatric facility. The social worker said RI #1 had previously been admitted to the facility, but on this admission RI #1 was there on an emergent order for evaluation and treatment. The social worker said the facility never informed RI #1 she would not be coming back to the facility and faxed the emergent notice to the psychiatrici facility (on 07/10/2023 the day of RI #1's court hearing) and wanted them to give it to RI #1. The social worker said RI#1 had been in their facility since 7/07/2023. The social worker said RI #1 had never received any paperwork from the nursing home and was under the impression he/she would be returning to the nursing home. On 07/28/2023 at 11:42 AM, an interview was conducted with EI #1. The Administrator (EI #1) said the emergent letter for RI #1 was done on 07/07/2023, but she did not give it to RI #1 until she arrived at the courtroom on 07/10/2023. EI #1 said the facility thought RI #1 had been basically discharged from the facility for commitment. EI #1 said this was because RI #1 was out of the facility. EI #1 said there were no attempts to fax the discharge notice to the psychiatric facility on 07/07/2023. EI #1 said residents and representatives need to receive copies of the discharge notices so they could make proper discharge plans. EI #1 said, the facility should complete a discharge summary for all residents being discharged from the facility. EI #1 said she did not know why RI #1's discharge summary was completed on 07/14/2023, and not at the time RI #1 was sent to the ER on [DATE]. EI #1 said she considered RI #1 was discharged from the facility on 07/07/2023. EI #1 said she did not know if RI #1 had a physician's order for a discharge from the facility but when a person is discharged from the facility there should be a doctor's order for the discharge. EI #1 said the facility was thinking when they went to court it was for the committal hearing, and when they got there, it was all about why the facility was not taking RI #1 back. EI #1 said she did inform the judge RI #1 would not be allowed to return to the facility. EI #1 said she was given a copy of the appeal letter appealing the decision to refuse RI #1 to return to facility dated 07/10/2023 from RI #1's lawyer. EI #1 was asked, what did she do or say when she reviewed the letter. EI #1 said she did not do or say anything. This deficiency was cited as a result of the investigation of complaint/report #AL00044792.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, facility's investigation, and a review of facility's policy titled, Abuse Policy, the facility failed to protect resident's funds from misappropriation when Employee Identifier (EI) #2 former Business Officer Manager stole $700 from Residents Trust Accounts. This deficient practice affected RI (Resident Identifier) #3, #15, #41, #48, #57 #62, #74, #83, #101, #103, #122, #132, #138, #139 and #142; fifteen of 73 sampled residents reviewed for misappropriation of residents' funds. Findings include: 1) RI #3 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #3 's Quarterly Minimum Data Set (MDS) Assessment, dated 10/28/2022, indicated he/she had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated the resident was cognitively intact. 2) RI #15 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #15 's yearly MDS, dated [DATE], indicated he/she had a BIMS score of 12 out of 15 which indicated the resident was cognitively intact. 3) RI #41 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #41 's Quarterly MDS, dated [DATE], indicated he/she had a BIMS score of 12 out of 15 which indicated the resident was cognitively intact. 4) RI #48 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #48 's Quarterly MDS, dated [DATE], indicated he/she had a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. 5) RI #57 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #57 's Quarterly MDS, dated [DATE], indicated he/she had a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. 6) RI #62 was admitted to the facility on [DATE]. RI #62 's Quarterly MDS Assessment, dated 08/26/2022, indicated he/she had a BIMS score of 10 out of 15 which indicated the resident was moderately cognitive impaired. 7) RI #74 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #74 's Quarterly MDS, dated [DATE], indicated he/she had a BIMS score of 11 out of 15 which indicated the resident was moderately cognitively impaired. 8) RI #83 was admitted to the facility on [DATE]. RI #83 's Quarterly MDS, dated [DATE], indicated he/she had a BIMS score of 9 out of 15 which indicated the resident was moderately cognitive impaired. 9) RI #101 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #101 's Quarterly MDS, dated [DATE], indicated he/she had a BIMS score of 5 out of 15 which indicated the resident was severely cognitively impaired. 10) RI #103 was admitted to the facility on [DATE]. RI #103 's Quarterly MDS, dated [DATE], indicated he/she had a BIMS score of 12 out of 15 which indicated the resident was cognitively intact. 11) RI #122 was admitted to the facility on [DATE]. RI #122 's Quarterly MDS, dated [DATE], indicated he/she had a BIMS score of 14 out of 15 which indicated the resident was cognitively intact. 12) RI #132 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #132 's Quarterly MDS, dated [DATE], indicated he/she had a BIMS score of 6 out of 15 which indicated the resident was severely cognitively impaired. 13) RI #138 was admitted to the facility on [DATE]. RI #138 's Quarterly MDS, dated [DATE], indicated he/she had a BIMS score blank which indicated the resident was severely cognitively impaired. 14) RI #139 was admitted to the facility on [DATE]. RI #139 's Quarterly MDS, dated [DATE], indicated he/she had a BIMS score of 12 out of 15 which indicated the resident was cognitively intact. 15) RI #142 was admitted to the facility on [DATE]. RI #142 's Quarterly MDS, dated [DATE], indicated he/she had a BIMS score of 10 out of 15 which indicated the resident was moderately cognitively impaired. The facility's policy titled, ABUSE POLICY with an effective date of November 2016, revealed, .IT IS THE POLICY . TO ENSURE THAT EACH RESIDENT IS FREE FROM . MISAPPROPRIATION OF RESIDENT PROPERTY AND EXPLOITATION . Definitions. Misappropriation of Resident's Property- Misappropriation of resident property is the deliberate misplacement, exploitation or wrongful, temporary, or permanent use of resident's belongings, property or money without the resident's consent. Acts that constitute the misappropriation of resident property include, but are not limited to, the theft or attempted theft of a resident's money or personal property, theft of a resident's medication, or the inappropriate use of a resident's funds or property The facility's policy titled PATIENT PERSONAL PROPERTY POLICY dated November 2016 revealed, . each resident is encouraged to keep all personal property . including money, in the business office. Resident . money will be kept . in the business office and the facility will take full responsibility . A signed untitled letter from facility's administrator dated, 09/16/2022, documented, . we do substantiate and believe that (EI #2), Business Office Manager, has misappropriated resident funds. On Friday, September 9, 2022, (EI #6), facility screener, observed (EI #2) writing out several resident trust fund receipts and subsequently throwing away three (3) yellow carbon copy receipts. This aroused (EI #6)'s suspicions since these yellow copies are typically given to the resident or family member following a request to withdraw personal funds. (EI #6) retrieved the receipts from the trash can, gave them to the Administrator, and reported what she had observed. The receipts were dated September 9, 2022, authorizing withdrawal of funds from the resident trust fund accounts of (RI #142, RI #83, and RI #13) . Each of the three withdrawal receipts were for $50. It became apparent while looking at these receipts that (EI #2) had forged each residents' signature as well as (EI #6)'s initials as a witness of the transaction on both (RI #142)'s and (RI #13)'s receipts. The witness initials on (RI #83)'s receipt were left blank. An immediate audit showed that $50.00 had been withdrawn from both (RI #142) and (RI #83)'s resident trust fund accounts. However, (RI #13)'s $50.00 had not been withdrawn from his/her account at that time but was likely (EI #2)'s intent. each resident denied requesting funds to be withdrawn from their accounts . The facility has reimbursed (RI #142) $50.00 and (RI #83)'s $50.00 that was determined to have been misappropriated. the facility has determined that (EI #2) did not always follow proper procedures when making trust fund withdrawal transactions. The procedure was for (EI #2) to have an employee witness each transaction which was not always followed. We have also determined that (EI #2) forged the witness signature on multiple occasions . Facility report titled, Resident Trust Audit, dated 09/16/2022, documented, . Summary Description Proven Theft Total $700 . A review of Resident Trust Account receipts revealed RI #3, #15, #41, #48, #57 #62, #74, #101, #103, and #122 had receipts that the resident's copy did not match the facility's copy indicating the amount withdrawn from the account was altered. RI #83 and RI #142 had facility receipts that could not be matched to a resident's copy. RI #132, #138, and #139 each had deposit receipts that were not credited to their accounts. On 11/09/2022 at 2:50 PM, a telephone interview was conducted with EI #6, Screener. EI #6 stated she witnessed EI #2 pull out green binder and started looking at it. She stated EI #2 wrote three names on receipts. EI #6 stated no residents had come up to office to get money during this time. EI #6 stated EI #2 tore yellow copy up and threw in trash. EI #6 stated she got the yellow copies out of trash and then went into social service office and taped them up. She stated she asked Social Services to go ask residents if they had gotten any money and the residents said no. She stated she then informed Administrator of what she witnessed. On 11/09/2022 at 3:08 PM, a telephone interview was conducted with EI #3, Corporate Auditor. EI #3 stated an independent audit of Resident Trust Accounts began on 09/13/2022. She stated $700 was determined to be stolen from 15 resident's accounts. She stated theft was determined by reviewing receipts and comparing the white (facility copy) and yellow copies (given to residents). EI #3 stated it was determined $475 was stolen from cash out ticket (receipts) and $225 was stolen because it was not posted to resident's accounts after someone deposited into their accounts. EI #3 stated all receipts were issued by EI #2. On 11/09/2022 at 5:19 PM, a telephone interview was conducted with EI #2, Former Business Office Manager (BOM). EI #2 informed that she was arrested on 11/07/2022 for forgery and exploitation. EI #2 stated on 09/09/2022, she wrote three receipts out for residents. EI #2 stated she threw receipts away. She admitted she wrote resident's signatures on them. On 11/10/2022 at 9:22 AM, an interview was conducted with EI #1, Administrator/Abuse Coordinator. EI #1 informed she became aware of misappropriation on 09/09/2022 when EI #6 told her she witnessed EI #2 scroll through Resident Trust Account Folder and filled out receipts for three people, rip receipts and threw yellow copy in trash can. EI #1 stated EI #6 informed her that she retrieved the receipts out of trash, and they were filled out for three residents, and each denied getting money that date. EI #1 stated she confirmed EI #6's statement with Social Service Department. EI #1 stated she contacted her boss and was informed to contact local law enforcement. EI #1 stated petty cash box was balanced and it was determined that EI #2 misappropriated $50 from RI # 83 and RI #142. On 09/13/2022, an audit of all Resident Trust Accounts began. The audit revealed $700 in theft. The following residents were impacted: 1) EI #1 stated RI #3's ticket number 24094 (09/02/2022) yellow copy was blank, white copy documented $30. It was determined EI #2 stole $30. EI #1 stated RI #3 reported receiving $5 in ones for drink machine no witness signature on ticket. 2) EI #1 stated RI #15's ticket number 24101 (09/07/2022) yellow copy documented $10 and the white copy documented $30. It was determined EI #2 stole $20. 3) EI #1 stated RI #41's ticket number 23683 (04/04/2022) yellow copy documented $5 and the white copy documented $15. It was determined EI #2 stole $10. Ticket # 23981 (03/21/2022) yellow copy documented $5 and white copy documented $15. It was determined EI #2 stole $10. Ticket # 24352 (05/29/2022) yellow copy documented $5 and white copy documented $15. It was determined EI #2 stole $10. Ticket # 24410 (05/17/2022) yellow copy documented $5 and white copy documented $15. It was determined EI #2 stole $10. Ticket # 24481 (06/07/2022) yellow copy documented $5 and white copy documented $25. It was determined EI #2 stole $20. 4) EI #1 stated RI #48's ticket number 24975 (08/24/2022) yellow copy blank and the white copy documented $100. It was determined EI #2 stole $50. EI #1 stated RI #48 stated he/she requested $50. 5) EI #1 stated RI #57's ticket number 24160 (09/07/2022) yellow copy documented $40 and the white copy documented $50. It was determined EI #2 stole $10. 6) EI #1 stated RI #62's ticket number 24096 (09/03/2022) yellow copy documented $5 and the white copy documented $25. It was determined EI #2 stole $20. 7) EI #1 stated RI #74's ticket number 24875 (07/13/2022) yellow copy blank and the white copy documented $5. It was determined EI #2 stole $5. Ticket # 24116 yellow copy documented $5 and white copy documented $15. It was determined EI #2 stole $10. 8) EI #1 stated RI #83's ticket number 24105 (09/09/2022) yellow copy documented $50 and the white copy documented $50. It was determined EI #2 stole $50. EI #1 stated RI #83 did not receive money when torn receipt was found in trash. 9) EI #1 stated RI #101's ticket number 24134 (08/30/2022) yellow copy (none) and the white copy documented $20. It was determined EI #2 stole $10. EI #1 stated $10 was given to RI #101 by weekend person and EI #2 changed ticket to $20 upon her return to work. 10) EI #1 stated RI #103's ticket number 24997 (09/01/2022) yellow copy documented $6 and the white copy documented $36. It was determined EI #2 stole $30. 11) EI #1 stated RI #122's ticket number 24087 (09/02/2022) yellow copy documented $30 and the white copy documented $40. It was determined EI #2 stole $10. 12) EI #1 stated RI #132's receipt number 250696 (08/14/2022) for deposit was theft. EI #2 received $10 for RI #132 and never deposited the money. It was determined EI #2 stole $10. 13) EI #1 stated RI #138's receipt number 756244 (03/24/2022) for deposit was theft. EI #1 stated EI #2 received $40 for RI #138 but money was never deposited. It was determined EI #2 stole $40. 14) EI #1 stated RI #139's receipt number 250680 (02/09/2022) for deposit was theft. EI #1 stated EI #2 received $175 for RI #139. EI #2 wrote receipt, but money was never deposited. It was determined EI #2 stole $175. 15) EI #1 stated RI #142's ticket number 24125 (08/29/2022) yellow copy (none) and the white copy documented $80. It was determined EI #2 stole $80. EI #1 stated RI #142 stated he/she has not received any money lately. Ticket number 24106 (09/09/2022) yellow copy documented $50 and white copy documented $50. It was determined EI #2 stole $50. EI #1 stated RI #142 did not receive money when torn receipt was found in trash. On 11/10/2022 at 3:21 PM, a follow-up interview was conducted with EI #1, Administrator. EI #1 stated before the incident on 09/09/2022, the facility did not have a procedure for reviewing/processing petty cash tickets (receipts). She stated no one was reviewing tickets and there was never a need to review tickets until now. EI #1 stated the facility was balancing accounts on a monthly basis. EI #1 admitted EI #2 did not follow facility procedure of issuing cash to residents and stated EI #2 misappropriated residents' funds. This deficient practice was cited as a result of the investigation of complaint/report number AL00042100. The facility took immediate action to correct the noncompliance by: 1. Reported to Alabama Department of Public Health (ADPH) 09/09/2022 and conducted an investigation 2. Suspended [NAME] 09/09/2022 3. Terminated [NAME] 09/14/2022 4. Policy revision on Resident Trust Funds 09/23/2022 and educated staff responsible 09/26/2022-10/25/2022 5. Audit conducted by independent Crown Management 09/13/2022-09/20/2022 6. Resident Care Surveys completed 09/14/2022-09/18/2022 7. Training for all staff on misappropriation 09/13/2022-10/12/2022 8. Quality Assurance (QA) Meeting 09/13/2022 to determine root cause and create Plan of Correction (POC), morning meeting held 09/14/2022, Follow-up meeting 09/23/2022 9. Resident Council conducted 09/14/2022, Social Services interviewed all residents with trust funds that did not attend 10. Administrator monitored resident cash receipts daily for two weeks for inaccuracies/suspicious activities 09/08/2022-09/25/2022 11. Monitored weekly for 4 weeks for any inaccuracies/suspicious activities 09/26/2022-10/22/2022 12. Monitored monthly 10/21/2022-ongoing 13. Counseled [NAME], [NAME], [NAME], [NAME] and [NAME] for no witness signatures 14. Corporate educated Administrator on trust fund guidelines 09/14/2022 15. New Hire (10/19/2022) for Business Officer Manager received specific training 10/26/2022 and 11/03/2022 16. Reported to Law Enforcement, 17. Reported to Ombudsman 09/09/2022 and 09/22/2022 18. Reported to Attorney General Office/Medicaid Fraud 09/09/2022 19. Replaced $50 to RI #42 and RI #183's accounts on 9/9/2022. 20. Replinished $600.00 total to the remaining resident's who whose accounts were identified as proven theft. After review of documentation supporting the corrective actions, including in-service records, employee files, education records, and interviews with staff, the survey team verified the facility had implemented corrective actions from 09/09/2022 through 10/25/2022 and had an ongoing monitoring system in place; thus, past non-compliance was cited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, review of a facility document titled, Maintaining Patient Trust Receipts, review of a facility document titled, Resident Trust Audit, and review of two unnamed facility documents, the facility failed to ensure residents' trust accounts were safeguarded when staff failed to follow facility procedure for issuing money from Resident Trust Accounts. This affected 66 of 73 residents sampled for review of personal funds including Resident Identifier (RI) #4, RI #6, RI #11, RI #13, RI #14, RI #15, RI #17, RI #19, RI #21, RI #23, RI #25, RI #28, RI #29, RI #31, RI #34, RI #40, RI #41, RI #42, RI #48, RI #49, RI #54, RI #55, RI #57, RI #60, RI #62, RI #66, RI #67, RI #68, RI #71, RI #74, RI #83, RI #84, RI #85, RI #86, RI #87, RI #89, RI #95, RI #101, RI #102, RI #105, RI #113, RI #114, RI #115, RI #119, RI #122, RI #132, RI #139, RI #142, RI #154, RI #208, RI #209, RI #210, RI #211, RI #213, RI #215, RI #218, RI #219, RI #220, RI #221, RI #222, RI #223, RI #224, RI #225, RI #260, RI #261 and RI #262. Findings Include: Review of undated facility document titled Maintaining Patient Trust Receipts revealed Resident wishes to withdraw funds from their account: After checking the resident's account to ensure he or she has the available funds the resident must sign a receipt after completing it with the amount requested, date, and name of resident . If the resident cannot sign, they must attempt to make an X on the receipt. You will then write their name in by the X and another Crowne employee must sign. The Crowne employee disbursing the funds must also sign the receipt. Review of facility document titled, Resident Trust Audit, dated 09/16/2022, documented policy violations identified were Witness Signature Disputed and No Witness Signature. The Witness Signature Disputed effected $13,678.00 in resident fund receipts. The No Witness Signature effected $6,552.51 in resident fund receipts. Review of an untitled, undated document identified as the facility's audit results revealed there were 483 Resident Trust Accounts receipts without witness signatures and 700 Resident Trust Accounts receipts with a disputed witness signature. RI #4, RI #6, RI #11, RI #13, RI #14, RI #15, RI #17, RI #19, RI #21, RI #23, RI #25, RI #28, RI #29, RI #31, RI #34, RI #40, RI #41, RI #42, RI #48, RI #49, RI #54, RI #55, RI #57, RI #60, RI #62, RI #66, RI #67, RI #68, RI #71, RI #74, RI #83, RI #84, RI #85, RI #86, RI #87, RI #89, RI #95, RI #101, RI #102, RI #105, RI #113, RI #114, RI #115, RI #119, RI #122, RI #132, RI #139, RI #142, RI #154, RI #208, RI #209, RI #210, RI #211, RI #213, RI #215, RI #218, RI #219, RI #220, RI #221, RI #222, RI #223, RI #224, RI #225, RI #260, RI #261 and RI #262 were listed on the audit results as having Resident Trust Account receipts with a missing witness signature or a disputed witness signature. In an interview on 11/09/2022 at 3:08 PM, Employee Identifier (EI) # 3, Corporate Auditor, reported she initiated an audit at the facility on 09/13/2022 due to an allegation of misappropriation of resident funds. The audit consisted of every cash receipt issued to a resident. EI #6, Screener, normally witnessed the receipts so she went through all the resident cash receipts and determined if she witnessed the transaction or not. EI #3 then determined if the receipt was missing any information or appeared suspicious. EI #3 stated the audit revealed $13,678.00 in resident fund receipts where the witness signature was disputed and $6,552.51 in resident fund receipts where there was no witness signature. EI #3 stated the facility's procedure was to have a witness to every receipt. EI #3 stated the facility could not determine whether there was theft or not because the proper policy was not followed. EI #3 stated she determined EI #2, EI #4, EI #5, EI #7, and EI #8 did not follow proper policy. In an interview on 11/09/2022 at 4:48 PM, EI #7, Bookkeeping staff, reported the proper procedure for disbursing resident funds was to have a witness. EI #7 stated she was taught to have a witness signature on the receipt because it protected the staff and the resident. She stated that it was brought to her attention that there were receipts that she did not get a witness signature and was retrained. EI #7 stated facility policy was not followed regarding a witness signature. In an interview on 11/09/2022 at 4:59 PM, EI #4, Medical Records/Unit Secretary Supervisor, reported the facility's procedure for disbursing resident funds included a witness signing the receipt and staff disbursing the funds signature. EI #4 stated she probably had completed a receipt without a witness signature and that she had been retrained never to do it again. She stated she should have found a witness. EI #4 stated the facility policy was not followed since she did not get a witness signature. EI #4 stated she should get a witness signature to ensure the appropriate resident received the right amount of money. In an interview on 11/09/2022 at 5:10 PM, EI #5, part-time weekend Secretary, reported a witness was required before she disbursed any resident funds. EI #5 stated she did not get a witness signature before and was corrected on the proper procedure. EI #5 stated a witness was required to make sure everything was honest, and she had given out the correct amount of money. EI #5 stated facility policy was not followed when she did not get the witness signature. In an interview on 11/09/2022 at 5:19 PM, EI #2, former Business Office Manager, reported her signature, the resident's signature and another employee's signature were required on the receipts. EI #2 stated she did not always get a witness to sign the receipt if she was in a hurry. EI #2 stated facility procedure was not followed when she did not get a witness signature. EI #2 stated there were times when she would write EI #6's initials on the receipts. EI #2 stated facility procedure was not followed when she initialed for EI #6. EI #2 stated she signed a resident's name on a receipt on one occasion, but she did not remember the amount on the receipt. In an interview on 11/10/2022 at 9:22 AM, EI #1, Administrator, reported she was investigating an allegation of misappropriation of resident funds when she discovered EI #2 did not obtain a witness signature which was against facility procedure. An audit was conducted which revealed $13,678.00 in receipts with a witness signature disputed and $6,552.51 in receipts with no witness signature. EI #1 stated the policy on funds required a witness to confirm the funds were disbursed. EI #1 stated the witness was required to sign the receipt. In a follow-up interview on 11/10/2022 at 3:21 PM, EI #1, Administrator, reported disputed witness signatures were determined by looking at the receipts and asking EI #6 if the initials belonged to her. The questionable receipts had initials and not signatures. EI #1 stated the staff that disbursed funds without a witness signature did not follow facility procedures. This deficient practice was cited as a result of the investigation of complaint/report number AL00042100. The facility took immediate action to correct the noncompliance by: 1. Reported to Alabama Department of Public Health (ADPH) 09/09/2022 and conducted an investigation 2. Suspended [NAME] 09/09/2022 3. Terminated [NAME] 09/14/2022 4. Policy revision on Resident Trust Funds 09/23/2022 and educated staff responsible 09/26/2022-10/25/2022 5. Audit conducted by independent Crown Management 09/13/2022-09/20/2022 6. Resident Care Surveys completed 09/14/2022-09/18/2022 7. Training for all staff on misappropriation 09/13/2022-10/12/2022 8. Quality Assurance (QA) Meeting 09/13/2022 to determine root cause and create Plan of Correction (POC), morning meeting held 09/14/2022, Follow-up meeting 09/23/2022 9. Resident Council conducted 09/14/2022, Social Services interviewed all residents with trust funds that did not attend 10. Administrator monitored resident cash receipts daily for two weeks for inaccuracies/suspicious activities 09/08/2022-09/25/2022 11. Monitored weekly for 4 weeks for any inaccuracies/suspicious activities 09/26/2022-10/22/2022 12. Monitored monthly 10/21/2022-ongoing 13. Counseled [NAME], [NAME], [NAME], [NAME], and [NAME] for no witness signatures 14. Corporate educated Administrator on trust fund guidelines 09/14/2022 15. New Hire (10/19/2022) for Business Officer Manager received specific training 10/26/2022 and 11/03/2022 16. Reported to Law Enforcement, 17. Reported to Ombudsman 09/09/2022 and 09/22/2022 18. Reported to Attorney General Office/Medicaid Fraud 09/09/2022 19. Replinished resident accounts on 9/26/22 $13,678.00 due to witness signature disputed and $6552.51 due to no witness signature. After review of documentation supporting the corrective actions, including in-service records, employee files, education records, and interviews with staff, the survey team verified the facility had implemented corrective actions from 09/09/2022 through 10/25/2022 and had an ongoing monitoring system in place; thus, past non-compliance was cited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide Activities of Daily Living (ADL) assistance according to the resident's bathing preference for one of four residents sampled for ADLs, Resident #3. Findings included: Resident Identifier (RI) #3 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Anemia, Bursitis of left shoulder, Hypertension, Splenomegaly, Ovarian Cyst, and Cataract. Review of RI #3's Clinical Record since 3/1/21 revealed no documentation of resident refusals of care. Review of RI #3's Annual Minimum Data Set (MDS) dated [DATE] recorded the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated intact cognition. The MDS recorded the resident had no delirium, psychosis or negative behaviors and a mood severity score of zero (0). The MDS recorded the resident required physical help in part of the bathing activity. Review of the RI #3's Care Plan revealed a Smart Chart task list which states, *FYI [For your information]: Bath - Monday/Wednesday/Friday/Sunday (CNA) [Certified Nursing Assistant] *FYI: Shower- Tuesday/Thursday/Saturday (CNA) Review of the Falls care plan dated 7/08/2020 and updated 6/2021 revealed the problem statement: FALLS-I am at risk for falls re: [sic] to decreased srrength, [sic] unsteady gait, balance problems. The care plan included the following interventions to prevent falls: Cue me to use the grab bar to hold on to in the bathroom. Ensure I wear proper fitting shoes with non-skid soles. Encourage resident to make position changes slowly and carefully. When resident is restless assist to bathroom, offer food and/or liquids, take for walk. Notify my doctor for transfer to the hospital for observation if I hit my head. Gripper socks when in bed or when shoes are not an option. Allow me rest periods during tasks. Notify nurse for signs of dizziness. [NAME] for ambulation, wheelchair is primary mode of locomotion on and off unit. During interview with RI #3 on 7/7/21 at approximately 12:40 p.m., RI #3 said the facility doesn't offer showers very often and so (he/she) washes him/herself up. The resident said it has been couple months since he/she had a shower and wished he/she could get it once a week, at least. RI #3 said he/she just sits on the toilet and stick his/her head under the faucet to wash his/her hair. RI #3 said that on the 29th of June he/she had a doctor's appointment and asked the day before for a shower and they said ok. The resident said he/she didn't not know who to talk to about it. An observation of the resident at that time revealed the resident appeared groomed with clean clothing and hair that appeared greasy. During an interview on 7/9/21 at 10:59 a.m., Employee Identifier (EI) #5, Certified Nursing Assistant (CNA) stated the residents got showers three times per week before COVID, but just once a week right now; everyone got a bed bath every day unless they shower, and all three shifts do showers. When asked how she knew who to give a shower to, EI #5 stated there was a schedule for which shift did which rooms. During an interview on 7/9/21 at 11:10 a.m., the Unit Supervisor, Employee Identifier (EI) #1, Registered Nurse (RN) was asked about the shower schedule. EI #1 stated, Everyone gets a shower once a week. Showers are given Monday through Friday. The evening and night shifts, the rooms are assigned for the showers. When asked about the day shift shower schedule, EI #1 stated the front hall was done on day shift, but didn't know how the CNAs knew who to shower and thought the charge nurse assigned it. EI #1 stated the CNAs reported verbally at the end of the shift to the charge nurse whether they gave the assigned resident a shower. If the resident refused a shower when offered, the CNA let the nurse know right away. But if the shower or bed bath was completed, they let the nurse know at the end of shift. During a follow up interview on 7/9/21 at 11:19 a.m., RI #3 said they don't offer a shower. RI #3 said he/she thinks it was about two months ago he/she had one, and then on the 29th of June. RI #3 said they (staff) know he/she bathes him/herself, so that's probably why they don't ask. During an interview on 7/9/21 at 12:07 p.m., Employee Identifier (EI) #9, CNA stated she took care of RI #3 that day. When asked how she knew who to give a shower to that day, EI #9 stated, To know who to give a shower to, there's a schedule in the book at the desk. When the CNA realized there was not a day shift schedule at the desk, she stated, Well we talk to each other on who should get a shower. EI #9 stated for RI#3, I just set [him/her] up and [he/she] does [bathes] [him/herself]; (he/she) wants to. EI #5 stated, Yes, we are supposed to offer a shower to the residents. When asked, the CNA stated she did offer a shower to Resident #3 that morning, but the resident refused today. EI #9 stated, When they refuse, I'm only supposed to document it in the computer; I do not have to tell anyone, and she was only supposed to document it under patient care refused in the computer. During an interview on 7/9/21 at 12:15 p.m., the Employee Identifier (EI) #2. Charge Nurse, Licensed Practical Nurse (LPN) stated he/she was the charge nurse on the day shift Monday through Friday. EI #2 stated for showers, on the day shift, they were done before COVID three times per week. When COVID hit, bed baths were given. EI #2 stated the facility started showers again and the CNAs each took two people from the hall each week to the shower. EI #2 stated the current system was the CNAs had a census sheet and they would mark the residents off when they were due for a shower. When asked how the CNAs were monitored that the showers were given, EI#2 stated, I don't monitor it [showers] at all. I see them [CNAs] take people go to the showers. I don't know how to know if a resident doesn't get one. EI #2 stated, No, the CNAs do not report to me who got a shower, no, but I may ask them if I have a reason to. EI #2 stated RI #3 was alert and oriented, had no behaviors and was very trustworthy. When asked about the expectations for the CNAs, the charge nurse stated, I expect the CNA to offer (him/her) a shower once a week; (he/she) washes (his/her) hair in the bathroom sink? Nobody reported that to me. During an interview on 7/9/21 at 3:39 p.m., the Director of Nursing (DON) stated once a week showers started on March 16, 2021 since the facility transitioned to post-COVID. The DON stated his/her expectation was that, Everybody [residents] should get a shower every week. The DON stated starting March 16, 2021 the facility went to once per week for showers, and the CNAs, charge nurse or supervisor should all monitor the showers were done and should offer a shower to the resident on their shower day. The supervisor should ensure the showers are done every week and be accountable for it. On 7/9/21 at 4:15 p.m., the Director of Nursing (DON) presented a written communication which stated, I do not have an individual policy on the residents bathing schedule. The bath is offered three x [times] weekly and as needed. Resident's have the right to refuse a bath unless they become offensive to others.

Based on observation, interview and policy review the facility staff failed to implement the Infection Control Policy designed to prevent transmission of infections during meal service in the dining room of the Memory Care Unit. This failure could result in cross-contamination between residents during meal service and had the potential to affect residents receiving meals on the Memory Care Unit. Findings include: Review of the facility Surveillance and Education Policy revised 3/17 reflected the Infection Control Nurse (ICRN) reviews findings relevant to infection control issues including .proper hand hygiene and topics of infection control training include .hand hygiene. Review of the facility's Hand Hygiene Policy and Procedure revised 4/2020 reflected perform hand hygiene .assisting a resident with meals, between resident contacts, after handling soiled equipment .and when otherwise indicated to avoid transfer of microorganisms to other residents or environments. Observation of meal service in the Memory Care dining room on 7/7/21 revealed Certified Nursing Assistants (CNAs) #6, 7 and 8 as they removed the residents meal trays from the tables while the residents were still seated at the tables. The Activities Assistant (AA) was also in the area working with residents. None of the CNAs were wearing gloves, and none were observed performing hand hygiene at any time during the observation. CNA #6 picked up a meal tray and trash from a resident's table where the resident was sitting and threw some trash in a trash can that was next to the table. CNA #6 was observed picking something out of the trash. While CNA #6 was leaning over, something dropped into a dustpan that was by the trashcan. CNA #6 then was observed picking something out of the dustpan. CNA #6 then put the tray on the kitchen cart for used trays, went back to the resident's table, put her hand on a resident's shoulder, then picked up another tray and took it to the kitchen cart. The CNA failed to perform hand hygiene during this observation. CNA #8 was observed on 7/7/21 at 12:45 p.m. as she picked up a tray from a resident seated at the dining table. The CNA the put the tray onto the kitchen cart. Without stopping to sanitize her hands, CNA #4 picked up a clean glass and filled it with water and took it to a different resident in the dining room. The CNA failed to sanitize her hands prior to getting the clean glass and filling it was water then serving it to a resident. At that time the surveyor asked CNA #4 about the policy for hand hygiene and infection control. CNA #4 was holding another tray and said that they washed their hands before serving the residents and then said they also made sure the resident hands were washed before meals. During an interview on 7/7/21 at 12:50 p.m. with LPN #3, she said that she was the nurse for the unit. When asked about the policy and procedures for hand hygiene, LPN #2 said that CNAs had been trained in hand hygiene and should perform hand hygiene between resident contact. During an interview on 7/7/21 6:30 p.m. while exiting the facility for the day the Administrator asked the surveyor what had happened in the locked unit. She said that she had heard that there as an issue, and that they had already started working to resolve the issue. When asked her expectations for hand hygiene the Administrator stated that all staff should perform hand hygiene between residents per policy and procedure. During an interview on 7/8/21 at 2:04 p.m. with the Director of Nursing (DON) the DON said that it was her expectation that all staff perform hand hygiene between all patient contact and that there are a lot of alcohol-based hand rub (ABH) stations convenient to them. During an interview on 7/8/21 at 3:40 p.m. with the ICRN the ICRN said that she and the training coordinator do staff training for infection control including policies and procedures. She said that it was her expectation that staff members follow the facility's policies and procedures.

Based on interviews, Minimum Data Set (MDS) assessments and a review of CMS's (Centers for Medicare and Medicaid) RAI (Resident Assessment Instrument) Version 3.0 Manual, the facility failed to ensure RI #4's Significant Change (SC) MDS and RI #7's Annual MDS assessments were submitted timely. This had the potential to affect 2 of 4 residents whose assessments were reviewed for being over 120 days late. Findings Include: A review of CMS's RAI Version 3.0 Chapter 5: Submission and Correction of the MDS Assessments . page 5-3 specifies, the assessment must be submitted within 14 days of the MDS Completion Date A review of RI #4's 2/25/2019 Annual MDS, section VO200C was signed and dated 3/18/19. The document should have been submitted by 4/1/19. A review of RI #7's 2/25/2019 SC MDS section VO200C was signed and dated 3/18/2019. The MDS should have been submitted by 4/1/2019. On 5/02/2019 at 8:39 a.m., the surveyor reviewed four residents' assessments that were identified by CMS as 120 days over-due. On 5/02/2019 at 9:22 a.m., an interview was conducted with Registered Nurse (RN), EI (Employer Identifier) #8. EI #8 was asked when did she submit the assessments for RI #4 and RI #7 to CMS. EI #8 replied, 5/1/2019. EI #8 was asked when should RI #4's Annual and RI #7's SC assessments have been submitted. EI #8 replied, RI #4's transmitted date was 4/1/2019 and EI #7 was the same. EI #8 was asked why were the residents' assessments submitted late. EI #8 replied, it did not show up on their report to submit. EI #8 was asked what was showing in the assessment section of the MDS of RI #4 and #7's assessments. EI #8 replied, opened. EI #8 was asked why was it showing opened. EI #8 explained because it was not closed and submitted. EI #8 replied, it was never submitted to the state. EI #8 was asked did she change open to closed, or accepted on RI #4 and RI #7's assessments on the day before. EI #8 replied, yes ma'am. EI #8 was asked who was responsible for submitting residents' assessments. EI #8 replied, they all were responsible for submitting. EI #8 was asked were RI #4 and RI #7's resident assessments submitted in a timely manner. EI #8 replied, no ma'am. EI #8 was asked why was it important that resident's assessment be submitted timely. EI #8 replied it was CMS guidelines. Those were their rules. EI #8 was asked who was responsible for submitting RI #4 and #7's resident assessments. EI #8 replied she was. On 5/02/2019 at 9:31 a.m., an interview was conducted with EI #7, RN (Registered Nurse). EI #7 was asked what was showing in the assessment section of the MDS of RI #4 and #7. EI #7 replied, opened. EI #7 was asked did she change open to closed, or accepted on 5/1/2019. EI #7 replied, she closed the assessment and transmitted the document to CMS. EI #7 was asked why did she submit to CMS on 5/1/2019. EI #7 explained, once an error was found, they had 14 days to make corrections. EI #7 was asked how did she discover the error. EI #7 replied, it was brought to her attention by the surveyor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of a facility policy titled, Policy and Procedures for Aseptic Technique with Dressing Changes, the facility failed to ensure the licensed staff did not use the same gloves to clean a wound for Resident Identifier (RI) #106, then place the clean treatment and outer covering. This affected one of one resident observed for wound care. 1. A review of a facility policy titled Policy and Procedure for Aseptic Technique with Dressing Changes with a date of 7/18/05 revealed: . The goals for treating a wound are to prevent cross contamination and/or infection of an open area and to prevent additional trauma to area. RI #106 was readmitted to the facility on [DATE] with a diagnosis of Pressure ulcer of sacral region, stage 2. A review of RI #106's April 2019 Physician Orders revealed . 2/20/19 .Cleanse Unstageable Pressure Wound To Sacrum With Normal Saline Pat Dry . Apply Medihoney Calcium Alginate To Wound Bed Every Day Cover With . Adhesive. On 4/30/19 at 9:46 AM, Employee Identifier (EI) #2, Licensed Practical Nurse, (LPN), Treatment Nurse was observed performing wound care for RI #106. EI #2 prepared the supplies without wearing gloves, then took the supplies into the room and placed them on a barrier. EI #2 washed her hands, put on gloves and removed the soiled dressing. EI #2 removed her gloves, washed her hands, put on new gloves. EI #12 cleansed the wound, patted the wound dry and placed the alginate treatment and the outer dressing on the wound, using the same gloves she had on to clean the wound. After the wound care EI #2 was interviewed. EI #2 was asked what was the policy for cleaning a wound. EI #2 replied wash her hands before starting, take off dirty gloves, was hands, place clean gloves on treat the wound and dress it. EI #2 was asked when should gloves be changed during wound care. EI #2 replied, before wound care and after removing the soiled dressing. EI #2 was asked if the hand she used to clean a wound was considered dirty or clean. EI #2 replied, dirty. EI #2 was asked if a nurse should clean a wound, then with the same dirty gloves, apply the treatment and the outer dressing. EI #2 replied, they should not. EI #2 was asked what was the harm in cleaning a wound, then with the same gloves, apply the clean treatment and outer covering. EI #2 replied, cross contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and a review of facility's policy titled, INFECTION CONTROL OXYGEN EQUIPMENT, the facility failed to ensure oxygen tubing and the humidifier bottle were replaced and dated appropriately for Resident Identifier(RI) #313. This affected 1 of 3 residents observed for oxygen therapy. Findings Include: A review of a facility policy titled, INFECTION CONTROL OXYGEN EQUIPMENT with a revised date of 8/2012, revealed: . Procedures . 4. Humidifiers are to be replaced weekly and dated. 5. Oxygen tubing, mask, and cannula's are to be replaced weekly and dated. RI #313 was admitted to the facility on [DATE] with a diagnosis of Hypoxemia and dependence of supplemental oxygen. A Physician orders, dated 04/18/19, revealed the order for oxygen (O2) at 2 liters per minute per nasal cannula as needed for shortness of breath and low O2 saturations. On 04/29/19 at 3:18 PM, the surveyor observed RI #313 resting in bed, wearing oxygen. No dates were observed on either the oxygen tubing or the humidifier bottle. On 04/29/19 at 3:34 PM, an interview was conducted with Employee Identifier (EI) #6, LPN staff nurse. EI #6 was asked if RI #313 was wearing oxygen via nasal cannula. EI #6 replied, yes. EI #6 was asked what was the setting for liters per minute. EI #6 replied, 2 liters per minute. EI #6 was asked what was the physician order for oxygen for RI #313. EI #6 replied, 2 liters oxygen per minute. EI #6 was asked was there a date on the tubing. EI #6 replied, no. EI #6 was asked if there was a date on the water bottle (humidifier). EI #6 replied, no. EI #6 was asked when did the tubing and water bottle get changed. EI #6 replied, changed Sunday per policy, but not exactly sure. EI #6 was asked, who was responsible for changing these. EI #6 replied, the 11 p to 7 a nurse. EI #6 was asked, should there be a date on the tubing and/or humidifier bottle. EI #6 replied, yes. EI #6 was asked why was it important to change the tubing and water humidifier bottle. EI #6 replied, Infection control. EI #6 was asked could she tell the surveyor when the tubing and water bottle were last changed, EI #6 replied, no she could not. EI #6 was asked what was the potential harm in not labeling the tubing and water bottle with a date when changing these. EI #6 replied, there was no idea when last changed and potential for bacteria to grow.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of facility a policy titled, Medication Administration - General Guidelines, the facility failed to ensure that licensed staff did not leave a medication cart unlocked and unattended while administering medications to Resident Identifier (RI) #2. This affected one of five nurses observed for medication pass. Findings Include: A review of the facility policy titled, Medication Administration - General Guidelines with a date of 01/12 revealed: .Procedures . 11. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. RI #2 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of: Encounter for attention to gastrostomy and Dementia in other diseases classified elsewhere. On 4/30/19 at 5:00 PM, Employee Identifier (EI) #5 a Licensed Practical Nurse (LPN) was observed preparing medication for RI #2. EI #5 prepared the following medications: Carafate, Ceftin, and Maxitrol eye drops, then placed the medications on a tray. At 5:05 PM, EI #5 entered RI #2's room and closed the door, leaving the medication cart unlocked, unattended, and out of sight with residents and staff in the hall. A second surveyor observed 6 residents and 8 staff walk by the unlocked medication cart while EI #5 remained in RI #2's room behind the closed door. The cart remained unlocked until 5:15 PM. On 4/30/19 at 5:20 PM, an interview was conducted with EI #5. EI #5 was asked, did she leave the medication cart unlocked while she went in to give RI #2's medication. EI #5 replied, yes she was told she had. EI #5 was asked, what was policy on locking the medication cart when unattended. EI #5 replied, always lock when you leave the cart. EI #5 was asked, when should a medication cart be left unlocked when unattended. EI #5 replied, never. EI #5 was asked, what would the harm be in leaving a medication cart unlocked while unattended. EI #5 replied, someone could get into the cart and remove medication. On 5/01/19 at 11:30 AM, an interview was conducted with EI #1, the Director of Nursing. EI #1 was asked, what was the policy on locking the medication cart when unattended. EI #1 replied, it was to be locked at all times when not in view of the nurse. EI #1 was asked, when should a medication cart be left unlocked and unattended. EI #1 replied, never. EI #1 was asked, what would the harm be in leaving a medication cart unlocked and unattended. EI #1 replied, potential for someone, resident or employee, to take a non-controlled medication out of the cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of a facility policy titled, Medication Administration Procedures Eye Drops the facility failed to ensure: 1. licensed staff washed her hands before administering eye drops for RI #122 and 2. licensed staff did not handle tablet medication with her bare hands, then touch the inside of a crush medication bag while preparing medication for RI #2. This affected one of one resident observed for eye drop medication and one of one resident observed for medication administered by tube. Findings Include: 1. A review of a facility policy titled, Medication Administration Procedures Eye Drops, with a date of 1/12 revealed: .Procedures .3. Wash your hand with soap and water . 9. Instruct the resident to look upward and place one drop .14. Wash your hands with soap and water . RI #122 was admitted to the facility on [DATE] with a diagnosis of Unspecified Glaucoma. A review of RI #122's April 2019 Physician Orders revealed: . 3/06/19 Dorzolamide .Eye Drops Instill 1 Drop Into Both Eyes Twice A Day . On 4/30/19 at 4:20 PM, EI #4, LPN, was observed giving RI #122 medication. EI #4 prepared the Dorzolamide eye drops and Valporic Acid liquid. EI #4 administered the by-mouth medication. RI #122 took the medication cup, placed the medication in her mouth, then handed the medication cup back to EI #4. RI #122 took the water cup, drank the water, and handed the water cup back to EI #4. EI #4 did not put on gloves after providing RI #122 with the oral medications and before administering the eye drops, using her left hand to hold the resident's eye lid open. On 4/30/19 at 4:39 PM, an interview was conducted with EI #4. EI #4 was asked what was the policy for administering eye drops. EI #4 replied she was unsure, then brought a policy to the surveyor and said she should wash her hands before putting the drops in. EI #4 was asked if she wore gloves to administer the eye drops. EI # replied, no. EI #4 was asked if she should touch a medication and water cup after a resident had touched them, then administer eye drops. EI #4 replied, she should not. EI #4 was asked if she washed her hands before administering the eye drops. EI #4 replied, no. EI #4 was asked what was the harm in not wearing gloves or washing her hands before administering eye drops. EI #4 replied, cross contamination. 2. RI #2 was admitted to the facility on [DATE], with a diagnosis of Encounter for Attention to Gastrostomy. A review of RI #2's April 2019 Physician Orders revealed, . Carafate . 4/25/19 Add may crush to Carafate .4/29/19 Ceftin . On 4/30/19 at 5:00 PM, LPN, EI #5 was observed preparing medication for RI #2. EI #5 prepared the Carafate in a medication cup, then the Ceftin tablet, touching the medication with her bare hand as she placed it in a medication cup. EI #5 took a medication crush bag, placed the Carafate tablet inside the bag, and crushed the tablet. EI #5 put her finger inside the bag after crushing the tablet, before placing it into a medication cup. On 4/30/19 at 5:20 PM, EI #5 was interviewed. She was asked when should she touch medications with bare hands. EI #5 replied, never. EI #5 was asked if she touched the Carafate with her bare hand. EI #5 replied, she normally did not. EI #5 was asked what was the harm in touching medications with bare hands. EI #5 replied, contamination. EI #5 was asked when should she touch the inside of the medication crush bag with her bare hands. EI #5 replied, never. EI #5 was asked what was the harm in touching a medication and the inside of a medication crush bag with bare hands. EI #5 replied, contamination. On 5/1/19 at 11:30 AM, an over-all interview was conducted with EI #1, the Director of Nursing/Acting Infection Control Nurse. EI #1 was asked what was the policy for administering eye drops. EI #1 replied, wash hands, administer the drops and wash hands (again). EI #1 was asked if staff should wear gloves to administer eye drops. EI #1 replied, no they should wash hands before and after. EI #1 was asked if a nurse should touch a medication cup and water cup after a resident had touched them, then administer eye drops without washing hands or wearing gloves. EI #1 replied, the nurse should wash their hands between the oral medications and administering eye drops. EI #1 was asked what was the harm in a nurse not wearing gloves or washing hands while administering eye drops. EI #1 replied, the potential for infection. EI #1 was asked when should a nurse touch medications with their bare hands. EI #1 replied, never. EI #1 was asked what was the harm in a nurse touching medications with her bare hands. EI #1 replied, potential for infection. EI #1 was asked when should a nurse touch the inside of a medication crush bag. EI #1 replied, never. EI #1 was asked what was the harm in a nurse touching inside medication crush bag with bare hands. EI #1 replied, the potential for infection.

Based on observations made in the kitchen on 04/29/19 and 05/01/19, interviews with facility staff and a review of the facility's Food Storage and Personal Food Storage policies and a facility document titled Resource: Food Safety for Your Loved One, dietary staff failed to consistently label frozen meat and vegetables removed from their original packaging with an open and use by date. In addition, Nursing staff failed to label residents' food items brought in by family members and stored at each of the three nursing stations, with date of storage and use-by date to ensure timely disposal. This had the potential to affect all 159 residents for whom meals were prepared and served, as well as residents' refrigerated storage on 3 of 3 nursing stations. Findings Included: 1) DIETARY FOOD STORAGE The facility's Food Storage policy (dated 2013) specifies the following: . Procedure: . 15. Frozen Foods: .c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. On 04/29/19 at 3:49 PM, the Surveyor observed a large zip-lock bag of raw frozen hamburger meat in the walk-in freezer, as well as a blue plastic bag containing (frozen) breaded squash. Neither item was labeled with an open or use by date. On 05/01/19 at 11:06 AM, the surveyor observed in the walk-in freezer, a clear plastic zip-lock bag of raw, frozen hamburger meat. The bag included no dated label or use-by date. On 05/01/19 at 5:00 PM, the surveyor informed the Certified Dietary Manager, Employee Identifier (EI) #9, of the bag of frozen raw hamburger in the walk-in freezer observed earlier that day, with no dated label, or use by date. The surveyor asked what the facility's policy was about the dating of frozen food. EI #9 explained the frozen food was supposed to have both an open date and a use by date. When the surveyor mentioned the frozen, undated breaded squash, that another surveyor had observed on 04/29/19, EI #9 explained they had thrown the squash out because they did not know when it was placed in the freezer. EI #9 stated he had also discarded the hamburger meat. 2) RESIDENTS' PERSONAL FOOD STORAGE The facility's policy related to Personal Food Storage (undated) specifies: . Food or beverage brought in from outside sources for storage in facility pantries, refrigeration units, or personal room refrigeration units will be monitored by designated facility staff for food safety. .Foods or beverage items without a manufacturer's expiration date should be dated upon arrival in the facility and thrown away three days after the date marked. Foods in unmarked or unlabeled containers should be marked with the current date the food item was stored. A facility document titled, Resource: Food Safety For Your Loved, no date, revealed, . Food or beverages should be labeled and dated to monitor for food safety: . * Foods or beverage items without a manufacturer's expiration date should be dated upon arrival in the facility and thrown away three days after the date marked. * Foods in unmarked or unlabeled containers should be marked with the current date the food item was stored. a) On 05/02/19 at 8:14 AM, the refrigerator on the first nursing station was observed. The refrigerator contained a previously opened box of strawberry cheesecake, labeled with the resident's name. The box contained no open or use by date. A second observation was made at 9:37 AM, of the same items in the refrigerator, with Certified Nursing Assistant (CNA) EI #15. She stated she thought the pie had been brought in the previous evening, but she did not know how long it could be stored. EI #15 stated she would write a 3-day use by date on package as soon as the date of storage was confirmed. b) On 05/02/19 at 08:19 AM, the surveyor checked the second nursing station refrigerator with LPN (EI #13). The following food items were observed with no identification/name, and no date of storage or use by date: a) a sack of left-over doughnuts; b) a sack containing two biscuits with sausage; c) a plastic container of cooked turnip greens (believed by EI #13 to belong to a staff member); d) one sack containing a package of bologna (identified by EI #13 as belonging to a resident); e) one sack with a container of chef's salad and individual portion packs of salad dressing, which EI #13 stated belonged to a resident; f) a sack with a container with chicken and bread; and g) a sack with a container of cooked meat, baked beans, and potato salad (which staff stated belonged to a resident); A sign adhered to the front of the refrigerator documented, All drinks and food without a name and date will be thrown away. After the observation was made, EI #13 was asked who was responsible for monitoring the contents of the refrigerator. EI #13 explained the staff on the first shift checked the refrigerator temperatures, and the 11 PM-7 AM staff cleaned out the refrigerator. EI #13 stated whomever accepted the food was responsible for labeling each item with the resident's name, and date(s). The surveyor then interviewed the Assistant Director of Nursing (EI #14) on 05/02/19 at 8:30 AM. When asked how she knew when to discard the food, EI #14 explained, the staff would discard the food after 48 hours. EI #14 stated they pulled the older dated milk to the front and put newer milk to the back. EI #14 explained dietary staff checked their own sandwiches to ensure they were not there more than 48 hours, but that dietary staff did not check the residents' food. When asked what their policy was for the storage of employee foods, EI #14 explained all employees' food was to be stored in the employee break room, down the hall. The surveyor asked what the problem was with undated food. EI #14 responded, they would not know how long the food had been stored; that it could cause food poisoning. When asked about the storage of staff food with residents' food, EI #14 explained they did not know how long it had been prepared/handled, and it could get mixed up with residents' food. The staff's food needed to be labeled also, as staff's food could be given to a resident by mistake and cause potential harm. Staff then affirmed after checking with one resident, that that resident's container of food had been stored in the refrigerator since 04/28/19 (four days prior). 3) On 05/02/19 at 08:53 AM, the third nourishment refrigerator was observed with LPN, EI #12. The following items were stored with no identification of owner, date of storage and/or use by date: a) a frozen box of Shrimp Scampi in the freezer; b) bottle of unopened Pure Leaf sweet tea; c) 20 oz bottle of Cherry Coke; d) Bottle of Moss Water; e) one sack with two bottles of salad dressing (best by dates were missing/torn off); f) a container of grated cheese (EI #12 believed it belonged to a staff member); and a g) case of canned diet Dr. Pepper on the floor in the medication room, which EI #12 explained had been brought by a resident's family member. EI #12 affirmed the residents' food was typically stored in this refrigerator, as well as staff food. On 05/02/19 at 9:00 AM, the surveyor asked the RN Supervisor, EI #11 whose responsibility it was to monitor the contents of the refrigerator and whether staff could store their food in this refrigerator. EI #11 explained that Housekeeping monitored the refrigerator (cleaning) and Nursing staff monitored the temperatures. EI #11 stated staff did not store their food in that refrigerator; she thought staff might store their food in the employee lounge, but was not sure. When asked who was responsible for labeling or dating food items brought in by family members, EI #11 explained it was the responsibility of whomever accepted the food, and put it in the refrigerator. EI #11 stated the food was to be labeled with date and name. 3) The refrigerator on the locked unit was checked on 05/02/19 at 9:05 AM. The contents of this refrigerator with no label as to name, or dates included: a) a sack with a container left-over stew; b) a yellow bag with a container of left-over white rice, fried chicken and pasta/cheese, as well as a 12-ounce (oz) can of Fanta Berry soda; c) one 4-oz container of Yoplait yogurt (Red Raspberry), with an expired use by date of 5/1/19; and d) six 4-oz containers of Danimals yogurt (strawberry banana) with use by dates of of 04/3/19 (one), and 04/11/19 (five). An interview was conducted with the Certified Nursing Assistant, EI #10, assigned to the locked unit on 05/02/19 at 9:10 AM. The surveyor asked EI #10 about the stored food. EI #10 explained the two sacks of food were left by staff from another shift. EI #10 thought the 11 PM to 7 AM staff monitored the refrigerator, as well as housekeeping staff. Dietary stocked the refrigerator (with yogurt). When questioned whether staff stored their food in the small refrigerator, EI #10 responded, yes. EI #10 stated the food was supposed to be labeled with name and dates for the staff food. No food was usually stored for the residents, according to EI #10.