**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, interviews, and a facility policy titled Comprehensive Care Plans the facility failed to to develop a care plan for RI #105 for the use of anticoagulant (AC) medication since 3/6/21. This affected one of 13 sampled residents for whom care plans were reviewed. Findings Include: A review of a policy titled Comprehensive Care Plan with a revision date of 1/30/18 documented: .Purpose: To provide individualized care for each resident. Goal: To attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . RI #105 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Hypertension and history of Transient Ischemic Attack/Cerebral Infarction. A review of RI #105's physician orders documented a start date of 3/06/21 for Plavix 75 milligrams (mg) to be given daily for Cerebrovascular Accident. A review of RI #105's care plans did not reveal a care plan for the use of AC medication or Plavix. On 2/24/22 at 4:27 PM an interview was conducted with Employee Identifier (EI) # 2. EI #2 was asked if RI #105 was receiving AC medication. EI #2 responded yes Plavix 75 mg started on 3/6/21. EI #2 further stated the Medication Administration Record (MAR) documented RI #105 received AC medication in February 2022. EI # 2 was asked if RI #105 had a current care plan for AC medication. EI #2 responded no. EI #2 was asked why a resident should be care planned for the use of AC medication. EI #2 stated, to monitor for bleeding and the risk of bleeding. EI #2 was asked why RI #105 was not care planned for AC medication. EI #2 stated she was not sure but it appeared to be missed.

Based on interview, review of the RECORD OF MEDICATION DESTRUCTION Control Drug Destructions forms, and review of a facility policy titled Disposal of Medications, the facility failed to ensure the required signatures were on the Controlled Drug Destruction forms. This affected two of five months, February and October of 2021, reviewed for destruction of controlled medications. Findings Include: Review of the facility policy titled Disposal of Medications, dated 12/2012, revealed the following: . PROCEDURES . 2. b. For the State of Alabama, these controlled substances shall be disposed of by the nursing care center in the presence of appropriately titled professionals . • x Two licensed nurses employed by the nursing care center • x Administrator and licensed nurse employed by the nursing care center • x Others as listed: Pharmacist . On 02/25/2022 at 8:19 AM, the surveyor observed the Controlled Medication Destruction forms for February 2022 (three signatures noted), October 2021 (two signatures noted), September 2021 (three signatures noted), July 2021 (three signatures noted), and February 2021 (two signatures noted). Two of the five months were without the required signatures. On 02/25/2022 at 11:42 AM, the surveyor conducted an interview with Employee Identifier (EI) #1, the Administrator. The surveyor asked EI #1 who was responsible for destroying narcotic (controlled) medications. EI #1 said two registered nurses and the pharmacist came every month. When asked how many signatures should be on the Controlled Drug Destruction form, EI #1 said two. The surveyor showed EI #1 a copy of a Record of Medication Destruction form for controlled medications, and EI #1 stated he saw where it needed to be two witnesses as well as the pharmacists signature.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5) RI #155 was admitted to the facility on [DATE]. A review of RI #155's comprehensive MDS Assessment revealed RI #155's last comprehensive MDS Assessment was transmitted to CMS on 03/09/20. On 02/24/22 at 5:33 PM an interview was conducted with EI #2. EI #2 was asked when was RI #155's last comprehensive assessment completed and what was it. EI #2 said 03/09/20 and it was a quarterly. EI #2 was asked when the MDS wavier ended on 5/10/21 what MDS assessments should have been done. EI #2 said RI #155 should have had an annual in June 2021. EI #2 was asked was there evidence this assessment was completed. EI #2 said there was no evidence this assessment was completed. EI #2 was asked should this MDS assessment have been done. EI #2 said yes, it should have been done. 6) RI #153 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. A review of RI #153's Comprehensive MDS Assessments revealed RI #153's last Comprehensive MDS Assessment was transmitted to CMS on 05/20/20. On 02/24/22 at 5:33 PM an interview was conducted with EI #2. EI #2 was asked when was RI #153's last comprehensive assessment completed. EI #2 said 05/20/20 and it was a Readmission. EI #2 was asked when the MDS wavier ended on 05/10/21, what MDS assessments should have been completed. EI #2 said an Annual MDS in 11/2021. EI #2 was asked where was the evidence that the Annual MDS in November 2021 was done. EI #2 said there was no evidence the assessment was done. 7) RI #101 was readmitted to the facility on [DATE]. A record review on 02/24/2022 at 8:45 AM revealed a missed Annual Minimum Data assessment due in December of 2021. An interview was conducted with EI #2 on 2/24/22 at 5:50 PM. EI #2 was asked when was the last MDS completed for RI #101. EI #2 stated a readmission MDS in August of 2021. EI #2 was asked what Annual MDS was missing since May of 2021. EI #2 stated an Annual in September 2021. EI #2 was asked if there was any evidence that the MDS had been completed. EI #2 stated no evidence that the MDS was completed. 8) RI #102 was readmitted to the facility on [DATE]. A record review for RI #102 revealed a missing annual MDS for June 2021. In the continued interview with EI #2 on 2/24/22 at 5:50 PM, EI #2 was asked when was the last MDS completed for RI #102. EI #2 stated a quarterly MDS in February of 2022. EI #2 was asked what annual MDS was missing since May of 2021. EI #2 stated an annual in June 2021. EI #2 was asked if there was any evidence the missing MDS had been completed. EI #2 stated there was no evidence the MDS had been completed. 9) RI #103 was readmitted to the facility on [DATE]. A record review for RI #103 revealed a missing annual MDS for November 2021. In the continued interview with EI #2, on 2/24/22 at 5:50 PM, EI #2 was asked when was the last MDS completed for RI #103. EI #2 stated a quarterly MDS in February of 2022. EI #2 was asked what annual MDS was missing since May of 2021. EI #2 stated an annual in November 2021. EI #2 was asked if there was any evidence the missing MDS had been completed. EI #2 stated there was no evidence the MDS had been completed. EI #2 was asked what was the importance of completing MDS Assessments. EI #2 stated quality indicators for the facility, shows a mechanism for identifying change and helps support claims and payments. EI #2 was asked why the resident MDS were missing. EI #2 stated she did not know, due to only working at the facility for two weeks. Based on interviews, resident record review, review of the MDS (Minimum Data Set) Coordinator - Job Description, and review of the updated CMS (Centers for Medicare & Medicaid Services) QSO (Quality, Safety & [and] Oversight Group) -21-17-NH (Nursing Home) Memo, the facility failed to ensure Comprehensive MDS assessments were completed in a timely manner after CMS ended the Emergency Blanket MDS waiver on 02/10/2021. This deficient practice affected Resident Identifier #'s 53, 54, 55, 56, 153, 155, 101, 102 and 103, nine of 13 residents whose MDS assessments were reviewed. Findings Include: A review of the updated CMS QSO-21-17-NH Memo, with an update of 02/10/2021, revealed the following: . SUBJECT: Updates to Long-Term Care (LTC) Emergency Regulatory Waivers issued in response to COVID-19 . Ending of Select Emergency Blanket Waivers During the COVID-19 PHE (Public Health Emergency) . Emergency Blanket Waiver of Minimum Data Set (MDS) Timeframe Requirements (42 CFR 483.20) CMS waived the MDS timeframe requirement at 42 CRF 483.20 for assessments to allow providers flexibility in completing and transmitting assessments. This action was intended to allow facilities to prioritize infection control effects in response to the PHE. However, the majority of facilities have been completing and transmitting assessments timely, therefore we believe all providers should be able to complete and transmit MDS assessments as required at 42 CRF 483.20. Also, CMS believes nursing homes should have developed practices for completing these assessments timely, which are critical for resident care planning. As a result, CMS is ending the emergency blanket waiver for 42 CRF 483.20 . Review of the MDS Coordinator - Job Description, with an effective date of 01/01/2022, revealed the following: . 11. Monitors all of the facility's resident assessments and care plans to ensure that they: a. Are completed in a timely manner . 1) RI #53 was admitted to the facility on [DATE], and readmitted on [DATE]. A review of RI #53's Comprehensive MDS assessments revealed RI #53's last Comprehensive MDS assessment was transmitted to CMS on 09/24/2019. On 02/24/2022 at 5:17 PM, an interview was conducted with Employee Identifier (EI) #2, the Interim Director of Nursing (DON). When asked what her job responsibilities were when it came to the residents MDS assessments, EI #2 said she was initially attempting to get the MDS assessments caught up. The surveyor asked EI #2 was she aware that according to an updated CMS QSO Memo dated 05/10/2021, facilities were to resume completing MDS assessments as they normally would. EI #2 said she was not aware of that until today (02/24/2022). The surveyor asked EI #2, on reviewing RI #53's MDS assessments, when was a Comprehensive MDS assessment last completed for RI #53. EI #2 said in August of 2019. When asked when CMS ended the MDS Wavier on 05/10/2021, when should a Comprehensive MDS assessment have been completed for RI #53, EI #2 said an Annual (which is a Comprehensive assessment) MDS assessment should have been completed in August of 2021. The surveyor asked EI #2 where was there evidence a Comprehensive MDS assessment had been completed for RI #53 after the MDS waiver ended on 05/10/2021. EI #2 said there was no evidence any MDS assessment was completed for RI #53, after 05/10/2021, until 02/22/2022. 2) RI #54 was admitted to the facility on [DATE]. A review of RI #54's Comprehensive MDS assessments revealed RI #54's last Comprehensive MDS assessment was transmitted to CMS on 04/13/2020. On 02/24/22 at 5:17 PM in a continued interview with EI #2, EI #2 said when CMS ended the MDS Wavier on 05/10/2021, RI #54 should have had a Comprehensive MDS assessment completed in December of 2021. When asked where was there evidence a Comprehensive MDS assessment was completed for RI #54 after 05/10/2021, EI #2 said there was no evidence one was completed. 3) RI #55 was admitted to the facility on [DATE]. A review of RI #55's MDS assessments revealed only one MDS assessment, a Comprehensive MDS assessment dated [DATE], had been transmitted to CMS since RI #55's admission to the facility. On 02/24/22 at 5:17 PM in a continued interview with EI #2, the surveyor asked EI #2 when was RI #55 admitted to the facility. EI #2 said RI #55 was admitted to the facility on [DATE]. EI #2 said the only assessment that has been completed for RI #55 was an admission MDS assessment which was completed on 2/20/2022. 4) RI #56 was admitted to the facility on [DATE], and readmitted on [DATE]. A review of RI #56's MDS assessments revealed the last Comprehensive MDS assessment transmitted to CMS was dated 04/17/2019. On 02/24/22 at 5:17 PM a continued interview was conducted with EI #2. The surveyor asked EI #2 what type MDS assessment was first completed for RI #56 after 05/10/2021. EI #2 said there was a Quarterly MDS assessment completed for RI #56 on 08/05/2021. When asked what type MDS assessment should have been completed for RI #56 after the Quarterly MDS assessment, EI #2 said RI #56 should have had an Annual MDS assessment completed in October of 2021. EI #2 said there was no evidence the Comprehensive MDS assessment had been completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) RI #153 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. A review of RI #153's Comprehensive MDS Assessments revealed RI #153 had two Quarterly MDS Assessments not completed. On 02/24/22 at 5:33 PM an interview was conducted with EI #2. EI #2 was asked when was RI #153's last comprehensive assessment completed. EI #2 said on 05/20/20 and it was a readmission. EI #2 was asked when the MDS wavier ended on 05/10/2021, what MDS assessments should have been completed. EI #2 said a quarterly in May and August of 2021. EI #2 was asked where was the evidence that the Quarterly MDS's in May and August of 2021 was done. EI #2 said there was no evidence the assessments were done. 5) RI #155 was admitted to the facility on [DATE]. A review of RI #155's MDS Assessments revealed RI #155 had two Quarterly MDS assessments not completed. On 02/24/22 at 5:33 PM an interview was conducted with EI #2. EI #2 was asked when was RI #155's last comprehensive assessment completed and what was it. EI #2 said 03/09/20 and it was a quarterly. EI #2 was asked when the MDS wavier ended on 5/10/21 what MDS assessments should have been done. EI #2 said RI #155 should have had two quarterly MDS assessments one in September and December 2021. EI #2 was asked was there evidence these assessment were completed. EI #2 said there was no evidence these assessments were completed. EI #2 was asked should these MDS assessment have been done. EI #2 said yes, it should have been done. 6) RI #153 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. A review of RI #153's Comprehensive MDS Assessments revealed RI #153's last Comprehensive MDS Assessment was transmitted to CMS on 05/20/20. On 02/24/22 at 5:33 PM an interview was conducted with EI #2. EI #2 was asked when was RI #153's last comprehensive assessment completed. EI #2 said on 05/20/20 and it was a readmission. EI #2 was asked when the MDS wavier ended on 05/10/2021, what MDS assessments should have been completed. EI #2 said a quarterly in May and August of 2021. EI #2 was asked where was the evidence that the Quarterly MDS's in May and August of 2021 was done. EI #2 said there was no evidence the assessments were done. 6) RI #101 was readmitted to the facility on [DATE]. A record review on 2/24/22 at 8:45 AM revealed a missed Quarterly Minimum Data due in December of 2021. An interview was conducted with EI #2, on 2/24/22 at 5:50 PM. EI #2 was asked when was the last MDS completed for RI #101. EI #2 stated a readmission MDS in August of 2021. EI #2 was asked what quarterly MDS was missing since May of 2021. EI #2 stated a Quarterly in December 2021. EI #2 was asked if there was any evidence the MDS had been completed. EI #2 stated there was no evidence the MDS had been completed. 7) RI #102 was readmitted to the facility on [DATE]. A record review for RI #102 revealed a missing quarterly MDS for September 2021 and December 2021. An interview was conducted with EI #2 on 2/24/22 at 5:50 PM. EI #2 was asked when was the last MDS completed for RI #102. EI #2 stated a quarterly MDS in February of 2022. EI #2 was asked what quarterly MDS was missing since May of 2021. EI #2 stated a Quarterly in September 2021 and December 2021. EI #2 was asked if there was any evidence the missing MDS had been completed. EI #2 stated there was no evidence the MDS had been completed. 8) RI #103 was readmitted to the facility on [DATE]. A record review for RI #103 revealed a missing quarterly MDS for May 2021 and August 2021. An interview was conducted with EI #2 on 2/24/22 at 5:50 PM. EI #2 was asked when was the last MDS completed for RI #103. EI #2 stated a quarterly MDS in February of 2022. EI #2 was asked what quarterly MDS was missing since May of 2021. EI #2 stated a Quarterly in May 2021 and August 2021. EI #2 was asked if there was any evidence the missing MDS had been completed. EI #2 stated there was no evidence the MDS had been completed 9) RI #104 was readmitted to the facility on [DATE]. A record review for RI #104 revealed a missing quarterly MDS for May 2021 and November 2021. An interview was conducted with EI #2 on 2/24/22 at 5:50 PM. EI 2 was asked when was the last MDS completed for RI #104. EI #2 stated an annual MDS in February of 2022. EI #2 was asked what quarterly MDS was missing since May of 2021. EI #2 stated a Quarterly in May 2021 and November 2021. EI #2 was asked if there was any evidence the missing MDS had been completed. EI #2 stated there was no evidence the MDS had been completed 10) RI #105 was readmitted to the facility on [DATE]. A record review for RI #105 revealed a missing quarterly MDS for May 2021 and November 2021. An interview was conducted with EI #2 on 2/24/22 at 5:50 PM. EI #2 was asked when was the last MDS completed for RI #104. EI #2 stated an annual MDS in February of 2022. EI #2 was asked what quarterly MDS was missing since May of 2021. EI #2 stated a Quarterly in May 2021, August 2021, and November 2021. EI #2 was asked if there was any evidence the missing MDS had been completed. EI #2 stated there was no evidence the MDS had been completed. EI #2 was asked what was the importance of completing MDS Assessments. EI #2 stated quality indicators for the facility, shows a mechanism for identifying change and helps support claims and payments. EI #2 was asked why the resident MDS were missing. EI #2 stated she did not know, due to only working at the facility for two weeks. Based on interviews, resident record review, review of the MDS (Minimum Data Set) Coordinator - Job Description, and review of the updated CMS (Centers for Medicare & Medicaid Services) QSO (Quality, Safety & [and] Oversight Group) -21-17-NH (Nursing Home) Memo, the facility failed to ensure Quarterly MDS assessments were completed in a timely manner after CMS ended the Emergency Blanket MDS waiver on 02/10/2021. This deficient practice for Resident Identifier #'s 53, 54, 55, 153, 155, 101, 102, 103, 104 and 105, 10 of 13 residents whose MDS assessments were reviewed. Findings Include: A review of the updated CMS QSO-21-17-NH Memo, with an update of 02/10/2021, revealed the following: . SUBJECT: Updates to Long-Term Care (LTC) Emergency Regulatory Waivers issued in response to COVID-19 . Ending of Select Emergency Blanket Waivers During the COVID-19 PHE (Public Health Emergency) . Emergency Blanket Waiver of Minimum Data Set (MDS) Timeframe Requirements (42 CFR 483.20) CMS waived the MDS timeframe requirement at 42 CRF 483.20 for assessments to allow providers flexibility in completing and transmitting assessments. This action was intended to allow facilities to prioritize infection control effects in response to the PHE. However, the majority of facilities have been completing and transmitting assessments timely, therefore we believe all providers should be able to complete and transmit MDS assessments as required at 42 CRF 483.20. Also, CMS believes nursing homes should have developed practices for completing these assessments timely, which are critical for resident care planning. As a result, CMS is ending the emergency blanket waiver for 42 CRF 483.20 . Review of the MDS Coordinator - Job Description, with an effective date of 01/01/2022, revealed the following: . 11. Monitors all of the facility's resident assessments and care plans to ensure that they: a. Are completed in a timely manner . 1) RI #53 was admitted to the facility on [DATE], and readmitted on [DATE]. A review of RI #53's Comprehensive MDS assessments revealed RI #53's last Quarterly MDS assessment transmitted to CMS before 03/08/2022 was on on 03/12/2019. On 02/24/2022 at 5:17 PM, an interview was conducted with Employee Identifier (EI) #2, the Interim Director of Nursing (DON). EI #2 said the last MDS assessment completed for RI #53 was on 02/22/2022, and it was a Quarterly MDS assessment. EI #2 said in May of 2021 and in November of 2021, RI #53 should have had Quarterly MDS assessments completed. The surveyor asked EI #2 where was there evidence the Quarterly MDS assessments were completed for RI #53. EI #2 said there was no evidence they had been completed. 2) RI #54 was admitted to the facility on [DATE]. A review of RI #54's Quarterly MDS assessments revealed RI #54's last Quarterly MDS assessment was transmitted to CMS on 09/06/2021. On 02/24/22 at 5:17 PM in a continued interview with EI #2. When asked when should a Quarterly MDS assessment have been completed next, EI #2 said in December of 2021, but there was no evidence one had been completed. 3) RI #55 was admitted to the facility on [DATE]. A review of RI #55's MDS assessments revealed only one MDS assessment, a Comprehensive MDS assessment dated [DATE], had been transmitted to CMS since RI #55's admission to the facility. On 02/24/22 at 5:17 PM in a continued interview with EI #2, the surveyor asked EI #2 when was RI #55 admitted to the facility. EI #2 said RI #55 was admitted to the facility on [DATE]. The surveyor asked EI #2 how many Quarterly MDS assessments should have been completed after the MDS waiver ended on 05/10/2021, EI #2 said two. When asked where was there evidence RI #55 had Quarterly assessments completed as required, EI #2 said there was no evidence RI #55 had any Quarterly MDS assessments completed.

Based on interviews, resident group meeting, the facility's document titled RESIDENT'S RIGHTS and CMS (Center for Medicare & (and) Medicaid Services) Memorandum (Memo) QSO-20-39-NH, the facility failed to implement visitation for residents of the facility since 11/12/21. This deficient practice had the potential to affect all 36 residents residing in the facility. Findings Include: An undated facility document titled RESIDENT'S RIGHTS documented: . Right to convenient visits and communications with others. A CMS Memorandum QSO-20-29-NH with a revised date of 11/12/21 documented: .Visitation Guidance: CMS is issuing new guidance for visitation in nursing homes during the COVID-19 PHE (Public Health Emergency), . Visitation is now allowed for all residents at all times . Indoor- Visitation Facilities must allow indoor visitation at all times for all residents as permitted under the regulations. facilities can no longer limit the frequency and length of visits for residents, the number of of visitors , or require advance scheduling of visits. A resident council group meeting was held on 02/24/22 at 10:00 AM with eleven residents present. All residents confirmed they have not had any family/sponsor visits in two or three months or more. On 02/24/22 at 10:27 AM an interview was conducted with EI (Employee Identifier) #1 Administrator. EI #1 was asked when families/sponsors were last able to visit. EI #1 said August 5, 2021. EI #1 was asked if the facility had started family/sponsors visitation back. EI #1 said no, the families/sponsors had not been notified of visitation. EI #1 was asked why had the facility not had family visitation since August 5, 2021. EI #1 said he, the MD (medical doctor), and Quality Assurance agreed to suspend visiting due to COVID. EI #1 had not read and was not aware of any new guidance regarding visitation. On 02/25/22 at 10:21 AM an interview was conducted with EI #4, Social Worker per phone. EI #4 was asked if families/sponsors were visiting residents. EI # 4 said no, they had not had in house visits. EI #4 was asked why had visitation not been allowed. EI #4 said because of COVID and the decision to not have visitation was not up to her, she was following the directive of the administrator. On 02/25/22 at 10:30 AM a follow up interview was conducted with EI #1. EI #1 said he had printed out a CMS Memo but had not read it. EI #1 was asked if the facility had implemented visitation for residents. EI #1 said no. EI #1 was asked why the facility had not implemented the procedure to allow visitation for all residents. EI #1 said he was not aware of the CMS Memo. EI #1 was asked if the residents had the right to have visits. EI #1 said, yes they do.

Based on observation, interview and a facility policy titled Proper Drying and Storage of Tableware the facility failed to ensure pots, pans, and serving utensils were air dried after being washed in the three compartment sink on 2/23/22 during observation of the kitchen. This had the potential to affect all residents receiving meals from the kitchen. Findings Include: A policy titled Proper Drying and Storage of Tableware, dated November 2018 documented: . All dishes, trays, utensils, . will be air dried. After proper machine and/or pot & (and) pan washing, rinsing, and sanitizing, all dishes, trays . will be air dried. On 2/23/22 at 4:52 PM, an observation was made of pots placed on top of serving utensils in the drain rack, stacked together to dry, by the three compartment sink. On 2/24/22 at 3:59 PM an interview was conducted with Employee Identifier (EI) #3, Dietary Manager. EI #3 was asked how pots and serving utensils were to be dried. EI #3 stated, air dried on a rack, after being washed in the three compartment sink. EI 3 was asked if pots should be stored on top of serving utensils to dry after being washed in the three compartment sink. EI #3 stated no, they should not be dried, stacked together. EI #3 was asked why pans should not be placed on top of serving utensils to dry. EI #3 stated, contamination, because water would drip on the serving utensils and could cause contamination. EI #3 was asked what was the potential negative outcome of placing items to dry on top of each other. EI #3 stated contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and a review of a facility policy titled, Change in Condition-Notification, the facility failed to ensure RI (Resident Identifier) #44's sponsor was notified of the resident's admission (transfer) to the hospital on 6/15/19 and readmission to the facility on 6/28/19. This deficient practice affected RI #44, one of three sampled residents who were reviewed for hospitalization. Findings include: A review of a facility policy titled, Change in Condition-Notification, with a reviewed dated of 06/2011 revealed: . The Nursing Home must promptly inform the resident and/or responsible party when there is a change in condition. Change in condition is defined as: . A decision to transfer or discharge the resident from the facility . Nursing Service Department is responsible for notification of . responsible party . Document as appropriate . RI #44 was admitted to the facility on [DATE], discharge(transferred) to the hospital on 6/15/19 and readmitted to the facility on [DATE]. RI #44's Nurses Notes documented: .6/15/2019 . Resident sent to the ER (emergency room) for bleeding . 6/28/2019 .Resident returned to facility . There was no documentation of notification of RI #44's sponsor/responsible party. On 8/8/19 at 11:35 a.m. an interview was conducted with EI ( Employee Identifier) #3, LPN (Licensed Practical Nurse). EI #3 was asked was RI #44 transferred to the hospital and readmitted to the facility. EI #3 said, RI #44 returned to the facility on 6/28/19. EI #3 was asked if she documented RI #44's admission and readmission in the nurses noted on 6/28/19. EI #3 said yes. EI #3 was asked if RI #44's sponsor/NOK (Next of kin) was notified of the resident's readmission on [DATE]. EI #3 said, I did not document it, so if I did not document it, it did not get done. EI #3 was asked if there was documentation of RI #44's sponsor/NOK being notified of his/her transfer to the hospital on 6/15/19. EI #3 said, I don't see any documentation that family was notified.EI #3 was asked if RI #44's sponsor/NOK should have been notified of his/her transfer to the hospital and readmission to the facility on 6/28/19. EI #3 said they should have. EI #3 was asked what was the facility's policy regarding a resident's change in condition. EI #3 said anytime there is a change in a resident's condition, the sponsor should be notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the CMS (Center for Medicare and Medicaid Services) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure RI (Resident Identifier ) #1's admission MDS (Minimum Data Set) assessment was completed within 14 days of admission. This deficient practice affected one of 14 sampled residents whose MDS assessments were reviewed. Findings Include: A review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Chapter 2: Assessment for the RAI (Resident Assessment Instrument) documented: .01. admission Assessment The admission Assessment is a comprehensive Assesment for a new resident and, .must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 . RI #1 was admitted to the facility on [DATE]. RI #1's admission MDS with an ARD (Assessment Reference Date) of 2/20/19 was listed as open. On 8/8/19 at 9:12 a.m., an interview was conducted with EI (Employee Indentifer) #4, MDS Coordinator. EI #4 was asked when was RI #1 admitted to the facility. EI #4 said on 2/20/19. EI #4 was asked why was RI #1's admission MDS still opened. EI #4 said it was opened and that it had not been done. EI #4 was asked should RI #1's admission MDS have been done. EI #4 said yes it should have been done. EI #4 was asked who was responsible for ensuring MDSs were done. EI #4 said the MDS Coordinator.

Based on observations, interviews, review of a facility policy titled, FOOD STORAGE LABELING and review of the 2017 Food and Drug Administration (FDA) Food Code, the facility failed to ensure: 1) Items in a standing refrigerator unit in the kitchen were labeled and dated; and 2) Two frozen turkeys were not thawing in a pan on the floor of the walk in cooler/refrigerator. This had the potential to affect all 41 residents receiving meals from the kitchen. Findings Include: 1) A review of a facility policy with a revised date of 6/2019, titled, FOOD STORAGE LABELING, revealed: POLICY: The facility will ensure the safety and quality of food by following good storage and labeling procedures. PROCEDURE: 1. All food items must be labeled with the date they are received. 2. All food items that are not in their original containers must be labeled with the common food name of the food and the date they are received. 2. Suggested labeling includes: a. Common Name b. Date of preparation or Use By Date c. Example: Food prepared on 2/1 must be used or discarded by 2/7 . On 8/05/19 at 4:10 PM, during the initial tour of the kitchen, the surveyor observed a container of red onions with no label or dating on the plastic container in the stand up refrigerator. On 08/07/19 at 3:07 PM, an interview was conducted with EI (Employee Identifier) #1, a dietary aide. EI #1 was asked who was responsible for labeling and dating food in the stand up refrigerator. EI #1 stated, Mostly the cooks or dietary staff. EI #1 was asked why was it important to label and date food in the refrigerator. EI #1 replied, Because you don't know how long its been in the refrigerator and you don't want anyone to get sick. EI #1 was asked what is the concern of not labeling and dating items in the refrigerator. EI#1 stated, Cross contamination and airborne sickness. On 08/07/19 at 3:27 PM, an interview was conducted with EI #2, the Dietary Manager. EI #2 was asked who was responsible for labeling and dating food in the stand up refrigerator. EI #2 stated, Any dietary worker in the kitchen. If you prep and prepare it then you are responsible for labeling and dating and left overs as well. EI #2 was asked why was it important to label and date food in the refrigerator. EI #2 replied, Cross contamination and certain patients may have allergies and we don't want to spread food borne illness. EI #2 was asked what is the concern of not labeling and dating items in the refrigerator. EI #2 said, it might make someone sick or cross contamination. 2) Review of the FDA Food Code 2017 revealed the following: . Preventing Contamination from the Premises 3-305.11 Food Storage. . (3) At least 15 cm (6 inches) above the floor. On 8/05/19 at 4:13 PM, during the initial tour in the walk in cooler/refrigerator, the surveyor observed two frozen turkey's on the floor of the cooler/refrigerator inside a pan thawing, according to the dietary manager. On 8/07/19 at 3:12 PM, an interview was conducted with EI #1, dietary aide. EI #1 was asked how should meats be thawed. EI #1 stated, The day before cooking, in the cooler, in the bus pan like we had it and up off the floor. EI #1 was asked if meats should be in a pan flat on the floor in the cooler being thawed. EI #1 responded, No. EI #1 was asked the concern of thawing foods in a pan flat on the floor. EI #1 stated, Something could fall off into it. On 8/07/19 at 3:41 PM, an interview was conducted with EI #2. Dietary Manager. EI #2 was asked how should meats be thawed. EI #2 stated, In refrigerator of walk in 6 inches off the floor. EI #2 was asked if meats should be in a pan flat on the floor in the cooler being thawed. EI #2 responded, No ma'am. EI # 2 was asked who placed the turkeys in the cooler on the floor and why. EI #2 said, I don't know. EI #2 was asked the concern of thawing foods in a pan flat on the floor. EI #2 stated, If on the floor a chemical on the floor could seep through the container.

Based on observation, interview and a facility policy titled, Mental Grievance Policy,the facility failed to ensure residents in the group meeting held on 07/7/17 at 10:00 a. m. were aware of the grievance process. This affected all 10 residents attending the group meeting. Finding Include: A review of a facility policy titled, Mental Grievance Policy, with a revision date of 01/31/18 documented: RESIDENT GRIEVANCE PROCEDURE GOAL To ensure that the voiced grievances of a resident are made without discrimination or reprisal in a timely manner . On 7/17/18 at 10:00 a.m., a resident council meeting was held. A total of 10 residents attended the meeting. The residents were asked if they knew how to file a grievance. All 10 residents at the meeting stated they did not know how to file a grievance. On 7/17/18 at 3:36 p.m. an interview was conducted with EI (Employee Indentifer) #2, Social Service Designee. EI #2 was asked how are residents made of aware of the how to file a written grievance. EI #2 said when she is at work she completes the form, when she is not at work residents tell the nurse and she follows up. EI #2 was asked if residents knew where to get the form to file a written grievance. EI #2 said they probably don't because she usually completes the forms. EI #2 was asked if residents were aware of the grievance process. EI #2 said, No they are not. EI #2 was asked were there notices throughout the facility about the grievance process. EI #2 said, No

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and medical record review, the facility failed to adequately code RI (Resident Identifiers) #12's and # 37's Yearly MDS (Minimum Data Set) Assessments to reflect tobacco users. This affected 2 out of 5 residents who were identified as smokers in the facility. Finding Include: RI #13 was readmitted to the facility on [DATE]. A review of RI #13's Resident Smoking assessment dated [DATE] documented resident as a smoker. A review of RI #13's Yearly MDS with an ARD (Assessment Reference Date ) of 08/17/2017 revealed Section J 1300 was not coded for tobacco use. RI #37 was admitted to the facility on [DATE]. A review of RI #37's Resident Smoking assessment dated [DATE] documented resident as a smoker. RI #37's Yearly MDS with and ARD of 06/08/2016 revealed Section J1300 was not coded for tobacco use. On 7/17/18 at 6:35 p.m., the Surveyor observed RI #13 and RI #37 smoking in designated smoking area supervised by staff. On 7/19/18 an interview was conducted with EI (Employee Identifier)#3, RN (Registered Nurse), MDS Coordinator. EI #3 was asked if RI #13 and RI #37 were smokers. EI #3 said yes. EI #3 was asked if RI #13 and RI #37 were coded on his/her yearly MDS Assessment for tobacco use. EI # 3 said, No they were not.

Based on interview, record review and a document review titled, CEU's (Continuing Education Units) for CNA's (Certified Nursing Assistant), the facility failed to ensure CNA's, Employee Identifiers (EI) #'s 5, 6, 7, 8 and 9 received 12 hours of mandatory annual training. This deficient practice affected 5 out 12 CNA's whose training records were reviewed. A review of a document titled, CEU's for CNA's, documented EI #s 5, 6, 7, 8, and 9 did not have the 12 hours of mandatory annual training for the calendar year. On 7/19/2018 at 2:19 p.m., an interview was conducted with EI #1, RN (Registered Nurse), Acting DON( Director of Nurses). EI #1 was asked how many CEUs are required for the CNA's per calendar year. EI #1 said 12 CEU's. EI #1 was asked did EI #'s 5, 6, 7, 8 7, 8, and 9 have their 12 CEU's for the calendar year. EI #1 said, No. EI #1 was asked what was the importance of CNA's having CEU's. EI #1 said to learn new things to do their job adequately.

Based on observations, interview and the facility policies titled, STORAGE OF REFRIGERATED FOOD AND FOOD STORAGE LABELING , the facility failed to ensure: 1. a container of Vanilla Icing had a used by date 2. a box of cabbages and a carton of liquid eggs had an open and use-by-date, 3. a tray of sausage and bacon was labeled and 4. 2 gallons of buttermilk was discarded on 7/9/18. This deficient practice had the potential to affected 45 of 45 residents receiving meals from the kitchen. Finding Include: A review of a facility policy titled, STORAGE OF REFRIGERATED FOOD, with revision dates November 2017- March 2018 revealed: .PROCEDURE: .5. All opened foods are labeled with common name of food,date stored and use-by-date. 6 .foods .may be stored for 7 days . A review of a facility policy titled, FOOD STORAGE LABELING, with no effective date, revealed: .POLICY The facility will ensure the safety and quality of food by following good storage and labeling procedures. PROCEDURE: .2 All food items that are not in their original containers must be labled with the common name of the food, and the date they are received .5 iv .discard foods that have passed its .use-by date or expiration date On 7/9/18 at 5:40 p.m., during the initial tour of the kitchen, the surveyor observed the following in the the walk in cooler: 1 container of Vanilla Icing dated with no used by date, a box of cabbages and a carton of liquid eggs with no open of used by date and a tray of sausage and bacon with plastic wrap with no label and 2 half of gallon of buttermilk date 7/9/18. On 07/19/18 at 9:30 an interview was conducted with Employee Identifier (EI) #4, Dietary Manager. EI # 4 was asked during the initial tour on 7/16/18, what food items in the walk in cooler did not have an open and used by date. EI #4 said a pan of breakfast meat, a carton of liquid eggs and a contain of Vanilla Icing had an open date but no use-by-date, and a box of cabbages with no label, no open or use by date. EI #4 was asked what food items in the walk in cooler had expired. EI #4 said 2 half of gallons of buttermilk with an expired date of 7/9/18. EI #4 was asked when should food items be tabled. EI #4 said any food that is open and and used required and open and used by date. EI #4 was asked what is the potential harm with food items not having an open and use- by date and expired date. EI #4 said it could caused an outbreak with one resident getting sick. in the walk in cooler did not have an open and used by date. A. The pan of breakfast meat did not have an open or used by date, a carton of liquid eggs. The Vanilla Icing container had an open date, but no use by date. The case/box cabbage did have a label, no open or used by date. Q. What food items in the walk in cooler had an expired date. A. 2 half a gallons Buttermilk and it expired on 7/9/18. Q. When should food items be labeled. A. Anything that is open and not used up fully, it is required to have an open and used by date. Q. What is the potential harm to residents when food items are not labeled, no open or used by date. A. It could cause a potential outbreak with one patient/resident being sick. EI#4 agreed with above statement.