Based on observation, interview, record review, and review of the facility policy, the facility failed to store, prepare, and serve food under sanitary conditions for 38 of 38 residents who received food prepared in the kitchen. Observations on 4/6/21 in the kitchen revealed uncovered, unrefrigerated, and unlabeled food, no dates on prepared food, storage containers containing debris and unclean workstations. Findings include: An initial tour of the kitchen was conducted on 4/6/21 at 9:21 am. Upon inspection of the sandwich prep refrigerator located by the steamtable, the following items were observed: Sliced lemons covered with no date, sliced red onion covered with no date, a green pepper cut open sitting on top of other food items unwrapped, yellow sliced cheese wrapped with no date, white sliced cheese wrapped with no date, a small container of chicken salad with no date of preparation or expiration, and a small container of egg salad with no date of preparation or expiration. An inspection of the reach-in refrigerator located by the toaster, the following items were observed: One sixth (1/6) pan of red sauce with no label identifying the contents and no date of expiration, one sixth (1/6) pan white sauce with no label identifying the content and no date of expiration, one half (1/2) gallon Cambro of red sauce with no label identifying the contents and no date of expiration, one half (1/2) pan of cooked noodles with no date of preparation or expiration, one sixth (1/6) pan of raw shrimp with no date of expiration, and two (2) one sixth (1/6) pans of raw chicken with no date of expiration. During an observation of the prep area by the cooks, the following items were observed: One sixth (1/6) pan of chopped tomatoes sitting on the counter next to toaster unrefrigerated and no date of preparation or expiration, eight (8) bags of opened bread with no date of opening or expiration, exposed slices of bread in the bottom of the storage container, one half (1/2) pan of cooked bacon and sausage covered with no date of preparation sitting on the counter by the toaster unrefrigerated, an opened box of eight (8) croissants with no date of expiration, one sixth (1/6) pan of cooked scrambled eggs with cheese sitting on the prep counter unrefrigerated, uncovered with no date of preparation or expiration, and one sixth (1/6) pan of pureed meat uncovered and unrefrigerated. During an inspection of the reach-in refrigerator labeled number five (#5), the following was observed: One sixth (1/6) containers of: sliced cucumbers, chopped onions, olives, shredded cheese, sliced mushrooms and parmesan cheese were uncovered with no dates of preparation and expiration, six (6) Styrofoam containers of ambrosia with no date of preparation or expiration, one (1) gallon of mayonnaise opened with no date of opening or expiration, one (1) gallon of mayonnaise opened with no lid and no date of opening, one (1) gallon of Caesar salad dressing opened with no date of opening or expiration, and a 12-quart Cambro with yellow liquid with no label identifying the contents and no date of preparation or expiration. The bottom of the refrigerator contained dried pieces of food and debris. An inspection of the dry storage room revealed six (6) Cambro storage bins with dirty lids. The bins labeled rice flour, rice and cornmeal had scoops in the product. The baseboard by the entrance to the bakery was missing and the wall was broken, exposing the interior of the wall. During an observation of the walk-in freezer, the following items were observed: A bag of frozen Brussel Sprouts was opened exposing the contents, ice had formed on the top of the product and a tray of 12 vegie burgers were unwrapped with no date of expiration. An inspection of the walk-in refrigerator revealed a large Cambro of fruit cocktail that had no date of preparation or expiration. Two (2) trays of sliced carrots, one (1) tray of asparagus and 16 bowls of fresh fruit were uncovered with no date of preparation or expiration. An inspection of the cook's area revealed a build-up of grease on the floor and fryer mechanism around the deep fryer. A one half (1/2) pan labeled roux, undated and unrefrigerated, was stored on the bottom shelf. An opened box of cream of wheat cereal had no date of opening and there was an undated opened bag of grits. The shelves were covered with a white dried substance. In an interview on 4/6/21 at 12:22 p.m. with the Certified Dietary Manager (CDM), he/she stated that he/she had been the manager of the kitchen since January of 2021. An observation of the cleaning schedule was conducted with the CDM. The posted cleaning schedule dated 3/19/21 through 3/25/21 and titled Culinary Sanitation Schedule had three pages of 26 kitchen sanitation assignments. On 3/19/21 and 3/25/21, there were no signatures on the schedule indicating completion of cleaning duties. On 3/20/21, 13 of the 26-kitchen sanitation assignments had signatures of completion. On 3/21/21, there were three (3) of 26 tasks signed as completed. On 3/22/21, there were two (2) of 26 tasks signed as completed. On 3/23/21, there were five (5) of 26 tasks signed as completed. On 3/24/21, there were five (5) of 26 tasks signed as completed. The CDM stated that the schedule was maintained and monitored for completion by the executive chef who was currently on vacation and unavailable for an interview. The CDM stated that it was his/her responsibility to maintain and monitor the schedule when the executive chef was not available. He/she stated that he/she was not aware there was not a current cleaning schedule posted. He/she agreed that an unsigned cleaning tasks would indicate an incomplete task and that all the spaces on the cleaning schedule should be signed as completed. During the interview the CDM was asked if there was any current sanitation in-service provided for the kitchen staff. The CDM stated that he/she did huddles with the staff to cover topics because he/she was concerned with group meetings due to the pandemic. The DM provided copies an in-service dated 6/30/2020 which included topics of wrapping, labeling, dating, and re-closing bags. The in-service was signed by 17 employees that had attended the training. The DM stated that this had been the last documented official in-service. The DM also provided a copy of the huddle attendance sheet. A review of the attendance sheet dated 1/26/21, 2/1/21, and 2/24/21 documented the employees who were in attendance of the meetings, but no topics were documented for those meetings. The meeting dated 3/9/21 documented the employees who attended with a topic sheet attached which included labeling and dating, kitchen, and service area inspection as discussion topics. A review of the policy titled Cleaning and Sanitation Culinary and Nutrition Department, dated 11/13, documented that the Culinary and Nutrition (CNS) Services management team was responsible for developing a written daily cleaning schedule and assuring compliance with the schedule. A review of the policy titled Date Marking Read-To-Eat Foods, dated 12/17, documented that all ready-to-eat foods must be labeled with the product name, and date the product was prepared or opened and the date the product should be used by and that all potentially hazardous foods should be refrigerated at 41 degrees or below.

Based on observations, interviews, and review of a facility policy titled PERSONAL APPEARANCE STANDARDS, the facility failed to ensure: 1) opened and undated foods were not observed in the freezer; 2) the ice machine was not found with a black residue inside the ice storage compartment; and 3) hair was not uncovered on staff while working in the kitchen. This had the potential to affect all forty-two residents receiving meals from the kitchen. Findings Include: 1) On 2/12/2019 at 7:56 AM, during the tour of the kitchen, a brown paper bag of hashbrowns was observed opened and exposed with no date. A brown paper bag of tater tots was also observed open and exposed to air, without a date. On 2/14/2019 at 1:35 PM, Employee Identifier (EI) 3, the Director of Culinary Services, was interviewed. When asked what the facility's policy was regarding opened and undated food items in the freezer, EI #3 said the items should be sealed and dated, and if there was no date, the item should be discarded. He said if items were open and exposed or undated, there was a potential for contamination. 2) On 2/12/2019 at 7:56 AM, during the tour of the kitchen the ice machine was noted with a black substance on the left wall, above the ice. A black substance was also noted on the white strip that crosses over the ice, and attaches to the ceiling of the ice storage bin. On 2/14/2019 at 11:03 AM , EI #3 was asked to use a white napkin or paper towel to wipe across the left wall inside the storage unit containing ice. As EI #3 wiped the black residue with the dry white napkin, residue was observed on the napkin, and EI #3 confirmed its presence. EI #3 then wiped the white strip with the napkin, and a moderate amount of black residue was observed on the napkin. The same residue was noted when EI #3 wiped the back of the ice storage unit above the ice. During an interview on 2/14/2019 at 1:35 PM, EI #3 said the black substance was observed in the ice machine because it was not being cleaned as frequently as it should. EI #3 also stated the black residue/substance inside the ice storage unit created the potential for contamination. 3) Review of the facility policy titled PERSONAL APPEARANCE STANDARDS, revised 1/2016, revealed the following: .PROCEDURE: 3. Freshly shaven face 4. Men with facial hair, moustache and/or beard, must wear a bear guard while in the production kitchen. 5. Hair restraints such as hats, hair coverings, or nets, and clothing that cover's body hair shall be worn when in the production area where food is prepared or plated . On 2/13/19 at 5:04 PM, EI #9 was observed in the kitchen with two hair pieces outside of his hair restraint. 02/13/19 at 5:26 PM EI #9 was observed in the kitchen washing dishes with two long pieces of hair hanging out of his hair restraint. EI #9 then walked over beside the food tray line. EI #9 confirmed he had hair outside of his hair restraint. When asked the concern with that, EI #9 said the hair could get into the residents' food. On 2/13/19 at 5:06 PM EI #7, a Cook, was observed at tray line with a hat on, but no mustache restraint. On 2/13/19 at 5:38, EI #3, the Director of Culinary Services, confirmed the male staff member in the serving area (EI #7) had a mustache, but was not wearing a restraint. EI #3 said EI #7 should have been wearing a mustache restraint to prevent hair from getting in the food and causing cross contamination. EI #7, the Cook, was interviewed on 2/13/19 at 5:43 PM. EI #7 confirmed he was not wearing a mustache restrain when he was on the serving line. EI #7 said the concern in that was that hair could get in the food and cause contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and a review of POTTER/[NAME], FUNDAMENTALS OF NURSING the facility failed to ensure the documents of an abuse investigation were complete and correct as evidenced by forms with no dates, times, and incorrect dates. This was revealed in one of three allegations of abuse reported to the State Agency and affected RI (Resident Identifier) #4, one of three reports reviewed for alleged abuse. Findings Include: A review of POTTER/[NAME], FUNDAMENTALS OF NURSING, 9TH EDITION, Chapter twenty-six, Documentation, page 361, revealed: .Guidelines for Quality Documentation, . High quality documentation is necessary to enhance efficient, individualized patient care. Quality documentation has five important characteristics: it is factual, accurate, complete . Accurate . you need to date and time all entries in medical records and there needs to be a method to identify the author of all entries. A review of the allegation of abuse report for RI #4 revealed the following: A facility form titled, Incident Report Residents & (and) Visitors had an entry space for the date and time at the top of the form. The entry date on the form was 12/9/17, with a time entry of 10:30 (the Administrator stated he entered the time, the nurse did not). The form required additional resident information, such as name, room number, record number, diagnoses, medications, and information related to the incident, such as what happened to the resident, if the incident was witnessed and by whom, and who was notified about the incident. At the bottom of the form there was a place for the signature of the author, Person/title Preparing Report: (signed by the nurse completing the form). DATE: (ACTUAL DATE WRITTEN IN) 8/9/17. There was a hand written document in the file, written by the same nurse who signed the incident report, with a date of 12/9/17 and a time of 1:50 (did not indicate a.m. or p.m.). In this allegation of abuse file for RI #4, there was a witness statement dated 10/9/17. In addition, another witness statement was dated at the top of the form 12/9/17 and at the bottom of the page dated 12/10/17. A review of the nursing notes for RI #4 for 12/9/17, revealed a time entry of 4:00 p.m. by the R.N. (Registered Nurse) supervisor who reported the allegation of abuse to the Abuse Coordinator. A review of all nursing documentation for RI #4 was reviewed for 12/9/17 and there were no other entries made for 12/9/17. On 2/28/18 at 11:49 a.m. an interview was conducted with EI (Employee Identifier)#7, a LPN (Licensed Practical Nurse). EI #7 was the charge nurse working on the 7-3 shift on 12/9/17, when the alleged physical abuse was observed and reported. EI #7 was asked if EI #6, a CNA, reported anything to her on 12/9/17, regarding RI #4, the resident listed in the abuse allegation. EI #7 replied yes. EI #7 stated that EI #6 reported RI #4 was slapped in the face by a visitor. EI #7 was asked what was done. EI #7 replied EI #6 (CNA) was instructed to report the incident to the Supervisor on the shift. EI #7 also stated the incident was reported by her to the Supervisor. EI #7 was asked what time the incident occurred. EI #7 replied it was in the morning. EI #7 was asked where the documentation of EI #6's report to her was located. EI #7 replied it was not documented. On 02/28/18 at 2:01 p.m., an interview was conducted with EI #6. EI #6 was asked to look at the witness statement she completed. EI #6 stated the statement was her writing, however, the date entry did not look like her hand writing. EI #6 stated she wrote the statement but she did not know if she could say she put the date on the form at the top. EI #6 said the statement was brought back to her to date and she dated the statement at the bottom by her name. On 2/28/18 at 4:18 p.m., the surveyor asked EI #1, DON (Director of Nursing) to look at RI #4's 12/9/17 allegation of abuse investigation report. EI #1 was asked if she saw anything unusual about the documents in the report. EI #1 replied yes the dates were all over the place. EI #1 stated the report should have been checked more carefully for correctness, completeness, full dates and times on reports. On 03/01/2018 at 11:30 a.m., EI #2, the Administrator, was asked to look at the abuse allegation file for RI #4. EI #2 was asked if he saw anything that was a possible concern to him in the file. EI #2 stated the CNA (EI #6) changed her story a little. EI #2 was asked about the dates and times on the different documents in the file. EI #2 replied he entered this 10:30 time on the incident report. EI #2 was asked where he obtained that time and EI #2 could not determine the answer to the question. An interview was conducted with EI #3, the Regional DON, at 2:45 p.m. on 03/01/2018 related to the documentation issues in RI #4's alleged abuse file. EI #3 was asked if she had reviewed this file and she replied no, however, she should have before it was sent to anyone. EI #3 stated documentation was to be complete and accurate on all forms to include dates and times with the signature of the person documenting.

Based on interviews and a review of a facility policy titled, Abuse, Neglect . the facility failed to ensure the Abuse Policy indicated the reporting time of alleged abuse within two hours of being reported by staff to administration. This affected RI #4, #5, and #15, three of three residents named in allegations of abuse reviewed and had the potential to affect all residents involved in abuse allegations residing in the facility. Findings Include: A review of the facility's policy titled, SUBJECT: ABUSE, NEGLECT, INVOLUNTARY SECLUSION, EXPLOITATION, AND MISAPPROPRIATION OF PROPERTY PREVENTION, with a revision date of 11/17, revealed: POLICY: To strive to ensure residents will be safeguarded and protected from any form of abuse, . PURPOSE: The purpose of this policy is to promote the maintenance of a living environment that fosters the reporting of concerns/problems and protects residents; preserving their dignity and quality of life . Reporting: . 4. The executive director, administrator, or designee will take the following actions: A. Notify the appropriate state agency immediately (within 24 hours) . Three allegations of abuse that were facility-reported to the State Agency were reviewed. The allegations revealed the following: 1) An allegation of Physical Abuse with the alleged occurrence date and time of 12/09/17 at 10:30 a.m. was submitted to the Alabama Department of Public Health on 12/10/17 at 10:49 a.m. 2) An allegation of Physical Abuse with an alleged occurrence date and time of 12/17/17 at 12:00 p.m. was submitted to the Alabama Department of Public Health on 12/20/17 at 9:40 a.m. 3) An allegation of Verbal Abuse with an alleged occurrence date and time of 1/29/18 at 7:00 p.m. was submitted to the Alabama Department of Public Health on 1/30/18 at 12:46 p.m. On 02/28/18 at 4:18 p.m., an interview was conducted with EI (Employee Identifier) #1, the Director of Nursing. EI #1 was asked what was the facility's policy regarding reporting allegations of abuse. EI #1 replied the abuse policy indicated any suspicion of any types of abuse should be reported immediately by the staff to a supervisor or to the Abuse Coordinator. EI #1 said if there was bodily injury, they (facility) have to report it within two hours and, other than that, they have 24 hours to report. EI #1 was given a copy of the facility's Abuse Policy to review and was asked where the above information mentioned was located in the Abuse Policy. EI #1 stated the policy provided was not the policy on the reporting times and that it was in another policy. EI #1 provided the policy related to reporting times. However, the policy provided to the surveyor was in regards to crimes related to the elderly. The policy did not include the required two hour reporting of alleged abuse. On 03/01/18 at 8:14 a.m., an interview was conducted with EI #2, the Administrator. EI #2 was asked what was the regulation requirement for reporting alleged abuse. EI #2 replied if there was willful physical abuse they (facility) have a two hour window to report the alleged abuse. EI #2 further stated that all other reportable concerns or complaints of possible abuse were to be reported within 24 hours by the facility. EI #2 indicated he was the Abuse Coordinator and he was responsible for getting the reports done per policy. EI #2 was asked who reviewed and revised policies and procedures. EI #2 replied policies and procedures were reviewed and revised at the corporate level. EI #2 continued to say, he learned about the new revision and new policies and procedures at regional meetings and when new policies were sent out. EI #2 added the two hour rule was just an over-site by all of them. EI #2 stated he knew there was a new two hour regulation. EI #2 continued by stating he really did not read the new revision that closely. EI #2 stated he thought the regulation was included in the revision done on 11/17.

Based on interviews, review of abuse allegation files, and the review of a facility policy titled, Abuse, Neglect ., the facility failed to ensure three allegations of abuse were reported to the State Agency within two hours of being reported by staff to the administration. This affected RI (Resident Identifier) #4, #5, and #15, three of three residents named in allegations of abuse the facility reported to the State Agency and had the potential to affect all residents involved in abuse allegations residing in the facility. Findings Include: A review of the facility's policy titled, SUBJECT: ABUSE, NEGLECT, INVOLUNTARY SECLUSION, EXPLOITATION, AND MISAPPROPRIATION OF PROPERTY PREVENTION, with a revision date of 11/17, revealed: POLICY: To strive to ensure residents will be safeguarded and protected from any form of abuse, . PURPOSE: The purpose of this policy is to promote the maintenance of a living environment that fosters the reporting of concerns/problems and protects residents; preserving their dignity and quality of life . Reporting: . 4. The executive director, administrator, or designee will take the following actions: A. Notify the appropriate state agency immediately (within 24 hours) . Three allegations of abuse that were facility-reported to the State Agency were reviewed. The allegations revealed the following: 1) An allegation of Physical Abuse with the alleged occurrence date and time of 12/09/17 at 10:30 a.m. was submitted to the Alabama Department of Public Health on 12/10/17 at 10:49 a.m. 2) An allegation of Physical Abuse with an alleged occurrence date and time of 12/17/17 at 12:00 p.m. was submitted to the Alabama Department of Public Health on 12/20/17 at 9:40 a.m. 3) An allegation of Verbal Abuse with an alleged occurrence date and time of 1/29/18 at 7:00 p.m. was submitted to the Alabama Department of Public Health on 1/30/18 at 12:46 p.m. On 02/28/18 at 4:18 p.m., an interview was conducted with EI (Employee Identifier) #1, the DON (Director of Nursing). EI #1 was asked what was the facility's policy regarding reporting allegations of abuse. EI #1 replied the abuse policy indicated any suspicion of any types of abuse should be reported immediately by the staff to a supervisor or the Abuse Coordinator. EI #1 further stated if there was bodily injury they (facility) had to report it within two hours. EI #1 was asked if the above allegations of abuse were reported as the regulation required within two hours and EI #2 replied no. An interview was conducted on 03/01/18 at 8:14 a.m. with EI #2, the Administrator. EI #2 was asked what the facility's abuse policy indicated regarding the reporting of alleged abuse. EI #2 replied with the new regulation there was a new requirement that with physical abuse they had a two hour window to report it and all other reportable issues they had 24 hours to report. EI #2 stated he was the Abuse Coordinator and he was responsible for completing the reports per policy. EI #2 was asked if the facility had any allegations in the past twelve months that had been reported to the State Agency. EI #2 replied yes. EI #2 was asked how many and he replied six, but only three since the new regulations went into place. EI #2 was asked to review each of the three allegations reported since the new regulation became effective November 28, 2017. EI #2 stated all three allegations were related to alleged abuse, were reported immediately to a supervisor, and reported within 24 hours to the State Agency. EI #2 was asked if the facility was in compliance with the new reporting requirement of reporting all alleged abuse within two hours. EI #2 replied no. EI #2 was asked if he knew about the new regulation of reporting all alleged abuse within two hours. EI #2 replied yes, but it had to be willful physical abuse to be reported in the two hour regulation. EI #2 said he was aware the regulations were changed in November of 2017 to the two hour rule for an allegation of willful intent of abuse. An interview was conducted on 03/1/2018 at 2:45 p.m. with EI #3, the Regional Director of Nursing. EI #3 was asked what was the required time frame for reporting allegations of abuse. EI #3 replied their policy was based on the ELDER JUSTICE ACT. This surveyor explained the question was about abuse and not a crime. EI #3 was asked again what was the required reporting time for alleged abuse. EI #3 replied it was 24 hours. EI #3 then called the Clinical Supervisor and was told by the Clinical Supervisor, We missed it, we all missed it. All DON's, Corporate Compliance, and Corporate Regulatory. We missed the word or which makes all alleged abuse reportable within two hours.

Based on interviews, the Abuse Policy, and Alleged Abuse Reports submitted to the State Agency from 11/17 to 02/18, the facility failed to ensure the Administrator, who was responsible for the overall management of the facility, and the Director of Nursing, who was responsible for the overall management of the Nursing Department, ensured the facility reported alleged abuse of three residents within the two hour required time period. This affected RI (Resident Identifier) #4, #5, and RI #15, three of three residents named in alleged abuse incidents from 11/17 through 2/18, and had the potential to affect all residents involved in abuse allegations residing at the facility. Findings Include: A review of the facility's policy titled, SUBJECT: ABUSE, NEGLECT, INVOLUNTARY SECLUSION, EXPLOITATION, AND MISAPPROPRIATION OF PROPERTY PREVENTION with a revision date of 11/17, revealed: POLICY: To strive to ensure residents will be safeguarded and protected from any form of abuse, . PURPOSE: The purpose of this policy is to promote the maintenance of a living environment that fosters the reporting of concerns/problems and protects residents; preserving their dignity and quality of life . Reporting: . 1. Anyone who finds injury of unknown origin must immediately report the incident. 2. Anyone who witnesses and/or suspects an incident of resident abuse (verbal, sexual, mental, or physical), neglect, mistreatment, exploitation, involuntary seclusion, and misappropriation of property must immediately report the incident. 4. The executive director, administrator, or designee will take the following actions: A. Notify the appropriate state agency immediately (within 24 hours .) . A review of Abuse allegations submitted by the facility to the State Agency revealed: An allegation of physical abuse with the alleged occurrence date and time of 12/09/17 at 10:30 a.m. was submitted to the Alabama Department of Public Health on 12/10/17 at 10:49 a.m. An allegation of physical abuse with an alleged occurrence date and time of 12/17/17 at 12:00 p.m. was submitted to the Alabama Department of Public Health on 12/20/17 at 9:40 a.m. An allegation of verbal abuse with an alleged occurrence date and time of 1/29/18 at 7:00 p.m. was submitted to the Alabama Department of Public Health on 1/30/18 at 12:46 p.m. On 02/28/18 at 4:18 p.m., an interview was conducted with EI (Employee Identifier) #1, the DON (Director of Nursing). EI #1 was asked what was the facility's policy regarding reporting allegations of abuse. EI #1 replied the abuse policy was any suspicion of any type of abuse should be reported immediately by the staff to a supervisor or the Abuse Coordinator. If there was bodily injury, they have to report to the State Agency within two hours. EI #1 added other than that, they have 24 hours to report all other allegations. EI #1 was given a copy of the facility's Abuse Policy to review and was asked where the above information mentioned was located. EI #1 stated the policy provided was not the policy on the reporting times and that it was in another policy. EI #1 provided the policy related to reporting times. However, the policy provided to the surveyor was in regards to crimes related to the elderly. The policy did not include the required two hour reporting of abuse. EI #1 was asked if the facility had reported any allegations of abuse in the past twelve months. EI #1 replied yes they had. The surveyor gave EI #1 copies of the allegations of abuse for November 2017, December 2017, and January 2018. EI #1 was asked had the facility met the requirement of the reporting of abuse. EI #1 replied no. EI #1 was asked why the allegations of abuse were not reported within two hours. EI #1 replied there was confusion with the new regulations about the two hour time frame. EI #1 added they thought they still had 24 hours, unless there was serious bodily injury. EI #1 was asked who was responsible for reporting alleged abuse to the State Agency. EI #1 replied the Administrator and herself, the DON. An interview was conducted on 03/01/18 at 8:14 a.m. with EI #2, the Administrator. EI #2 was asked what the facility's abuse policy indicated regarding the reporting of alleged abuse. EI #2 replied with the new regulation there was a new requirement that with willful physical abuse they had a two hour window to report to the State Agency. EI #2 added with all other reportable concerns they had 24 hours to report. EI #2 reported he was the Abuse Coordinator, so he was responsible to get the reports done per policy. EI #2 was asked if the facility had any allegations of abuse in the past twelve months that had been reported to the State Agency. EI #2 replied yes. EI #2 was asked how many and he replied six, with only three occurring since the new regulations went into place. EI #2 was asked to review each of the three allegations reported since the new regulation became effective November 28, 2017. EI #2 stated all three allegations were related to alleged abuse, were reported immediately to a supervisor, and reported within 24 hours to the State Agency. EI #2 was asked if the facility was in compliance with the new reporting requirement of reporting all alleged abuse within two hours. EI #2 replied no. EI #2 was asked if he knew about the new regulation of reporting all alleged abuse within two hours. EI #2 replied yes, but it had to be willful physical abuse to be reported in the two hour regulation. EI #2 said he was aware the regulations were changed in November of 2017 to the two hour rule for an allegation of willful intent of abuse. EI #2 stated it was his understanding as he said above, policies on abuse were reviewed with him with the changes also. EI #2 was asked who reviewed the abuse policy and changes with the QAPI (Quality Assurance and Performance Improvement) committee at the meeting on 12/17. EI #2 replied he did, (the Administrator) and EI #3, the Regional Director of Nursing. EI #2 stated he just assumed the two hour rule was in the revision, he did not read it all.

Based on record review of the policy titled, SUBJECT: ABUSE, NEGLECT, INVOLUNTARY SECLUSION, EXPLOITATION, AND MISAPPROPRIATION OF PROPERTY PREVENTION, and interviews, the facility failed to ensure the Governing Body maintained a process that ensured the abuse policy contained the correct time frame for reporting alleged abuse. This was evidenced by the Abuse Policy not indicating the required two hour reporting period for all alleged abuse. This affected RI (Resident Identifier) #4, #5, and #15, three of three residents with facility reported alleged abuse allegations and had the potential to affect all residents involved in abuse allegations who reside in the facility. Findings Include: A review of the facility's policy titled, SUBJECT: ABUSE, NEGLECT, INVOLUNTARY SECLUSION, EXPLOITATION, AND MISAPPROPRIATION OF PROPERTY PREVENTION, with a revision date of 11/17, revealed: POLICY: To strive to ensure residents will be safeguarded and protected from any form of abuse, . Reporting: . 1. Anyone who finds injury of unknown origin must immediately report the incident. 2. Anyone who witnesses and/or suspects an incident of resident abuse (verbal, sexual, mental, or physical), neglect, mistreatment, exploitation, involuntary seclusion, and misappropriation of property must immediately report the incident. 4. The executive director, administrator, or designee will take the following actions: A. Notify the appropriate state agency immediately (within 24 hours .) . Three allegations of abuse that were facility-reported to the State Agency were reviewed. The allegations revealed the following: 1) An allegation of Physical Abuse with the alleged occurrence date and time of 12/09/17 at 10:30 a.m. was submitted to the Alabama Department of Public Health on 12/10/17 at 10:49 a.m. 2) An allegation of Physical Abuse with an alleged occurrence date and time of 12/17/2017 at 12:00 p.m. was submitted to the Alabama Department of Public Health on 12/20/17 at 9:40 a.m. 3) An allegation of Verbal Abuse with an alleged occurrence date and time of 1/29/18 at 7:00 p.m. was submitted to the Alabama Department of Public Health on 1/30/18 at 12:46 p.m. 03/01/18 8:14 a.m., an interview was conducted with EI (Employee Identifier) #2, the Administrator. EI #2 was asked what was the regulation requirement for reporting alleged abuse. EI #2 replied if there was willful physical abuse they had a two hour window to report. EI #2 said with all other reportable concerns, they had 24 hours. EI #2 stated he was the Abuse Coordinator so he was responsible for getting the reports done per policy. EI #2 was asked who reviewed and revised policy and procedures. EI #2 replied it was done at the corporate level. EI #2 stated he learned about it at meetings and when new policies were sent out. EI #2 said the two hour rule was just an over-site by all of them. EI #2 stated he knew there was a new two hour regulation for reporting. EI #2 continued and said he really did not read the new revision that closely. An interview was conducted on 03/01/18 at 2:45 p.m. with EI #3, the Regional Director of Nursing. EI #3 was asked what was the required time frame for reporting allegations of abuse. EI #3 replied their policy was based on the Elder Justice Act. This surveyor explained the question was about abuse and not a crime. EI #3 was asked again what was the required reporting time for alleged abuse. EI #3 replied it was 24 hours. EI #3 then called the Clinical Supervisor and returned a call to this surveyor. EI #3 said she was told by the Clinical Supervisor they missed it, they all missed it, (all DON's, Corporate Compliance, and Corporate Regulatory). EI #3 said they missed the word or. EI #3 was asked who and how were polices reviewed and revised. EI #3 replied the Regional DONs review and revise policy and procedure. Once the revision was completed the policy/procedure was reviewed by Corporate Compliance then the Corporate Regulatory Department reviewed the policy/procedure before releasing the new or revised policy/procedure to the facility. EI #3 stated as she said, they (Regional DON, Corporate Compliance and Corporate Regulatory) all missed it (the language for the two hour reporting period for all alleged abuse). EI #3 was asked if the changes were introduced to the QAPI (Quaility Assurance/Performance Improvement) Committee and to the Governing Body. EI #3 replied no not the way they should have been. EI #3 was asked should the QAPI Committee and Governing Body have been made aware of the new regulatory requirements of reporting all alleged abuse in two hours. EI #3 replied yes.

Based on interviews and a review of the facility policy and procedure titled, Subject: Quality Assurance, Performance Improvement (QAPI) and Compliance Program, the facility failed to ensure the QAPI committee reviewed and identified the required regulatory change for reporting allegations of abuse within two hours to the State Agency. This affected three of three reported allegations of abuse submitted to the Alabama Department of Public Health and had the potential to affect all residents involved in abuse allegations residing in the facility. Findings Include: A review of a facility policy titled,Quality Assurance, Performance Improvement and Compliance Manual, revealed: Subject: Quality Assurance, Performance Improvement (QAPI) and Compliance Program Purpose: The purpose of . is to take a proactive approach to strive to continually improve the quality of life, care and services for our residents, caregivers, and other partners legally, morally and ethically. To do this, employees will participate in ongoing QAPI and compliance efforts through the continuous evaluation of care and services provided on behalf of Improvement (QAPI) and Compliance Program. There are five (5) elements (building blocks) for developing, implementing, and sustaining QAPI and compliance. 1. Design and Scope - The QAPI and Compliance program should: . c. Address systems of care and management practices, including clinical care, quality of life, resident choice toward a person-centered environment, and care transitions. d. Aim for safety and high quality using best practices 2. Governance and Leadership - Administration should: a. Develop and lead the QAPI and Compliance program m. Ensure each department provides documented, routine, scheduled training, mandatory compliance education, code-of-conduct, in-services, that include all employees, advising them of the changes in policy, procedures, . Three allegations of abuse that were facility-reported to the State Agency were reviewed. The allegations revealed the following: 1) An allegation of Physical Abuse with the alleged occurrence date and time of 12/09/2017 at 10:30 a.m. was submitted to the Alabama Department of Public Health on 12/10/2017 at 10:49 a.m. 2) An allegation of Physical Abuse with an alleged occurrence date and time of 12/17/2017 at 12:00 p.m. was submitted to the Alabama Department of Public Health on 12/20/2017 at 9:40 a.m. 3) An allegation of Verbal Abuse with an alleged occurrence date and time of 1/29/2018 at 7:00 p.m. was submitted to the Alabama Department of Public Health on 1/30/2018 at 12:46 p.m. An interview was conducted on 03/01/2018 at 11:30 a.m. with EI (Employee Identifier) #2, the Administrator. EI #2 was asked how he was made aware of changes in policy and procedures. Also, how he was made aware of the changes to the reporting regulation on abuse. EI #2 replied it was reviewed with him. EI #2 was asked who reviewed the changes at the QAPI meeting on 12/17. EI #2 replied he and the Regional Director of Nursing reviewed the changes. EI #2 stated that he assumed the two hour rule was in the revision, however, he had not read it all. EI #2 stated QA policy changes was only a very small part of what they (QAPI) did. EI #2 reported the changes had been discussed in the Regional Director of Nursing and the Regional Administrators meeting. EI #2 stated no one attending the QAPI meeting had identified the two hour requirement was not in the revision. An interview was conducted on 03/01/2018 at 2:45 p.m. with EI #3, the Regional Director of Nursing. EI #3 was asked how changes in policy were shared with the facility and if the changes were to be presented to the QAPI committee. EI #3 replied each facility received the updated and changed policies and the new/revised policies were presented to the QAPI committee for approval prior to sharing with the staff.

Based on observations, interviews and record reviews, including the facility's policy titled, SUBJECT: OPERATIONAL STANDARDS REFRIGERATOR, and the Food and Drug Administration Food Code, the facility failed to ensure: 1) a container of chopped fruits, a tray of hamburger patties, and a container of green beans had an expiration date on them; 2) a tray of fruit cups and bowls of bread pudding were covered and dated; and 3) a pan of brownies in the cooler was covered. This affected 40 of 40 residents who receive a meal from the kitchen. Findings Include: A review of the Food and Drug Administration Food Code 2013, Chapter 3 Food Storage page 76, revealed the following: .3-305-11 Food Storage : (A) Except as specified in (B) and (C) of this section, Food shall be protected from contamination by storing the FOOD: .(2) Where it is not exposed to splash, dust, or other contamination; and A review of a facility policy, SUBJECT: OPERATIONAL STANDARDS REFRIGERATOR, with a revision date of 2/17, revealed: POLICY: To strive to ensure all refrigerators (kitchens, pantries and country kitchens) are maintained at all times. PROCEDURE: .4. Food is properly stored in appropriate containers labeled with product name, date prepared/opened, use-by date and employee initials 1) During the initial tour of the kitchen on 2/26/18 at 4:15 p.m., containers of chopped fruit (pineapple, honey dew melon, and cantaloupe) were observed to not have expiration dates. A tray of hamburger patties and a container of cooked green beans also did not have expiration dates on them. An observation was made of the dessert refrigerator. There was a tray of fruit cups and bread pudding with no covering or expiration dates. Further, a half pan of brownies was observed uncovered and without an expiration date. On 3/01/18 at 2:53 p.m., an interview was conducted with EI (Employee Identifier) #4, Director of Culinary and Nutrition Services. EI #4 was asked if these foods should have been dated with an expiration date. EI #4 answered yes. EI #4 was asked why they were not properly dated. EI #4 explained the sous/chef placed the items in the cooler, put his initial on them, but failed to put an expiration date. EI #4 was asked how should food be stored in the cooler. EI #4 said they should be placed in a container, covered and dated. EI # 4 was asked what was the facility's policy regarding the proper storage of foods. EI #4 said food should have a date of when it was placed in the cooler, when it was opened, and when it should be discarded. EI #4 was asked what was the concern of not having foods labeled properly. EI #4 said spoilage and foodborne illness. On 3/01/18 at 3:00 p.m., an interview was conducted with EI #5, the Executive Chef. EI #5 was asked should a container of pineapple, honeydew melons, and cantaloupe have been stored in the cooler without an expiration date. EI #5 answered no. EI #5 was asked why they did not have the proper labeling. EI #5 said she did not believe it was labeled because the sous/chef did not know better and she believed he just overlooked it. EI #5 was asked would staff know when these foods should be discarded if they were not dated. EI #5 said it should be automatically thrown out if there were no dates. EI #5 was asked how should foods be stored in the cooler. EI #5 said foods should be covered and labeled and dated. EI #5 was asked why was a tray of fruit bowls, cups of bread pudding, and a half of pan of brownies with a knife laying in the pan stored in the dessert cooler without covering or expiration dates on them. EI #5 said someone failed to follow company procedure. EI #5 was asked should foods be stored without being covered. EI #5 said no. EI #5 was asked what was the concern of not having foods labeled properly. EI #5 said residents and guest could potentially become ill from undated and spoiled foods.