Every finding on record at Bedford Care Ctr-Monroe Hall

Based on observations, interviews, and policy reviews, the facility failed to ensure food safety on one (1) of four (4) survey days. Specifically, the facility failed to remove out-of-date grape juice from the reach-in cooler, failed to remove (34) four-ounce containers of expired yogurt from the refrigerator, and failed to prevent the service of expired food items to residents. Findings Include:A review of the facility's policy, Food Safety Requirements, revised 11/21/22, revealed, .Food will be served in accordance with professional standards for food service safety.Policy Interpretation and Implementation.8c. Additional strategies to prevent foodborne illness include.iv. Labeling, dating, and monitoring refrigerated foods so it is used by the use-by date or discarded.A review of the facility's policy, Food Receiving and Storage, reviewed 10/3/22, revealed, Food shall be stored in a manner that complies with safe food handling practices.Policy Interpretation and Implementation.14.The manufacturer's code will be used when available and may include a manufactured-on date, a best buy date, or an expiration date.On 8/25/25, at 10:07 AM, observation during the initial kitchen tour with the Dietary Manager, revealed there was one (1) container of grape juice in Reach-In Cooler #1 with an expiration date of 5/19/25. The Dietary Manager confirmed the finding and acknowledged the grape juice had been served at breakfast that morning.On 8/25/25 at 10:15 AM, there were (34) four-ounce containers of light vanilla yogurt in the refrigerator with a use-by date of 8/18/25. The Dietary Manager confirmed the finding and stated the yogurt had last been distributed during lunch on Sunday, 8/24/25.On 8/26/25 at 12:27 PM, during an interview with the Registered Dietitian Consultant, she stated her expectation is for the dietary department to check expiration dates and discard food prior to the use-by date, in accordance with policy and federal food service guidelines.On 8/27/25, at 3:45 PM, the Director of Nursing (DON) stated her expectation is for dietary staff to ensure residents are not served expired food and to follow food safety standards. She reported there had been no complaints of diarrhea or other foodborne illnesses in the past six months.On 8/28/25 at 11:56 AM, the Administrator confirmed awareness of the findings and stated his expectation is for dietary staff to check food dates consistently. He reported there had been no outbreaks of foodborne illness in the facility within the last six months.

Based on observation, interview record review and facility policy review, the facility failed to assure the resident's dignity in accordance with professional standards as evidenced by staff were standing while assisting a resident with feeding for one (1) of 20 residents sampled. Resident #6Findings include:A review of the facility's policy, Assisting with Meals, revised 8-2-22, revealed Policy Statements Residents shall receive assistance with meals in a manner that meets the individual needs of each resident .Policy Interpretation and Implementation .3. Residents Requiring Full Assistance .c. Residents who cannot feed themselves will be fed with attention to .dignity, for example: (1) Not standing over residents while assisting them with meals .On 08/25/2025 at 11:59 AM, during an observation from the hallway, Resident #6 was in his room, being assisted with feeding by the Infection Preventionist (IP). The IP was standing while feeding Resident #6 and was positioned above or over the resident who was lying in bed. The door to the room was open to the hallway, and several people passed by the residents' room. On 08/25/2025 at 12:30 PM, an interview with the IP, she acknowledged assisting Resident #6 with feeding while standing over him. The IP nurse revealed she was aware that this was a violation of the resident's dignity and explained that she had instructed other staff to sit while assisting with feedings and should have known better. On 08/27/2025 at 3:20 PM, during an interview, the Director of Nursing (DON) affirmed that this was a violation of the resident's dignity. The DON stated that the staff will be in-serviced on the proper way to assist residents with feeding, and she expects all staff to position themselves properly when assisting with feeding. A record review of the facility's admission Record revealed the facility admitted Resident #6 on 1/11/23 with diagnoses including Alzheimer's Disease.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/30/25 revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 8 indicating severe cognitive impairment.

Based on interview, record review, and facility policy review, the facility failed to ensure a resident was free from neglect, as evidenced by, on 10/21/24, at approximately 2:45 PM, after returning to an outing at a local fair, a resident was left in the facility's transportation van until approximately 5:00 PM, for one (1) of three (3) sampled residents. Resident #1 Findings include: A review of the facility's policy, Abuse Prevention Program, modified 8/2/22, revealed .Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation . On 10/28/24 at 11:20 AM, during an interview with the Administrator, he stated that on 10/21/24, following a trip to a local fair, five (5) residents were in the facility's transportation van. At approximately 2:45 PM the van returned to the facility and all the residents were unloaded except Resident #1. The van driver, who is also responsible for central supply, was requested to retrieve supplies for another resident. The front desk staff reported she always had eyes on the resident, while the resident was in the van alone, which was approximately 20 minutes. The Administrator confirmed that the Director of Nursing (DON) called him on 10/21/24 and advised him that Resident #1 was found inside the facility van at approximately 5:00 PM. The Administrator also stated that although the facility had video surveillance, the surveillance system was not operational on 10/21/24. During an interview on 10/28/25 at 12:45 PM, the van driver stated that on 10/21/24 at approximately 2:45 PM, he arrived at the facility with five (5) residents. Resident #1 was the only resident who was in a wheelchair. During their return to the facility as the residents were exiting, the van driver was called to get supplies for another resident, leaving Resident #1 in the van. He stated he was only gone for five (5) to six (6) minutes. Front Desk #1 informed him that she would watch Resident #1 while he went for supplies. Upon returning to the van, he assisted Resident #1 off the van and brought him to the front lobby. On 10/28/24 at 12:55 PM, during an interview with Front Desk #1, she stated that while the van driver was getting supplies for another resident, she walked outside, then back inside, and kept eyes on Resident #1 the entire time he was in the van. Approximately 10 minutes later, the van driver returned and assisted the resident off the van. On 10/28/24 at 1:32 PM, during a phone interview with Registered Nurse (RN) #1/Supervisor, she stated that on 10/21/24 at approximately 5:00 PM during the evening meal, she was informed the facility staff could not locate Resident #1. RN #1 explained that all staff began to search for Resident #1, both inside and outside of the facility. Certified Nurse Assistant (CNA) #1 stated that Resident #1 went to the fair earlier and went to the front of the facility and found Resident #1 in the locked van. She further explained that Licensed Practical Nurse (LPN) #1 retrieved the facility van keys from Front Desk #1 and opened the van. The van driver had returned to the facility and assisted with removing Resident #1 from the van. RN #1 stated the incident was reported to the Director of Nurses (DON), and the Nurse practitioner (NP) was notified. During an interview on 10/28/24 at 2:01 PM with LPN #2, she confirmed that on 10/21/24 during dinner time at the facility, Resident #1 was not present in the dining room, the staff went to search for him and found him in the facility van. The van was locked, and LPN #1 received the keys from the front desk staff and opened the van. Someone had called the van driver back to the facility and he came and assisted in getting Resident #1 out of the van, which was at approximately 5:00 PM. On 10/28/24 at 2:10 PM, during a phone interview with CNA #1, she revealed that when she realized Resident #1 was not in the dining room during the evening meal, she remembered he had gone with the other residents to the local fair. She immediately went to the van, which was in the handicapped parking spot, and saw him inside the van. CNA #1 recalled that a nurse got the keys from the front desk staff and the van driver assisted with getting the resident off the van and into the facility. On 10/28/24 at 3:15 PM, during an interview with CNA #2, she stated that on 10/21/24 at approximately, 4:00 PM, she observed Resident #1 in the front lobby playing basketball. On 10/28/24 at 3:24 PM, during a phone interview with LPN #1, she stated that on 10/21/24, when the facility staff discovered that Resident #1 was missing, she searched his room and bathroom. When he was found to be locked in the facility van, she got the keys from the front office to get him out of the van. She said the van was parked in its designated parking spot. She explained that someone had called the van driver to assist with getting the resident out. LPN #1 further explained that when the residents returned from the fair, she had documented that Resident #1 had returned in the computer system but admitted that she had not actually observed him in the facility. On 10/28/24 at 3:40 PM, in a follow up interview with Front Office #1, she recalled giving a nurse the van key on 10/21/24 sometime before she got off work at 6:00 PM but was unable to recall why the key was needed, the exact she gave the key out, and the name of the nurse she gave the key to because there was a lot of activity in the lobby. On 10/28/24 at 4:15 PM, during a follow up interview with the Administrator, he reiterated that following the outing to the fair, the residents returned to the facility on [DATE] between 2:15 to 2:30 PM. Later that day, after leaving the facility for the day, he received a phone call from the DON, informing him that she received a phone call at or around 6:00 PM stating that Resident #1 was alone in the van and that he had no injuries. The staff notified the Nurse Practitioner to assess the resident. The next day, he received statements from the van driver and Front Office #1. The Administrator stated that he concluded based off those two (2) interviews that the resident was in the van for less than an hour and was supervised the entire time. He explained that he trusted the van driver's statement because he had been employed at the facility for [AGE] years and Front Office #1 collaborated the statement. He admitted that he did not interview any of the nursing staff that had assisted Resident #1 off the van around 5:00 PM. He was also unaware that Front Office #1 had given the van key to a nurse around that same time. The Administrator was unable to explain the discrepancies in the statements made by the facility staff and the timeline of the event. The Administrator explained the facility held an emergency Quality Assurance (QA) meeting on 10/22/24 because a resident being left on the van for any amount of time could be an issue. On 10/29/24 at 9:27 AM, an interview with the Nurse Practitioner (NP) revealed on 10/21/24 at approximately 6:00 PM, he received a phone call from RN #1, stating that Resident #1 was left in the facility van for an undetermined amount of time. The NP explained that he did not witness Resident #1 being left in the facility's van. His note on 10/21/24 reflected to the best of his knowledge at the time of the incident what had been reported by the nursing staff. The NP stated he had provided an addendum to his note to clarify that he had no knowledge of how long the resident was left on the van. Following the incident as it was reported to him, he ordered basic blood work as the concern was that the resident had been left on the van for an undetermined amount of time. On 10/29/24 at 9:57 AM, an interview with the DON confirmed on 10/21/24 at approximately 5:00 PM, she received a phone call from RN #1, stating that Resident #1 was missing but that he had been found in the facility van. The NP was notified, and she had called the Administrator to let him know what the RN Supervisor had reported. She stated the facility completed in-services regarding completing documentation correctly since LPN #1 admitted that she had documented Resident #1 as being in the facility on 10/21/24 without seeing him. The facility also completed in-services on Abuse and Neglect. On 10/29/24 at 10:03 AM, in a follow up interview with RN #1, she stated that when it was reported to her that Resident #1 was missing, all staff started searching resident rooms, the shower room, and the outside courtyard. She did not issue a missing resident alert because he was found in the facility van. She confirmed that she went outside to the van and both the back and front door was open. She confirmed she observed the van driver return to the facility in his truck, and he was wearing a white t-shirt and shorts. In a follow up interview with LPN #1 on 10/29/24 at 5:15 PM, she stated she found Resident #1 in the facility van, secured in a seatbelt, and the van door was locked. She explained she went and got the keys from Front Office #1, and another staff member called the van driver, who quickly arrived back to the facility. A record review of the Admission Record revealed the facility admitted Resident #1 on 6/24/23 with diagnosis including Unspecified Intellectual Disabilities and Dementia. A record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/27/24, revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 6, which indicated his cognition was severely impaired. A record review of the Quality Assessment and Assurance Committee Minutes October 22, 2024 revealed, .Emergency QA meeting held related to resident being left in a van. The driver of the van parked the vehicle in the front parking @ (at) the front entrance of the facility but failed to unload the resident. The amount of time the resident was in the van is unknown exactly, but it wasn't greater than 1 (one) hour . Record review of the Progress Note from the NP, dated 10/21/24, revealed, .Patient seen today per facility request for environmental exposure, apparently left in transport van. I was contacted approximately 1800 (6:00 PM) hours by facility nursing staff regarding the patient spending several hours in the van after going to the fair .At approximately 19:30 (7:30 PM) I came and evaluated the patient .Document e-signed .on [DATE] . Record review of the Addendum from the NP Progress Note revealed, Addendum is made to give this note to more accurately reflect appropriate timeline. It should be noted that I was not a witness to the events described above. The amount time that the patient was been in the van at this time is indeterminate, however he was at the fair and overall outside facility for several hours .Document e-signed on [DATE] .

Based on staff interview, record review, and facility policy review, the facility failed to report a violation of neglect within 24 hours when the facility was notified that a resident had been left in a facility van for an undetermined amount of time for one (1) of three (3) residents. Resident #1 Findings include: A review of the facility's policy, Abuse Investigation and Reporting Prevention Program, modified 8/2/22, revealed, .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies .Reporting .2. An alleged violation of abuse, neglect .will be reported immediately, but not later than .b. Twenty-four (24) hours if alleged violation does not involve abuse AND has not resulted in serious bodily injury . During an interview with the Administrator on 10/28/24 at 4:15 PM, he stated that following the outing to the fair, the residents returned to the facility on [DATE] between 2:15 PM to 2:30 PM on the facility's transportation van. He confirmed that later that day after leaving the facility, he received a phone call from the Director of Nursing (DON) informing him that she had received a phone call at or around 6:00 PM from the facility staff stating that Resident #1 was alone in the van and that he had no injuries. The staff notified the Nurse Practitioner (NP) to assess the resident. The next day, he received statements from the van driver and Front Office #1 and he concluded based off those two (2) interviews that the resident was in the van for less than an hour and was supervised the entire time. He explained that he trusted the van driver's statement because he had been employed at the facility for [AGE] years and Front Office #1 collaborated the statement. He admitted that he did not interview any of the nursing staff that had assisted Resident #1 off the van around 5:00 PM. However, he felt that since the facility always had eyes on the resident and his investigation was completed, he did not need to report the event to the State Agency (SA). During an interview on 10/29/24 at 9:57 AM, the DON, confirmed that on 10/21/24 at approximately 5:00 PM, she received a phone call from RN #1, stating that Resident #1 was missing but had been found in the facility van. She notified the Administrator, but did not report or investigate the event because the Administrator stated he would do the investigation. A record review of the Admission Record revealed the facility admitted Resident #1 on 6/24/23 with diagnoses including Unspecified Intellectual Disabilities and Dementia. A record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/27/24, revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 6, which indicated his cognition was severely impaired. A record review of the Quality Assessment and Assurance Committee Minutes October 22, 2024 revealed, .Emergency QA (Quality Assessment) meeting held related to resident being left in a van. The driver of the van parked the vehicle in the front parking @ (at) the front entrance of the facility but failed to unload the resident. The amount of time the resident was in the van is unknown exactly, but it wasn't greater than 1 (one) hour . Record review of the Progress Note from the NP, dated 10/21/24, revealed, .Patient seen today per facility request for environmental exposure, apparently left in transport van. I was contacted approximately 1800 (6:00 PM) hours by facility nursing staff regarding the patient spending several hours in the van after going to the fair .At approximately 19:30 (7:30 PM) I came and evaluated the patient .Document e-signed .on [DATE] . Record review of the Addendum from the NP Progress Note revealed, Addendum is made to give this note to more accurately reflect appropriate timeline. It should be noted that I was not a witness to the events described above. The amount time that the patient was been in the van at this time is indeterminate, however he was at the fair and overall outside facility for several hours .Document e-signed on [DATE] .

Based on staff interview, record review, and facility policy review, the facility failed to conduct a thorough investigation related to a resident who was left on the facility's transportation van upon return from an outing for one (1) of 3 (three) sampled residents. Resident #1 Findings include: A review of the facility's policy, Abuse Investigation and Reporting, modified 8/2/22, revealed, .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be .thoroughly investigated by facility management .Policy Interpretation and Implementation Role of the Administrator: 1. If an incident or suspected incident of resident .neglect .is reported, the Administrator or designee will lead the investigation .Investigative Process: 1. The individual conducting the investigation will, as a minimum .c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident .g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .j. Review all events leading up to the alleged incident . The Administrator stated during an interview on 10/28/24 at 11:20 AM, that on 10/21/24, following a trip to a local fair, five (5) residents were in the facility's transportation van. At approximately 2:45 PM the van returned to the facility and all the residents were unloaded except Resident #1. The van driver, who is also responsible for central supply, was requested to retrieve supplies for another resident. The front desk staff reported she always had eyes on the resident, while the resident was in the van alone, which was approximately 20 minutes. The Administrator confirmed that the Director of Nursing (DON) called him on 10/21/24 and advised him that Resident #1 was found inside the facility van at approximately 5:00 PM. The Administrator also stated that although the facility had video surveillance, the surveillance system was not operational on 10/21/24. The Administrator reiterated on 10/28/24 at 4:15 PM, during a follow up interview that following the outing to the fair, the residents returned to the facility on [DATE] between 2:15 to 2:30 PM. He confirmed that later that day, after leaving the facility, he received a phone call from the DON, informing him that she received a phone call at or around 6:00 PM stating that Resident #1 was alone in the van and that he had no injuries. The staff notified the Nurse Practitioner to assess the resident. The next day, he received statements from the van driver and Front Office #1 and he concluded based off those two (2) interviews that the resident was in the van for less than an hour and was supervised the entire time. He explained that he trusted the van driver's statement because he had been employed at the facility for [AGE] years and Front Office #1 collaborated the statement. He admitted that he did not interview any of the nursing staff that had assisted Resident #1 off the van around 5:00 PM or any other facility staff that may have witnessed the incident. He also did not interview staff members on all shifts who had contact with the resident during the period of the alleged incident. The Administrator was unable to explain the discrepancies in the statements made by the facility staff and the timeline of the event. He stated that since the facility staff always had eyes on the resident, the investigations was completed, unsubstantiated, and required no further investigation. The DON confirmed during an interview on 10/29/24 at 9:57 AM, that on 10/21/24 at approximately 5:00 PM, she received a phone call from RN #1, stating that Resident #1 was missing but had been found in the facility's van. She notified the Administrator, but did not report or investigate the event because the Administrator stated he would do the investigation. A record review of the Admission Record revealed the facility admitted Resident #1 on 6/24/23 with diagnoses including Unspecified Intellectual Disabilities and Dementia. A record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/27/24, revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 6, which indicated his cognition was severely impaired. A record review of the Quality Assessment and Assurance Committee Minutes October 22, 2024 revealed, .Emergency QA (Quality Assessment) meeting held related to resident being left in a van. The driver of the van parked the vehicle in the front parking @ (at) the front entrance of the facility but failed to unload the resident. The amount of time the resident was in the van is unknown exactly, but it wasn't greater than 1 (one) hour . Record review of the Progress Note from the NP, dated 10/21/24, revealed, .Patient seen today per facility request for environmental exposure, apparently left in transport van. I was contacted approximately 1800 (6:00 PM) hours by facility nursing staff regarding the patient spending several hours in the van after going to the fair .At approximately 19:30 (7:30 PM) I came and evaluated the patient .Document e-signed .on [DATE] . Record review of the Addendum from the NP Progress Note revealed, Addendum is made to give this note to more accurately reflect appropriate timeline. It should be noted that I was not a witness to the events described above. The amount time that the patient was been in the van at this time is indeterminate, however he was at the fair and overall outside facility for several hours .Document e-signed on [DATE] .

Based on staff interview, record review, and facility policy review, the facility failed to transmit a Discharge Minimum Data Set (MDS) Assessment in a timely manner for one (1) of 19 residents reviewed for MDS assessments. (Resident # 58) Findings Include: Record review of the facility's policy, Resident Assessment Instrument, revised 06/17/2022 revealed, POLICY STATEMENT: A comprehensive assessment of a resident's needs shall be made .periodically .POLICY INTERPRETATION AND IMPLEMENTATION: 1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews . Record review of the Admission Record revealed the facility admitted Resident #58 on 10/31/23 and he had diagnoses including Atrial Fibrillation. Record review of a Physician's Order, dated 1/15/24, revealed Resident #1 was sent to a local emergency room (ER) for evaluation and treatment. Review of the medical record of Resident #1 revealed the MDS Discharge assessment was not transmitted when he was sent to the hospital on 1/15/24. During an interview on 03/27/24 at 9:47 AM, with Registered Nurse (RN) #1, he confirmed the facility failed to transmit the hospital discharge MDS for Resident #58 and confirmed the resident did not return to the facility. He reported the staff discussed in daily stand up about residents that are sent to the local hospital. RN #1 explained that it was his responsibility to transmit the hospital discharge within 14 days. He was unsure how it was missed because corporate also completed spot checks to ensure MDS were transmitted. During an interview on 3/28/24 at 10:04 AM, with the Director of Nurses (DON), she stated she expected the facility staff to transmit the hospital discharge MDS in a timely manner. She was unsure how the discharge transmittal was missed because they have systems in place to ensure they are submitted.

Based on observation, interviews, record review, and facility policy review, the facility failed ensure a nebulizer mask was stored in a designated storage bag one (1) of one (1) resident reviewed for respiratory care. Resident #179. Findings include: A record review of the facility's policy, Administering Medications through a Small Volume (Handheld) Nebulizer, revised date 8/2/22, revealed, The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway . 23. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it . A record review of the Order Summary Report, with active orders as of 03/27/24, revealed Resident #179 had a Physician's Order, dated 3/20/24, for Ipratropium-Albuterol Solution 0.5-2.5 (3) mg (milligram)/ 3 ml (milliliters) 1 vial inhale orally four times a day for wheezing/sob (shortness of breath). On 03/25/24 at 11:26 AM, during an observation, Resident #179 was lying in bed sleeping. A nebulizer mask was tied to the left bedrail and was not stored in a designated bag. At 12:39 PM on 03/25/24, during an observation and an interview with Licensed Practical Nurse (LPN) #1, she confirmed the nebulizer mask was tied directly onto the bedrail for Resident #179 and explained that the mask should have been stored in a plastic bag. LPN #1 was unable to find a designated storage bag in the room and stated she would get a bag to store the mask. LPN #1 reported that Resident #179 was not able to tie the mask to the bedrail and that a staff member must have placed it there. On 03/26/24 at 01:30 PM, during an interview with the Director of Nursing (DON), she explained all nebulizer masks should be stored in a clear bag, dated, and changed weekly with the oxygen tubing. She expected all nurses to follow the policy and store nebulizer masks in designated bags to prevent infections or complications. A record review of the Admission Record revealed the facility admitted Resident #179 on 03/20/20 with diagnoses including Alzheimer's Disease. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/07/24 revealed Resident #179 had a Brief Interview for Mental Status (BIMS) score of 02, which indicated his cognition was severely impaired.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure residents, who were unable to carry out Activities of Daily Living (ADLs), received the necessary services to maintain grooming and personal hygiene for four (4) of seven (7) sampled residents. Resident #1, Resident #3, Resident #5, and Resident #7. Findings include: Record review of the facility's policy, Care of Fingernails/Toenails, revised 8/2/22, revealed, The purposes of this procedure are to clean the nail bed, to keep nails trimmed .1. Nail care includes daily cleaning and regular trimming .13. Trim fingernails in an oval shape and toenails straight across. 14. Smooth the nails with a nail file or emery board . Record review of the facility's policy, Activities of Daily Living (ADLs), Supporting Policy, revised 8/2/22, revealed, Policy Interpretation and Implementation .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .including appropriate support and assistance with: a. hygiene ( .grooming .) . Resident #1 On 1/27/23 at 10:25 AM, during an observation with the Wound Care Nurse, Resident #1's toenails were long and ragged/jagged and his fingernails were long, jagged. The length of Resident #1's fingernails exceeded the tips of the fingers on his right hand 0.2 centimeters to 0.4 centimeters. On 1/27/23 at 10:30 AM, during an interview with the Wound Care Nurse, she described the toenails of Resident #1 as long and ragged. She confirmed Resident #1's fingernails were also long. She reported that fingernail care and toenail care were included in adequate grooming for residents. She also confirmed the resident was not able to trim his own fingernails or toenails and it was the responsibility of the resident's nurse or herself to provide toenail care. She stated the Certified Nurse Aides (CNAs) were responsible for reporting to the nurses if a resident's toenails or fingernails needed to be trimmed. Record review of the Admission Record for Resident #1 revealed the facility admitted him on 6/23/10, with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Parkinson's Disease, and Type 2 Diabetes Mellitus. Record review of the quarterly Minimum Data Set (MDS) for Resident #1 with an Assessment Reference Date (ARD) of 12/21/22 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 00 and documented the resident exhibited Disorganized Thinking .incoherent .unclear flow of ideas and Altered Level of Consciousness. Further MDS review, Section G, revealed Resident #1 required extensive assistance with personal hygiene. Resident #3 On 1/26/23 at 1:40 PM, observation and an interview with Resident #3 in her room revealed she was seated in a wheelchair in her room reading a book.Her fingernails were long and dirty. Her fingernails extended approximately 0.5 centimeters past the end of her fingers and were jagged, rough, and not smooth. Record review of the Admission Record for Resident #3 revealed the facility admitted her on 5/17/22 with diagnoses including Toxic Encephalopathy and Type 2 Diabetes Mellitus. Record review of the quarterly MDS with an ARD of 11/09/22 revealed Resident #3 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. Further review of the MDS, Section G, revealed Resident #3 required extensive assistance with personal hygiene. Resident #5 On 1/27/23 at 10:55 AM, an observation revealed the resident had long, rough, jagged toenails. Record review of the Admission Record for Resident #5 revealed she was admitted by the facility on 5/09/22 with diagnoses including Alzheimer's Disease and had Dementia. Record review of the Quarterly MDS with an ARD of 11/02/22 revealed the resident had a BIMS score of 00 with documentation of Delirium .Inattention. Further MDS review, Section G, revealed Resident #5 required extensive assistance with personal hygiene. Resident #7 On 1/27/23 at 11:10 AM, an observation revealed Resident #7 was seated in a wheelchair at a table in a common area. Both of her hands were balled up into tight fists. With the assistance of the Director of Nursing (DON) the resident's fingernails were assessed and noted to be long, rough, and jagged. On 1/27/23 at 11:15 AM, during an interview the DON, she confirmed that Resident #7's fingernails were long. She said that fingernails and toe nails were to be assessed by nurses and CNAs on an ongoing basis and fingernail and toenail care should be provided by staff as needed. She confirmed that there were criteria for CNAs to be able to use clippers to trim fingernails or toenails, but the CNAs responsibility included reporting to the nurse if a resident needed care and they were not able to provide the care. Record review of the Admission Record for Resident #7 revealed she was admitted by the facility on 5/19/17 with diagnoses including Alzheimer's Disease and Dementia. A record review of the quarterly MDS with an ARD of 12/7/22, revealed Resident #7 had long and short term memory problems and her cognitive skills for daily decision making was severely impaired. Further MDS review, Section G, revealed Resident #7 required extensive assistance with toilet use and personal hygiene. On 1/26/23 at 2:30 PM, during an interview with CNA #4, she reported that the facility provided in-service training for ADLs. On 1/26/23 at 3:00 PM, during an interview Registered Nurse (RN) #1, she stated she was responsible for supervision of Licensed Practical Nurses (LPNs) and the care of residents. She stated the CNAs were trained and reminded and provided with instruction to use and follow the Kardex in electronic health records software for ADL care. She confirmed that staff were expected to provide care based on the MDS assessment of each resident which was reflected in the resident's Kardex. She reported each resident was scheduled for showers every week, most every other day, and that fingernail care was supposed to be done on shower days. She said that if a resident was diabetic, had physician orders for anticoagulant therapy or was diagnosed with a bleeding disorder, the CNA should report to a licensed nurse if the resident's nails needed trimming, but they were allowed to use an emery board as needed to file or smooth any resident's nails. On 1/27/23 at 2:00 PM, during an interview the Staff Development Nurse (SDN), he stated that he was responsible for general facility orientation for CNAs and for checkoff competencies for CNAs when they are ready to be own their own. He confirmed the competencies included ADL care. He confirmed that all CNAs employed by the facility had received formal training in a certified training program which would have included correct ADL procedures. On 1/27/23 at 3:40 PM, an interview with the DON, she confirmed the nursing staff were responsible for assessment of the condition of resident fingernails and toenails and provide fingernail and toenail care as appropriate to prevent the fingernails and toenails from growing too long or being rough or jagged. She confirmed that fingernail care and toenail care were included in personal hygiene and grooming. On 1/27/23 at 3:50 PM, an interview with the facility Administrator, he confirmed the nursing staff were responsible for fingernail care and toenail care and that fingernail care and toenail care was considered personal hygiene/grooming.

Based on observation, interview, record review, and facility policy review the facility failed to ensure reasonable accommodation was provided to a resident when his call light device was not within reach for one (1) of seven (7) sampled residents. Resident #2 Findings include: Record review of the facility policy titled Call Lights: Accessibility and Timely Response, revised 8/2/22, revealed, Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside .to allow residents to call for assistance .Policy Explanation and Compliance Guidelines: 1. All staff will be educated on the proper use of the resident call system including .ensuring resident access to the call light .5. Staff will ensure the call light is within reach of resident and secured, as needed. 6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room . On 1/26/23 at 11:05 AM, during an observation and an interview with Resident #2, he was lying in bed and his call light device was hung over the headboard of the bed. Resident #2 reported that he was not able to reach the call light whenever it was placed over the headboard and that it was not unusual that it was not in his reach. He stated, I don't even worry about it anymore. On 1/26/23 at 1:30 PM and at 5:00 PM, during an observation and an interview with Resident #2, the call light device continued to be positioned hanging over the headboard out of his reach. Resident #2 reported that it had been out of his reach and had not been moved. On 1/27/23 at 10:10 AM, 11:50 AM, and 1:24 PM, during observations, the call light device for Resident #2 remained positioned on the bed's headboard, which was behind and out of reach of the resident. Resident #2 confirmed that he was not able to reach the call light and that it had not been moved although several staff members had entered his room on 1/27/23. He expressed that it was frustrating that the staff did not reposition the call device when they were in his room. On 1/27/23 at 2:00 PM, during an interview with the Staff Development Nurse (SDN), he confirmed that call lights were supposed to be in the residents' reach. On 1/27/23 at 2:15 PM, during an observation and an interview with Resident #2, the call light device was laying on the bed beside the resident and within his reach. Resident #2 stated, Yeah, they finally decided to give it to me. On 1/27/23 at 3:40 PM, during an interview the Director of Nursing (DON), she confirmed that staff were supposed to leave the resident's call light within their reach each time they left a resident's room. On 1/27/23 at 3:50 PM, during an interview with the facility's Administrator, he stated that staff should place call lights within a resident's reach upon completion of care. Record review of the Admission Record for Resident #2 revealed he was admitted by the facility on 6/04/21 with diagnoses including Orthostatic Hypotension, Atrial Fibrillation, and Dementia. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/11/23 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated he had moderate cognitive impairment. Further review of the MDS, Section G revealed that he required extensive assistance for transfers.

Based on observation, interviews, record review, and facility policy review the facility failed to ensure that a resident, who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections (UTIs) for one (1) of two (2) incontinence care. Resident #3 Findings include: Record review of the facility's policy, Perineal Care revised 8/2/22, revealed, The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections .10 . e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks (wipe from front to back) . On 1/27/23 at 12:00 PM, during an interview the Resident Representative (RR) for Resident #3 expressed concern related to the incontinence care provided for Resident #3 and that she was considering other facilities because she was not satisfied. She stated that she was worried because Resident #3 had previously been diagnosed with UTI, however, the resident did not actively have an infection. On 1/27/23 at 1:49 PM, during observation of incontinence care for Resident #3 performed by Certified Nurse Aide (CNA) #1 and CNA #2, with the Staff Development Nurse (SDN) present in the room, CNA #1 used a disposable cleansing cloth and wiped from the rectal area toward the vaginal area (back to front) of the resident. On 1/27/23 at 1:55 PM, during an interview with CNA #1, she stated that she was aware she had made a mistake during incontinence care, and she stated I got nervous; I wiped from back to front. I know better. She confirmed she knew that the correct procedure was to cleanse or wipe front to back to prevent urinary tract infections. On 1/27/23 at 2:00 PM, during an interview the SDN, he confirmed that he also had witnessed during the SA observation CNA #1 perform incontinence care for Resident #3 and that she had cleaned the resident by wiping from back to front, which did not coincide with the facility policy or current standards of practice designed to prevent urinary tract infections and it could have potentially lead to the resident obtaining a urinary tract infection. On 1/27/23 at 3:40 PM, during an interview the Director of Nursing, she confirmed that facility policy and accepted current standards of care specified that incontinence care should always include cleansing (wiping) from front to back and that for female residents that meant the vaginal area toward the rectal area, and never back to front. She stated that in-service training had been provided for all nursing staff in which facility incontinence care policy and procedure and current standards of care designed to prevent urinary tract infection were reviewed. She confirmed use of incorrect procedure could potentially lead to urinary tract infection. Record review of the Admission Record for Resident #3 revealed the facility admitted her on 5/17/22 with diagnoses including Toxic Encephalopathy and Type 2 Diabetes Mellitus. Record review of the quarterly MDS with an Assessment Reference Date (ARD) of 11/09/22 revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Further review revealed Resident #3 required extensive assistance with toilet use and personal hygiene and was assessed as Always Incontinent for Urinary Continence and Always Incontinent for Bowel Continence.

Based on staff interview, record review and facility policy review, the facility failed to ensure a resident's care plan was implemented related to the use of an assistive device when a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1. Findings include: A record review of the facility's policy Care Plans-Comprehensive, with a revised date of January 2013 revealed, Policy Statement, an individual Comprehensive Person-Centered Care Plan that includes measurable objectives and timetable to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation revealed, .1. Our facility Care Planning/Interdisciplinary Team, attending physician, registered nurse responsible for the resident, nurse aide responsible for the resident in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive person-centered care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Record review of the Admission Record Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/9/22 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 03, which indicated she is severely cognitively impaired, and she required an extensive two-person assist for transfers. Record review of Resident #1 Care Plan initiated 11/12/19 revealed, Problem The resident has an ADL (activities of daily living) self-care performance deficit related to Alzheimer's Dementia .Interventions/Task .TRANSFER: the resident requires mechanical STAND UP lift (medium belt-blue straps) with times 2 (X2) staff extensive assistance X2 for transfers . Record review of Resident #1 Visual/Bedside Kardex Report as of 3/1/2022, revealed the resident required the use of a mechanical stand-up lift (medium belt-blue straps) with two staff extensive assistance for transfers at the time of the fall. Record review of the written statement signed by CNA #2 and dated 3/12/22 revealed, .We did not use the total lift because we was told she could stand .We scooted her to the end and grabbed both side getting onto the floor standing straight .she began to holler 'My Legs' and bending them going to the floor (sitting on her legs) when we got her lowered to the ground, making sure she didn't fall . Record review of the written statement signed by NA #3 and dated 3/11/22 revealed, .After the shower I asked (Proper Name of CNA #2) to assist me with transferring her since the nurse had said she could stand up .When we stood her up all the way she didn't stand up she crossed her legs and went down, but she ended up sitting on her knees .Me and (Proper Name of CNA #2) tuned her onto her right side to get her legs from under her . On 4/13/22 at 1:15 PM, during an interview with the DON, she confirmed agency staff are trained when they come to the facility on how to read the resident's Kardex on the kiosk which is where the care plan interventions are located. She agreed it is very important for staff to follow the Care Plan/Kardex related to how to transfer a resident to avoid injuries. She also confirmed CNA #2 and NA #3 did not follow Resident #1's ADL care plan when they transferred her without using the stand-up lift. On 4/14/22 at 11:00 AM, an interview with the Administrator confirmed that CNA #2 and NA #3 did not follow the care plan on transferring Resident #1 when the fall occurred because they did not use the stand-up lift. His expectation is that all staff will follow the care plan. On 4/19/22 at 11:35 AM, an interview with LPN #2, MDS nurse revealed that she expects the staff to follow the care plan/Kardex to prevent injuries and she confirmed that CNA #2 and NA #3 did not follow the resident's care plan when they transferred Resident #1 without using the stand-up lift.

Based on interviews, record review, and facility policy review, the facility failed to ensure an assistive device was used during a transfer, causing a resident to be lowered to the floor by staff which caused multiple fractures for one (1) of four (4) residents sampled. Resident #1 (See F600 for additonal information.) Findings include: A record review of the facility's policy Safe Transfer and Lifting of Residents with a revised date of 09/2013 revealed Policy Statement In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation .II. Assessment Guidelines .10. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance .13. Transfer assessments will be documented in the resident's care plan and in the resident's profile in the KIOSK . A record review of the facility's written investigation revealed that at 8:30 AM on 3/11/22, Resident #1 was noted by Certified Nurse Assistant (CNA) #1 to have bruising to her bilateral lower extremities. CNA #1 immediately reported the bruising to Licensed Practical Nurse (LPN) #1. LPN #1 was unaware of any accident or injury to the resident and immediately evaluated the resident and notified the Director of Nursing (DON). At 9:00 AM, the DON assessed the resident and bruising to bilateral lower extremities and external rotation to the left lower extremity was noted. The resident was stable and in no acute distress. An investigation began immediately after the DON reported her findings to the Administrator 9:05 AM. The Nurse Practitioner (NP) was notified of Resident #1's condition and gave verbal orders to send the resident to the local emergency room (ER) for evaluation. At 9:20 AM, the resident's Responsible Representative (RR) was notified of the situation and the need to transport the resident to the hospital for evaluation. The RR agreed that the resident needed to be evaluated and the ambulance service was notified of the need for patient transportation to the emergency room . The ambulance arrived at the facility at 9:30 AM and at 0945 9:45 AM, the resident was loaded into the ambulance and began transport from the facility to the local emergency room . The Quality Assessment and Assurance Committee (QAC) on 3/11/22 for an emergency meeting. The facility Medical Director and the residents Primary Care Physician were both made aware of the incident and participated in the QAC review via phone conference. After reviewing a Root Cause Analysis (RCA) was conducted and the QAC has determined that Contract Agency staff members CNA #2 and NA #3, did not follow the residents plan of care when attempting to transfer the resident. The resident is to be transferred using a lift, but no lift was utilized during a transfer on 3/10/2022 at approximately 1:45 PM, per video review and corroborating statements from staff. The resident subsequently sustained an assisted fall, per CNA #2 and NA #3's written statement review. Also, CNA #2 and NA #3, in separate interviews held with the DON and the Administrator, both stated that the incident was not reported up the chain of command to the resident's primary nurse, nurse manager, or to Administration as per the facility policy. CNA #4, also an employee of the Contract Agency per written statement, interview, and video recording review, entered the resident's room and noted the resident to be on the floor. CNA #4 failed to notify nursing staff or Administration of the incident but did explain to CNA #2 and NA #3 the requirement to report the incident. CNA #2 and NA #3 were immediately suspended from working in facility, after their interviews were conducted the morning of 3/11/2022. Record review of the written statement signed by CNA #2 and dated 3/12/22 revealed, .Nurse (Proper Name) entered the room and told (Proper Name of NA #3) she could have used the stand up lift because she could stand .I went back to help her get dressed and be put back to bed. We did not use the total lift because we was told she could stand .We scooted her to the end and grabbed both side getting onto the floor standing straight .she began to holler 'My Legs' and bending them going to the floor (sitting on her legs) when we got her lowered to the ground, making sure she didn't fall . Record review of the written statement signed by NA #3 and dated 3/11/22 revealed, .I asked (Proper Name of CNA #2) to go get the shower bed because another aide had told me she was total .assisted me with the lift in the process of it a nurse .walked in and said 'You don't have to use the total lift she can stand up they normally put her in the chair to bath' .After the shower I asked (Proper Name of CNA #2) to assist me with transferring her since the nurse had said she could stand up .When we stood her up all the way she didn't stand up she crossed her legs and went down, but she ended up sitting on her knees .Me and (Proper Name of CNA #2) tuned her onto her right side to get her legs from under her . Record review Emergency Department (ED) Provider Notes revealed, .3/11/22 patient reportedly fell yesterday, unwitnessed. Impression revealed, .she is [AGE] year-old female who was brought to the hospital after a fall. She is found to have left proximal tibial and fibular fracture and right distal femur fracture. On 4/14/22 at 1:00 PM, the State Agency (SA) observed video surveillance recorded on 3/10/22 at 1:45 PM, that revealed CNA #2 and NA #3 walking in the hallway with Resident #1 on the shower bed. They entered the resident's room and did not take the mechanical lift into the resident's room. The mechanical lift was noted to be in the hallway the entire time they were in the resident's room. CNA #4 went into the room and exited. CNA #2 and NA #3 were in the resident's room for seven (7) minutes before exiting the room with the empty shower bed. Record review of the Admission Record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Periprosthetic Fracture around Internal Prosthetic Right Hip Joint, and Periprosthetic Fracture around Internal Prosthetic Left Hip Joint. Record review of quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/9/22 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 03, which indicated she is severely cognitively impaired, and she required an extensive two-person assist for transfers. Record review of Resident #1 Visual/Bedside Kardex Report as of 3/1/2022 revealed the resident required the use of a mechanical stand-up lift (medium belt-blue straps) with two staff extensive assistance for transfers at the time of the fall. Record review of Resident #1's Progress Note revealed a nurses note written by the DON with an effective date of 3/11/22 at 9:00 AM, Primary nurse stated to myself, I need to tell you something. Nurse proceeded to tell me that a CNA had reported an injury to her LPN, when assessed elder lower extremities noted with extensive bruising purple and reddish in color, left leg noted to be externally rotated, elder not voice pain at this time, notified RN (Registered Nurse) unit manager to call NP and RR. Record review of Resident #1's Progress Note revealed a nurses note by RN #1 with an effective date of 3/11/22 at 9:16 AM, Entered resident's room and noted bruising to BLE (Bilateral Lower Extremity). Also noted gross deformity to LLE (Left Lower Extremity) distal knee. (Proper Name of Nurse Practitioner) notified. New order to transfer to (Proper Name of Local Hospital) ER for evaluation. On 4/13/22 at 10:40 AM, an interview with LPN #2 revealed that on 3/10/22, she walked into Resident #1's room and saw CNA #2 and NA #3 using a full body mechanical lift to transfer the resident from her bed to the shower stretcher. She explained to them that Resident #1 was to be transferred with a stand-up lift and to let her know when they transferred her back to bed and she would give them assistance. The CNAs did not request her help to get Resident #1 back to bed and she had no idea the resident had been assisted to the floor during the transfer back to bed until the next morning. LPN #2 stated that all staff and agency CNAs are instructed to use the computer system so they may see the care plans and Kardex on each resident, for which type of lifts to use, and care that is required for residents. On 4/13/22 at 1:15 PM, during an interview with the DON, she confirmed the fall related to Resident #1 occurred on 3/10/22 with no one reporting it to the appropriate staff at the time the event occurred. Then on 3/11/22 when staff were making rounds, Resident #1 had bruising of her lower extremities and she was immediately sent to the local ER and the facility began an investigation. Contract staff are trained when they come to the facility on how to read the resident's Kardex on the kiosk. She agreed it is very important for staff to follow the Kardex related to how to transfer a resident to avoid injuries. On 4/14/22 at 9:58 AM in an interview with CNA #4, she stated that she walked into Resident #1's room to obtain the shower bed and noticed the resident was on the floor next to her bed, with CNA #2 and NA #3 in the room with her. There was no mechanical lift in room. CNA #2 and NA #3 informed CNA #4 that when they were transferring the resident from the shower bed to her bed, her legs went weak, and they slid her to the floor. CNA #4 assisted CNA #2 and NA #3 in transferring the resident from the floor to her bed and advised them to notify the supervisor and the DON of the accident. The CNA's agreed they would, and CNA #4 went to go take care of her residents. CNA #4 said that she really assumed they notified their nurse and DON. She confirmed that she was trained when she came to work at the facility on how to look at the kiosk to see how a resident should be transferred. On 4/14/22 at 11:00 AM, an interview with the Administrator revealed Resident #1's fall occurred on 3/10/22 and both CNA #2 and NA #3 admitted they had lowered her to the floor and did not use the mechanical lift while transferring her from the shower bed to her bed. CNA #2 and NA #3 were suspended immediately and not allowed to work at the facility. The facility held a QAC meeting and in-services were completed for all facility and agency staff on the topics of abuse, neglect, use of mechanical lifts, and the reporting of incidents. The Administrator confirmed all staff are trained on how to transfer a resident and to look at the resident's care plan or Kardex to find out how a resident is to be transferred. On 4/14/22 at 11:30 AM, an interview with Contract Agency Representative #1 revealed that the contract agency completes reference checks and background checks on their staff and conducts a CNA skills evaluation. Each facility has the obligation to orientate the contract staff to their facility. On 4/18/22 at 3:00 PM, during an interview with the DON, she explained the facility implemented additional steps in the orientation process for agency staff. When the Scheduler schedules an agency staff member that has never worked at the facility, the Scheduler will alert the DON to ensure orientation training is conducted for the agency staff member explaining policies and procedures. The agency staff will sign acknowledgement of receiving the education and this will be completed prior to the agency staff providing any direct resident care. When at all possible, the agency staff who is new to the facility will be assigned to a unit in which facility staff are also assigned to provide extra support and assistance during their first shift worked. The contract staff member will receive specific training and sign an acknowledgment (located in a binder at each nurse's station) on how to access a resident's Kardex which will provide information on how to care for the resident, including the type of transfer required. The binders will be readily available at the nurse's station with step-by-step instruction on accessing the Kardex and will be a tool for new contract staff and for contract staff who may work intermittently at the facility. Also, as another check, the nurse on duty will confirm that all staff knows how to access the Kardex through the kiosk during huddle, which is a communication meeting that occurs every shift with CNA's and nurses. On 4/19/22 at 11:35 AM, an interview with LPN #2, MDS nurse, revealed that the CNAs can view the Kardex from the KIOSK for all residents. The Kardex includes information about the resident including the type of lift required for transfers. Record review of the facility's Agency Orientation for Certified Nursing Assistants revealed Policy and Procedures .5. Falls 6. Incident and Accidents 7. Resident Lift and Transfer Policy .Additional Topics .CNA Documentation - Care Tracker/Kiosk . CNA #2 signed the document on 3/1/22 which indicated she received training on the facility's policy for resident lifting and transferring and documentation on the kiosk. Record review of the contract agency's Certified Nursing Assistant (CNA) - Skills Checklist revealed CNA #2 completed a competency checklist on 2/18/22 and listed, Familiar with various assistive devices/techniques .4.0 Proper use of Hoyer lifts as an experience level of 5 which indicated she could supervise/train others in the skill. Record review of the facility's Agency Orientation for Certified Nursing Assistants revealed Policy and Procedures .5. Falls 6. Incident and Accidents 7. Resident Lift and Transfer Policy .Additional Topics .CNA Documentation - Care Tracker/Kiosk . NA #3 signed the document on 3/7/22, which indicated she received training on the facility's policy for resident lifting and transferring and documentation on the kiosk. Record review of the contract agency's Certified Nursing Assistant (CNA) - Skills Checklist, revealed NA#3 completed a competency checklist on 2/28/22 and listed Familiar with various assistive devices/techniques .4.0 Proper use of Hoyer lifts as an experience level of 4 which indicated she is proficient in the skill.

Based on interviews, record review, and facility policy review, the facility neglected to ensure an assistive device was used during a transfer, causing a resident to be lowered to the floor by staff which resulted in multiple fractures for one (1) of four (4) residents sampled. Resident #1. (See F689 for additional information.) Findings include: A record review of the facility's policy Safe Transfer and Lifting of Residents with a revised date of 09/2013 revealed Policy Statement In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation .II. Assessment Guidelines .10. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance .13. Transfer assessments will be documented in the resident's care plan and in the resident's profile in the KIOSK . A record review of the facility's written investigation revealed that at 8:30 AM on 3/11/22, Resident #1 was noted by Certified Nurse Assistant (CNA) #1 to have bruising to her bilateral lower extremities. CNA #1 immediately reported the bruising to Licensed Practical Nurse (LPN) #1. LPN #1 was unaware of any accident or injury to the resident and immediately evaluated the resident and notified the Director of Nursing (DON). At 9:00 AM, the DON assessed the resident and bruising to bilateral lower extremities and external rotation to the left lower extremity was noted. The resident was stable and in no acute distress. An investigation began immediately after the DON reported her findings to the Administrator 9:05 AM. The Nurse Practitioner (NP) was notified of Resident #1's condition and gave verbal orders to send the resident to the local emergency room (ER) for evaluation. At 9:20 AM, the resident's Responsible Representative (RR) was notified of the situation and the need to transport the resident to the hospital for evaluation. The RR agreed that the resident needed to be evaluated and the ambulance service was notified of the need for patient transportation to the emergency room . The ambulance arrived at the facility at 9:30 AM and at 0945 9:45 AM, the resident was loaded into the ambulance and began transport from the facility to the local emergency room . The Quality Assessment and Assurance Committee (QAC) on 3/11/22 for an emergency meeting. The facility Medical Director and the residents Primary Care Physician were both made aware of the incident and participated in the QAC review via phone conference. After reviewing a Root Cause Analysis (RCA) was conducted and the QAC has determined that Contract Agency staff members CNA #2 and NA #3, did not follow the residents plan of care when attempting to transfer the resident. The resident is to be transferred using a lift, but no lift was utilized during a transfer on 3/10/2022 at approximately 1:45 PM, per video review and corroborating statements from staff. The resident subsequently sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Also, CNA #2 and NA #3, in separate interviews held with the DON and the Administrator, both stated that the incident was not reported up the chain of command to the resident's primary nurse, nurse manager, or to Administration as per the facility policy. CNA #4, also an employee of the Contract Agency per written statement, interview, and video recording review, entered the resident's room and noted the resident to be on the floor. CNA #4 failed to notify nursing staff or Administration of the incident but did explain to CNA #2 and NA #3 the requirement to report the incident. CNA #2 and NA #3 were immediately suspended from working in facility, after their interviews were conducted the morning of 3/11/2022. Record review of the written statement signed by CNA #2 and dated 3/12/22 revealed, .Nurse (Proper Name) entered the room and told (Proper Name of NA #3) she could have used the stand up lift because she could stand .I went back to help her get dressed and be put back to bed. We did not use the total lift because we was told she could stand .We scooted her to the end and grabbed both side getting onto the floor standing straight .she began to holler 'My Legs' and bending them going to the floor (sitting on her legs) when we got her lowered to the ground, making sure she didn't fall . Record review of the written statement signed by NA #3 and dated 3/11/22 revealed, .I asked (Proper Name of CNA #2) to go get the shower bed because another aide had told me she was total .assisted me with the lift in the process of it a nurse .walked in and said 'You don't have to use the total lift she can stand up they normally put her in the chair to bath' .After the shower I asked (Proper Name of CNA #2) to assist me with transferring her since the nurse had said she could stand up .When we stood her up all the way she didn't stand up she crossed her legs and went down, but she ended up sitting on her knees .Me and (Proper Name of CNA #2) tuned her onto her right side to get her legs from under her . Record review Emergency Department (ED) Provider Notes revealed, .3/11/22 patient reportedly fell yesterday, unwitnessed. Impression revealed, .she is [AGE] year-old female who was brought to the hospital after a fall. She is found to have left proximal tibial and fibular fracture and right distal femur fracture. On 4/14/22 at 1:00 PM, the State Agency (SA) observed video surveillance recorded on 3/10/22 at 1:45 PM, that revealed CNA #2 and NA #3 walking in the hallway with Resident #1 on the shower bed. They entered the resident's room and did not take the mechanical lift into the resident's room. The mechanical lift was noted to be in the hallway the entire time they were in the resident's room. CNA #4 went into the room and exited. CNA #2 and NA #3 were in the resident's room for seven (7) minutes before exiting the room with the empty shower bed. Record review of the Admission Record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/9/22 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 03, which indicated she is severely cognitively impaired, and she required an extensive two-person assist for transfers. Record review of Resident #1 Visual/Bedside Kardex Report as of 3/1/2022 revealed the resident required the use of a mechanical stand-up lift (medium belt-blue straps) with two staff extensive assistance for transfers at the time of the fall. Record review of Resident #1's Progress Note revealed a nurses note written by the DON with an effective date of 3/11/22 at 9:00 AM, Primary nurse stated to myself, I need to tell you something. Nurse proceeded to tell me that a CNA had reported an injury to her LPN, when assessed elder lower extremities noted with extensive bruising purple and reddish in color, left leg noted to be externally rotated, elder not voice pain at this time, notified RN (Registered Nurse) unit manager to call NP and RR. Record review of Resident #1's Progress Note revealed a nurses note by RN #1 with an effective date of 3/11/22 at 9:16 AM, Entered resident's room and noted bruising to BLE (Bilateral Lower Extremity). Also noted gross deformity to LLE (Left Lower Extremity) distal knee. (Proper Name of Nurse Practitioner) notified. New order to transfer to (Proper Name of Local Hospital) ER for evaluation. On 4/13/22 at 10:40 AM, an interview with LPN #2 revealed that on 3/10/22, she walked into Resident #1's room and saw CNA #2 and NA #3 using a full body mechanical lift to transfer the resident from her bed to the shower stretcher. She explained to them that Resident #1 was to be transferred with a stand-up lift and to let her know when they transferred her back to bed and she would give them assistance. The CNAs did not request her help to get Resident #1 back to bed and she had no idea the resident had been assisted to the floor during the transfer back to bed until the next morning. LPN #2 stated that all staff and agency CNAs are instructed to use the computer system so they may see the care plans and Kardex on each resident, for which type of lifts to use, and care that is required for residents. On 4/13/22 at 1:15 PM, during an interview with the DON, she confirmed the fall related to Resident #1 occurred on 3/10/22 with no one reporting it to the appropriate staff at the time the event occurred. Then on 3/11/22 when staff were making rounds, Resident #1 had bruising of her lower extremities and she was immediately sent to the local ER and the facility began an investigation. Contract staff are trained when they come to the facility on how to read the resident's Kardex on the kiosk. She agreed it is very important for staff to follow the Kardex related to how to transfer a resident to avoid injuries. On 4/14/22 at 9:58 AM in an interview with CNA #4, she stated that she walked into Resident #1's room to obtain the shower bed and noticed the resident was on the floor next to her bed, with CNA #2 and NA #3 in the room with her. There was no mechanical lift in room. CNA #2 and NA #3 informed CNA #4 that when they were transferring the resident from the shower bed to her bed, her legs went weak, and they slid her to the floor. CNA #4 assisted CNA #2 and NA #3 in transferring the resident from the floor to her bed and advised them to notify the supervisor and the DON of the accident. The CNA's agreed they would, and CNA #4 went to go take care of her residents. CNA #4 said that she really assumed they notified their nurse and DON. She confirmed that she was trained when she came to work at the facility on how to look at the kiosk to see how a resident should be transferred. On 4/14/22 at 11:00 AM, an interview with the Administrator revealed Resident #1's fall occurred on 3/10/22 and both CNA #2 and NA #3 admitted they had lowered her to the floor and did not use the mechanical lift while transferring her from the shower bed to her bed. CNA #2 and NA #3 were suspended immediately and not allowed to work at the facility. The facility held a QAC meeting and in-services were completed for all facility and agency staff on the topics of abuse, neglect, use of mechanical lifts, and the reporting of incidents. The Administrator confirmed all staff are trained on how to transfer a resident and to look at the resident's care plan or Kardex to find out how a resident is to be transferred. On 4/14/22 at 11:30 AM, an interview with Contract Agency Representative #1 revealed that the contract agency completes reference checks and background checks on their staff and conducts a CNA skills evaluation. Each facility has the obligation to orientate the contract staff to their facility. On 4/18/22 at 3:00 PM, during an interview with the DON, she explained the facility implemented additional steps in the orientation process for agency staff. When the Scheduler schedules an agency staff member that has never worked at the facility, the Scheduler will alert the DON to ensure orientation training is conducted for the agency staff member explaining policies and procedures. The agency staff will sign acknowledgement of receiving the education and this will be completed prior to the agency staff providing any direct resident care. When at all possible, the agency staff who is new to the facility will be assigned to a unit in which facility staff are also assigned to provide extra support and assistance during their first shift worked. The contract staff member will receive specific training and sign an acknowledgment (located in a binder at each nurse's station) on how to access a resident's Kardex which will provide information on how to care for the resident, including the type of transfer required. The binders will be readily available at the nurse's station with step-by-step instruction on accessing the Kardex and will be a tool for new contract staff and for contract staff who may work intermittently at the facility. Also, as another check, the nurse on duty will confirm that all staff knows how to access the Kardex through the kiosk during huddle, which is a communication meeting that occurs every shift with CNA's and nurses. On 4/19/22 at 11:35 AM, an interview with LPN #2, MDS nurse, revealed that the CNAs can view the Kardex from the KIOSK for all residents. The Kardex includes information about the resident including the type of lift required for transfers. Record review of the facility's Agency Orientation for Certified Nursing Assistants revealed Policy and Procedures .5. Falls 6. Incident and Accidents 7. Resident Lift and Transfer Policy .Additional Topics .CNA Documentation - Care Tracker/Kiosk . CNA #2 signed the document on 3/1/22 which indicated she received training on the facility's policy for resident lifting and transferring and documentation on the kiosk. Record review of the contract agency's Certified Nursing Assistant (CNA) - Skills Checklist revealed CNA #2 completed a competency checklist on 2/18/22 and listed, Familiar with various assistive devices/techniques .4.0 Proper use of Hoyer lifts as an experience level of 5 which indicated she could supervise/train others in the skill. Record review of the facility's Agency Orientation for Certified Nursing Assistants revealed Policy and Procedures .5. Falls 6. Incident and Accidents 7. Resident Lift and Transfer Policy .Additional Topics .CNA Documentation - Care Tracker/Kiosk . NA #3 signed the document on 3/7/22, which indicated she received training on the facility's policy for resident lifting and transferring and documentation on the kiosk. Record review of the contract agency's Certified Nursing Assistant (CNA) - Skills Checklist, revealed NA#3 completed a competency checklist on 2/28/22 and listed Familiar with various assistive devices/techniques .4.0 Proper use of Hoyer lifts as an experience level of 4 which indicated she is proficient in the skill.

Based on interviews, record review and facility policy review, the facility staff failed to report a fall with major injury which occurred during a transfer in which the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: A record review of the facility's policy Accidents and Incidents-Investigation and Reporting with a revised date of 9/21 revealed, Policy Statement All accidents or incidents involving residents shall be investigated and reported to the Director of Nursing and the Administrator. Policy Interpretation and Implementation .1. The Nurse Supervisor/Charge Nurse, or License Practical Nurse (LPN) shall promptly initiate and document investigation of the accident or incident by completing an Incident/Accident form in the electronic medical record. This nurse will notify the Director of Nursing and Administrator of the incident. A record review of the facility's written investigation revealed that at 8:30 AM on 3/11/22, Resident #1 was noted by Certified Nurse Assistant (CNA) #1 to have bruising to her bilateral lower extremities. CNA #1 immediately reported the bruising to Licensed Practical Nurse (LPN) #1. LPN #1 was unaware of any accident or injury to the resident and immediately evaluated the resident and notified the Director of Nursing (DON). At 9:00 AM, the DON assessed the resident and bruising to bilateral lower extremities and external rotation to the left lower extremity was noted. The resident was stable and in no acute distress. An investigation began immediately after the DON reported her findings to the Administrator 9:05 AM. The Nurse Practitioner (NP) was notified of Resident #1's condition and gave verbal orders to send the resident to the local emergency room for evaluation. At 9:20 AM, the resident's Responsible Representative (RR) was notified of the situation and the need to transport the resident to the hospital for evaluation. The Quality Assessment and Assurance Committee (QAC) on 3/11/22 for an emergency meeting. The facility Medical Director and the residents Primary Care Physician were both made aware of the incident and participated in the QAC review via phone conference. The resident subsequently sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Also, CNA #2 and NA #3, in separate interviews held with the DON and the Administrator, both stated that the incident was not reported up the chain of command to the resident's primary nurse, nurse manager, or to Administration as per the facility policy. CNA #4, also an employee of Contract Agency per written statement, interview, and video recording review, entered the resident's room and noted the resident to be on the floor. CNA #4 failed to notify nursing staff or Administration of the incident but did explain to CNA #2 and NA #3 the requirement to report the incident. CNA #2 and NA #3 were immediately suspended from working in facility, after their interviews were conducted the morning of 3/11/2022. On 4/13/22 at 1:15 PM, during an interview with the DON, she confirmed Resident #1's fall occurred on 3/10/22 with no one reporting the fall to staff at the facility. Then on 3/11/22 when staff was making rounds, Resident #1 was noticed to have bruising of her lower extremities. The DON verified that Agency staff are trained on the facility's policies and procedures related to incidents and accidents, which includes reporting, and lowering the resident to the floor is an incident should have been reported. A record review of the facility's written investigation revealed the facility submitted the investigative report to the State Agency (SA) and Attorney General (AG) on 3/11/22 at 9:30 AM. On 4/14/22 at 9:31 AM, an interview with LPN #1 revealed that she was at work on 3/10/22 during the day shift and no staff mentioned anything about Resident #1 falling or slipping to the floor. On 3/11/22, CNA #1 reported to her that Resident #1 had bruising to both her lower extremities and one leg looked misshaped. LPN #1 assessed the resident and reported her findings immediately to the DON. She confirmed that the CNAs should have reported the fall on 3/10/22 when they lowered the resident to the floor. On 4/14/22 at 9:58 AM, an interview with CNA #4 revealed that she walked into Resident #1's room and noticed the resident was on the floor next to her bed and CNA #2 and NA #3 were in the room. CNA #4 advised them to notify the supervisor and DON of the accident and they relayed they would. CNA #4 confirmed that both aides stated that the resident didn't fall because they had lowered her to the floor. On 4/14/22 at 11:00 AM, an interview with the Administrator revealed that the accident on Resident #1 occurred on 3/10/22 because both CNAs admitted Resident #1 sustained an assisted fall. The Administrator stated he couldn't believe it had happened and the agency staff should have known that lowering a resident to the floor is considered a fall or incident and they should have reported it. It is his expectation that all resident incidents are reported. Record review of the written statement signed by CNA #2 and dated 3/12/22, revealed, .We scooted her to the end and grabbed both side getting onto the floor standing straight .she began to holler 'My Legs' and bending them going to the floor (sitting on her legs) when we got her lowered to the ground, making sure she didn't fall .We then explained to that she never fell , we lowered her to the floor to keep her from falling because she was complaining about her legs .On the day of accident, we did not notify the DON and/or staff, because she did not fall, she slipped to the floor. Record review of the written statement signed by NA #3 and dated 3/11/22 revealed, .When we stood her up all the way she didn ' t stand up she crossed her legs and went down, but she ended up sitting on her knees .Me and (Proper Name of CNA #2) tuned her onto her right side to get her legs from under her . have to get her off the floor, we lowered her to the floor, but she didn ' t fall .We didn't file a fall report and/or tell anyone because we didn't consider it as a fall since we lowered her . Record review Emergency Department (ED) Provider Notes revealed, .3/11/22 patient reportedly fell yesterday, unwitnessed. Impression revealed, .she is [AGE] year-old female who was brought to the hospital after a fall. She is found to have left proximal tibial and fibular fracture and right distal femur fracture. Record review Admission Record Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/9/22 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 03, which indicated she is severely cognitively impaired, and she required an extensive two-person assist for transfers. Record review of the facility's Agency Orientation for Certified Nursing Assistants revealed Policy and Procedures .5. Falls 6. Incident and Accidents . CNA #2 signed the document on 3/1/22 which indicated she received training on the facility's policy for falls and incidents and accidents. Record review of the facility's Agency Orientation for Certified Nursing Assistants revealed Policy and Procedures .5. Falls 6. Incident and Accidents . NA #3 signed the document on 3/7/22, which indicated she received training on the facility's policy for falls and incidents and accidents.

Based on observations, interviews and facility policy review, the facility failed to prevent the possible spread of infection during medication administration and Percutaneous Endoscopic Gastrostomy (peg) site care for five (5) of seven (7) observations. Findings Include: Record review of the facility's policy, Hand washing/Hand Hygiene, with a revised date of August 2015 and reviewed date of 10/2021 revealed, Policy Statement The facility considers hand hygiene the primary means to prevent spread of infections. Policy Interpretation and Implementation .7. Use an alcohol-based hand rub containing at least 70% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . 7.b. Before and after direct contact with residents. 7.c. Before preparing or handling medications; .7. m. After removing gloves . On 2/17/22 at 8:23 AM, during an observation of medication pass, Licensed Practical Nurse (LPN) #2 left the medication cart with an uncovered cup of medications for Resident #31 in her left hand and some crackers in a cup in her right hand. LPN #2 entered Resident #19's room and gave her crackers and exited the room without washing or sanitizing her hands and continued to hold Resident #31's uncovered medications in a cup in her right hand. She then entered Resident #31's room and gave her the medication that was in the cup. LPN #2 exited Resident # 31's room and returned to medication cart and prepared medications for Resident #47. LPN #2 did not wash or sanitize her hands before preparing Resident #47's medications. LPN #2 entered Resident #47's room holding an Oxygen (O2) pulse oximetry device, resident medications, and a temple thermometer. She applied the O2 pulse oximeter to Resident #47's right finger. She then used the temple thermometer to obtain the resident's temperature. She placed the O2 pulse oximeter and the thermometer on a bedside table without a barrier. She donned one glove on her right hand and administrated the nasal spray medication. She removed the glove before exiting the room but did not wash or sanitize her hands. LPN #2 returned to the medication cart and opened a new box of disinfectant wipes by removing the top lid and placed the wipes in her bare hand and pulled them apart. She used a disinfectant wipe to clean the O2 pulse oximeter and used the same wipe to clean the thermometer. She used another wipe to clean her hands but did not use alcohol-based hand rub or soap. LPN #2 then prepared medications for Resident #50. She entered Resident #50's room and placed the thermometer and O2 pulse oximeter on the resident's bedside table and did not apply a barrier. She then gave the medications in the cup to the resident, and she spilled the medications on her bed and one pill rolled onto the floor. Resident #50 picked up the medications off the bed and placed them in the cup. LPN #2 took the cup of medications from the resident and picked up a pill identified as [MEDICATION(S)] HCI off the floor. LPN #2 then went to the medication cart, disposed of the pill in the sharps container, and retrieved another [MEDICATION(S)] HCI pill and did not wash or sanitize her hands before handling the medication. She went back into Resident #50's room and gave her the cup of medications that included the ones that had fallen onto the residents' bed. Resident #50 took the medications in the cup. LPN #2 exited the room and sanitized the equipment with a disinfectant wipe and wiped her hands with another wipe. On 2/17/22 at 10:45 AM, in an interview with LPN #2, stated she should have not taken Resident #31's medications into Resident #19's room. She stated she did not sanitize her hands between Resident #19's and Resident #31's rooms. She stated when she cleaned the equipment, she should have used one disinfectant wipes per item. She also confirmed she should have sanitized her hands each time before handling medications. She stated that her actions can cause cross contamination and cause the resident to have an infection and infections can be life threatening. On 2/17/22 at 3:46 PM, in an interview with Registered Nurse (RN) #1, she stated LPN #2 transferred what was on the equipment to the next resident She confirmed LPN #2 should have washed her hands before and after contact with each resident. She stated the pills that had fallen onto the bed should been discarded and the nurse should have prepared a new set of pills because the pills were contaminated. She stated LPN #2's actions can cause infection to spread from resident to resident. On 2/17/22 at 4:15 PM, in an interview with the Director of Nursing (DON) stated LPN #2 should have discarded the medications and prepared new medications after the resident wasted it on the bed. She also confirmed LPN #2 should have washed or sanitized her hands before and after resident contact. She stated LPN #2's actions put the resident at risk for infection. Resident #53 On 2/16/22 at 10:30 AM, during a medication administration observation, LPN #1 checked placement of Resident #53's Percutaneous Endoscopic Gastrostomy (peg) tube and did not remove gloves after checking placement and before administering medication per the peg tube. After administering the medication by peg tube, she removed her gloves and applied clean gloves, but did not wash or sanitize her hands before applying clean gloves. LPN #1 then realized that she did not have glucose test strips needed to perform an accucheck. LPN #1 exited the room, wearing gloves, and went down the hallway and retrieved a test strip from the medication cart drawer, opened the bottle to retrieve the strip and returned to the resident's room while still wearing the same gloves. LPN #1 checked Resident #53's blood sugar by wiping his right index finger with a clean alcohol wipe, pricked the resident's finger with a lancet, and obtained blood sample with test strip, while wearing the same gloves. LPN #1 opened an alcohol prep and cleaned the top of an insulin vial with the alcohol prep and drew up 15 units of insulin with her right hand while still holding the used alcohol prep in her left hand. LPN #1 used the contaminated alcohol prep to clean the left lower abdomen of the resident. LPN #1 administered the insulin and removed her gloves. She then applied clean gloves without washing or sanitizing her hands and cleaned the resident's peg site. After the procedure, she washed her hands, gathered supplies and barrier, and exited the room. On 2/16/22 at 2:05 PM, in an interview with LPN #1, she stated she should have washed her hands before applying clean gloves each time. She confirmed she should have removed her gloves before entering the hallway and her actions placed the resident at risk for infection. LPN #1 also verified she should have not cleaned the insulin injection site with the same wipe she had used to clean the top of the insulin vial. She stated she has had training on infection control and handwashing practices. On 2/17/22 at 3:25 PM, in an interview with RN #1/Infection Preventionist, she confirmed that LPN #1 should have washed her hands each time she removed her gloves, and she should have not been in the in the hallway with gloves on. LPN #1 should have made sure she had all supplies before beginning care and should have used another alcohol prep for the insulin injection instead of using the one she had used to clean the insulin vial. She stated these practices could have caused the resident to acquire a serious infection. On 2/17/22 at 4:00 PM, in an interview with the DON, she stated LPN #1 should have sanitized hands and changed gloves after checking for peg tube placement. The DON stated by the facility policy, LPN #1 should have used a new alcohol prep to clean the insulin injection site and she should have sanitized her hands after removing her gloves each time. She stated LPN #1 put the resident at risk for infection. Record review of a facility education form dated 1/12/22, with the Class Name listed as Med Administration, revealed LPN #1 and LPN #2 signed the in-service which indicated both nurses received training on medication administration. Record review of a facility education form dated 12/7/21, with the Class Name listed as .Hand Hygiene, revealed LPN #1 signed the in-service which indicated she received training on hand hygiene.

Based on observation, interviews, record review and facility policy review, the facility failed to ensure catheter tubing was anchored to minimize movement or prevent friction and trauma during catheter care and failed to provide catheter care in a manner to prevent infection for one (1) of three (3) catheter care observations. Resident #13. Findings include: The facility policy, Catheter Care, Urinary, revised September 2014 and reviewed 1/2022 revealed, Purpose The purpose of this procedure is to prevent catheter-associated urinary tract infections .Infection Control .2a Routine hygiene (e.g. to maintain routine hygiene cleansing of the meatal surface during daily bathing or showering is appropriate) . The staff should assess the urethral meatus prior to providing care. For a female resident use a washcloth with warm water and soap to cleanse the labia. Use one area of the washcloth for each downward, cleansing strokes. Change the position of the washcloth with each downward stroke. Next, change the position of the washcloth and cleanse around the urethra meatus. Do not allow the washcloth to drag on the resident skin or bid linen. With a clean washcloth, rinse with warm water using the above technique. The staff may use incontinent wipes. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately 4 inches outwards. During an interview on 2/16/22 at 3:45 PM, Resident #13 revealed the staff needs to be gentle when providing catheter care, because her catheter has come out several times. During an observation on 2/16/22 at 4:00 PM, of catheter/perineal care, Certified Nursing Assistant (CNA) #1 wiped down the center of the resident's vaginal area three times with the same side of the wet wipe. CNA #1 pulled out another wipe and went down the left side of the vaginal area with the same wipe three (3) times. CNA #1 pulled outward on the tubing without securing the tip near the meatus. During an interview on 2/16/22 at 4:15 PM, with CNA #1, she confirmed she failed to change wipes with each stroke while providing perineal care. CNA #1 also confirmed she failed to secure the tubing at the meatus. CNA #1 said she did not realize the tubing would come out by pulling on it. During an interview on 02/18/22 at 12:08 PM, with the Director of Nursing (DON), she confirmed CNA #1 failed to follow the facility policy by wiping the resident's vaginal area with the same wipe, without changing the position of the wipe. The DON also said CNA #1 should have secured the tubing at the meatus to prevent trauma or friction and the staff is trained to wipe one time and discard the wipe and trained to secure the tubing to prevent trauma or friction. The DON confirmed this could cause the resident to get an infection. The DON also confirmed Resident #13's catheter has come out several times. During an interview on 2/18/22 at 12:25 PM, Registered Nurse (RN) #2 confirmed CNA #1 failed to follow the Catheter/perineal policy. RN #2 said CNAs are trained to wipe one time with the wipe and to discard it. They are also trained to secure the tubing of the catheter at the meatus to prevent trauma and pulling the catheter out. RN #2 stated this could cause infection and trauma. RN #2 confirmed the resident's catheter has come out several times. Record review of the Admission Record revealed the facility admitted Resident #13 on 07/08/2016, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/1/21, revealed Resident #13 had a Brief Interview of Mental Status (BIMS) score of 15 that indicated Resident #13 is cognitively intact. Record review of the facility's Order Summary Report with active orders as of 2/18/22 revealed Resident #13 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Monitor Resident for elevation in temperature or chills. If present, notify physician. Record review of the facility's education sheet, titled Provides Catheter Care Skills Sheet, dated 6/6/21 revealed CNA #2 was trained on catheter care For Females: holds catheter near meatus two avoid tugging the catheter. Use wipe to cleanse the labia. Use one area of the wipe for each downward, cleansing stroke. Change position of wipe or obtain new wipe and cleanse around urethral meatus. Cleanse at least 4 inches of catheter nearest meatus, moving in only one direction (i.e. away from the meatus) using a clean area of the wipe for each stroke or obtain new wipe.

Based on interviews, record review, and facility policy review, the facility failed to ensure a Pre-Admission Screening (PASSR) Application was completed accurately for one (1) of nine (9) PASSR Applications reviewed. Resident #2. Findings Include: A record review of the facility's policy Admission Criteria with a reviewed date of June 2021, revealed, Policy Statement Our facility admits only residents who's medical and nursing care needs can be met Policy Interpretation and Implementation . 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. a. the facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. b. If the level I screen indicates that the individual may meet for a MD, ID, RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. (1) the admitting nurse notifies the social department when a resident is identified as having a possible (or evident) MD, ID, or RD. (2) The social worker is responsible for making referrals to the appropriate state-designated authority. A record review of Resident #2's Admission Record revealed the facility initially admitted Resident #2 on 08/27/21 and readmitted her on 2/3/22 with the medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #2's Pre-Admission Screening (PAS) Application for Long Term Care with a PAS date of 11/5/21 revealed the application was completed by the Social Worker. Selective Active Medical Conditions revealed [CONDITION(S)] which indicated the facility was aware Resident #2 had a major mental illness diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The answers to questions, Person has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #2's Order Summary Report revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/16/22 at 4:50 PM, during an interview with the Administrator, he explained the Social Worker completed PASRRs and confirmed the resident had two diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He confirmed a PASRR II should have been sent for evaluation, but the PAS did not flag for a PASRR II due to the PAS was marked incorrectly. On 02/16/22 at 5:00 PM, during an interview with the Social Worker, she reported she did not know where to look for the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . After reviewing the medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #23's Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 2/9/22 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interviews, record review and facility policy review, the facility failed to provide a written notice of transfer to the Responsible Representative (RR) for four (4) of four (4) residents reviewed. Resident #23, Resident #63, Resident #65 and Resident #67. Findings Include: Record review of the facility's policy, Transfer or Discharge, Emergency with a Revised Date of September 2012 and a Reviewed Date of 1/2022 revealed Our facility shall make an emergency transfer or discharge when it is in the best interest of the resident. 1.e. Notify the representative (sponsor) or other family member as appropriate in writing . Record review of the Re: Written Notice Requirements form revealed .our regulations require this facility to send a Written Notice to Resident Representatives each time a resident is transferred to the hospital or goes out on therapeutic leave . Resident #23 On 02/15/22 at 2:11 PM, during a phone interview with Resident #23's RR, she explained the facility called and informed her of her mother being transferred to the hospital, but she did not receive a notification in writing of the transfer. A record review of the Admission Record for Resident #23 revealed the facility admitted Resident #23 on 2/14/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #23's Order Audit Report revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident Notification of Transfer/Leave Bed Hold revealed the facility completed the portion of the form of Resident #23's name, date of transfer, and type of leave as transfer to hospital, but it did not indicate the reason for the transfer. A record review of nurse Progress Notes with an effective date of 2/08/22 for Resident #23 revealed, RN was notified that (Name of Nurse Practitioner) was sending Elder to ER (emergency room ) . A record review of Resident #23's Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/08/22 revealed she was discharged to an Acute Hospital on 2/8/22. Resident #63 Record review of the Admission Record revealed Resident #63 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the nurse Progress Notes with an effective date of 1/25/22 revealed, .On 1/21/22 staff reported .He was sent to (Name of Local Hospital) ER for evaluation . Record review of Resident #63's MDS with an ARD of 1/21/22 revealed Resident #63 was discharged to an acute hospital on 1/21/22. Record review of the medical chart revealed there was no written notification of transfer for Resident #63. Resident #65 Record review of the Admission Record revealed Resident #65 was admitted to the facility admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Physician Discharge Summary with a discharge date of [DATE] revealed .Elder sent to (Name of Local Hospital) ER for evaluation . Record review of Progress Notes with an effective date of 1/11/21 revealed, .New order to send patient to (Name of Local Hospital) ER for evaluation . Record review of the MDS with an ARD of 1/11/22 revealed Resident #65 was discharged to an acute hospital on 1/11/22. Record review of the medical chart revealed there was no written notification of transfer for Resident #65. Resident #67 Record review of the Admission Record revealed the facility originally admitted Resident #67 on 10/7/20 and readmitted her on 2/15/22. Resident #67 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #67's MDS with an ARD of 2/1/22 revealed she was discharged to another nursing home or swing bed on 2/1/22. Record review of the medical chart revealed there was no written notification of transfer for Resident #67. On 02/16/22 at 1:50 PM, during an interview with Social Service (SS), explained she had stopped sending a written notification of transfer to the residents' RRs about a year ago. The previous Administrator had removed that task from her responsibility because she had so much to do. She stated the nurse who initiates the resident transfer completes the transfer form and sends it along with the other information with the resident to the hospital. The facility then retains a copy of the form in the resident's medical chart. The nurses do not notify the RR in writing because the RR is notified verbally at the time of transfer. She confirmed the facility failed to notify RRs in writing of resident transfers, including the reason for the transfer. On 02/16/22 at 4:38 PM, during an interview with the Administrator, he reported that SS knew to notify the RR in writing by mailing the transfer/discharge letter to the resident's RR. On 02/18/22 at 01:47 PM, in an interview with Director of Nursing (DON), she stated SS was responsible for sending the written notice to the family. She stated she is aware that RRs did not receive written notification of the resident transfer and the forms should have been sent to the family.

Based on record review, staff and resident interview and facility policy review, the facility failed to thoroughly investigate an allegation of physical abuse for two (2) of four (4) sampled residents investigated for abuse of 20 residents screened for abuse. Resident #1 and Resident #2 Findings Include: A review of the facility's policy titled Abuse Prevention Program, with a revision date of December 2017 and review date of July 2019, revealed the facility's administration was to identify, assess, investigate, and report any allegation of abuse within timeframes as required by federal requirements. A review of the facility's policy titled POLICIES AND PROCEDURES FOR ABUSE PREVENTION, INVESTIGATION AND REPORTING, dated 1/01/21, revealed following an allegation of mistreatment or abuse The Administrator or designee will initiate an investigation utilizing the Alleged Abuse Incident Report form. The Facility will complete its investigation and submit a written report within 72 hours, pursuant to the MS Vulnerable Persons Act and provide a verbal report of the findings to the Resident's family. The policy and procedure further stated the facility's investigation would include, but not be limited to the following: 1) A summary of the Investigation; 2) Written statements of Witnesses; 3) Documentation of Resident's Assessment; and 4) Conclusion - valid, invalid, or inconclusive. The Administrator or designee was to complete the alleged Abuse Disposition Checklist to ensure appropriate interventions had been implemented. A review of the facility's policy titled Abuse Investigation and Reporting, with a revision date of July 2017 and a review date of July 2019, stated . Investigative Process: The individual conducting the investigation will, as a minimum .Interview the person(s) reporting the incident; Interview any witnesses to the incident; Interview the resident (as medically appropriate); Interview the resident's Attending Physician as needed .Interview the staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .Interview other residents to whom the accused employee provides care or services; and Review all events leading up to the alleged incident. An interview on 9/21/21 at 11:10 AM with the Administrator and the Director of Nurses (DON) revealed they had not had any recent complaints or incidents reported to them. In an interview on 9/21/21 at 12:51 PM with the DON she stated There was a thing between two staff not getting along. The CNA wrote a note and gave it to someone but not me. As soon as I found out I did an investigation. Resident #1 A review of the facility's Face Sheet for Resident #1 revealed the facility admitted the resident on 6/4/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/25/21, Section C, revealed Resident #1 had no Brief Interview for Mental Status (BIMS)score, which indicated the resident had significant cognitive impairment. A review of Resident #1's Medical Record revealed no documentation related to an allegation of abuse, and no notification to the physician, practitioner, or Responsible Party (RP) regarding an allegation of abuse. On 9/21/21 at 12:55 PM an interview and record review revealed the facility investigation consisted of a witness statement by Certified Nurse Assistant (CNA) #2 which alleged an incident of physical and verbal abuse against Resident #1 by CNA #1 and a statement by CNA #1 denying allegations of abuse. When the SA requested any other documentation of investigation, including documented assessment of Resident #1, the DON stated there was no other documentation, including no documentation of assessment of Resident #1. On 9/21/21 at 2:15 PM observation revealed Resident #1 was resting quietly in her bed in room [ROOM NUMBER] with her eyes open. Resident #1 was able to respond when spoken to and when asked if she was comfortable responded We're alright. She did not answer any other questions. She rested peacefully and exhibited no signs of being frightened or upset in any way. Her call light was in reach. On 9/21/21 at 2:18 PM an interview with CNA #1 revealed she had been called in to the DON's office on the afternoon of 9/17/21 regarding an allegation of abuse against her related to Resident #1. CNA #1 stated she had written and submitted a statement denying all allegations. CNA #1 stated she worked fast but was not abusive and denied verbally or physically abusing Resident #1. On 9/21/21 at 3:00 PM an interview with the MDS RN revealed on the morning of 9/17/21 CNA #2 reported an incident on the morning of 9/17/21 at approximately 11:00 AM involving CNA #1 being rough with Resident #1 and saying things she shouldn't in front of the resident. The MDS RN stated CNA #2 wrote a statement and gave it to her, (the MDS RN). The MDS RN stated she gave the statement to the DON around lunch time. Resident #2 A review Resident #2's Face Sheet revealed Resident #2 was admitted by the facility on 8/27/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #2's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/3/21 Section C, revealed the resident had a Brief Interview for Mental Status (BIMS) indicated moderate cognitive impairment. On 9/21/21 at 3:45 PM an interview with Resident #2 revealed she was alert, oriented, and able to communicate well. Resident #3 stated CNA #1 was her CNA on 9/17/21 during the 7-3 shift. Resident #2 stated she had suffered a stroke which left her unable to use her right side including her right arm and right leg. Resident #2 stated on 9/17/21 she reported to RN #1, RN #2 and the DON that She (CNA #1) was moving too fast. Resident #2 stated she did not intend to report it because I didn't want to make a big deal out of anything. Resident #2 denied pain and stated, I wasn't hurt, she was just moving too fast, and I didn't like it. An interview on 9/21/21 at 3:17 PM with RN #1 revealed she was the RN supervisor on Friday 9/17/21 day shift. RN #1 stated she had been made aware that a complaint had been voiced regarding alleged abuse against Resident #2 by CNA #1 and went to check on Resident #2 along with the RN #2. RN #1 stated when asked, Resident #2 confirmed that she felt that CNA #1, who was assigned to assist her on 9/17/21, had moved too fast while providing care. RN #1 stated she and RN #2 assessed Resident #2 and noted no signs of injury or abuse, and Resident #2 denied pain or injury. RN #1 stated she reassigned Resident #2 to CNA #3. RN #1 stated I let the DON know as well. On 9/21/21 at 5:12 PM the DON confirmed she was aware of both complaints about CNA #1 on Friday 9/17/21. She stated she received and read the statement written by CNA #2. The DON confirmed that after the allegations were received CNA #1 continued to work and was not suspended during the investigation of the allegations. The DON stated I called CNA #1 into my office on Friday, 9/17/21 after receiving the note. The CNA told me that is not true (the allegations). The DON stated the investigation was started on 9/17/21 upon receiving the note. The DON stated CNA #1 worked two (2) shifts on 9/17/21, 7-3 shift and 3-11 shift, but moved to another group of residents at 3:00 PM. The DON stated she and the Administrator spoke about the allegation on 9/17/21 and the Administrator read both the statement written by CNA #2 and a statement of response written by CNA #1. The DON stated RN #1 brought to her attention another, separate report concerning CNA #1 on 9/17/21 and she interviewed Resident #2 (who the DON described as alert and oriented) on 9/17/21. The DON stated Resident #2 reported Resident #2 didn't like the way CNA #1 handled her. Resident #2 said CNA #2 just works fast. The DON stated the decision was made to take CNA #2 off Resident #2's care. The DON stated based on her investigation I concluded on the abuse that there was no harm to the residents. When asked if there needed to be further investigation into the allegations the DON stated It did not cross my mind. I was at ease with no harm done. Maybe I need to do more with my investigations. An interview on 9/21/21 at 6:00 PM with the Administrator revealed he stated he was notified by the DON on 9/17/21 of the allegations in CNA#2's written statement at approximately 4:40 PM and he read the statement. He stated he was notified about the allegations made by Resident #2 on 9/20/21, he was not sure of the time. When asked who was responsible for the investigation the Administrator stated, Me. I am ultimately responsible. When asked if any actions were taken to protect the residents during any investigation, the Administrator stated CNA #1 was reassigned to other residents and Resident #1 and Resident #2 were assigned to other CNAs. He stated when he was made aware of the 9/17/21 allegations, he had to consider the source. When asked if he considered CNA #2's statement an allegation of abuse, the Administrator responded CNA #2 is not trustworthy and with her past history and she doesn't tell the whole truth. The Administrator stated the allegations made by CNA #2 regarding Resident #1 were determined false. The Administrator stated his impression of the allegation made by Resident #2 wasn't abuse. When asked why the facility had not followed its own policy and procedure for abuse allegation or completed the Alleged Abuse Incident Report form, the Administrator stated, I don't know. We should have done that. When asked if he considered the investigation completed on 9/17/21 the Administrator responded Yep. He stated, we concluded there was no abuse. He confirmed the allegation had not been reported to state agency. The Administrator stated he did not have any documentation of an investigation related to the statements made by Resident #2 to RN #1 and RN #2. On 9/22/21 at 10:00 AM an interview with the DON confirmed she did not complete the Alleged Abuse Incident Report form. The DON confirmed she had not yet interviewed the person reporting the incident, Interviews with any witnesses to the incident, interview the resident's Attending Physician as needed, or with other staff members (on all shifts) who had contact with the resident during the period of the alleged incident or interviews other residents to whom the accused employee provides care or services. She also confirmed any assessments of Resident #1 or Resident #2 were not documented. On 9/22/21 at 3:10 PM an interview with CNA #4 revealed she had worked at the facility for about a month. She stated she assisted CNA #1 with the care of Resident #2 on the afternoon of 9/17/21 and CNA #2 had not said or done anything untoward regarding Resident #2. She stated Nothing happened. We changed her. She denied any knowledge of any investigation done into any complaints voiced by Resident #2. An interview on 9/22/21 at 3:25 PM with RN #3, the facility Infection Preventionist (IP) revealed it was her opinion and she understood the best way to provide protection for residents during an investigation would be to remove the accused staff member from patient care and do an investigation. She stated as a QAPI committee member she would expect a thorough investigation to include (but not be limited to) documented assessments of involved residents, interviews with all involved and witnesses, documentation of actions taken to prevent further injury and end results of the investigation.

Based on record review, resident interview, staff interview and facility policy review, the facility failed to report an allegation of physical abuse and/or verbal abuse for two (2) of 4 sampled residents investigated for abuse of 20 residents screened for abuse. Resident #1 and Resident #2. Findings Include: A review of the facility's policy titled Abuse Prevention Program, with a revision date of December 2017 and review date of July 2019, revealed administration was to identify, assess, investigate, and report any allegation of abuse within timeframes as required by federal requirements. A review of the facility's policy titled Abuse Investigation and Reporting with a revision date of July 2017 and a review date of July 2019 revealed All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ('Abuse) shall be promptly reported to local, state, federal agencies (as defined by current regulations) .An alleged violation of abuse, neglect, exploitation or mistreatment .will be reported immediately, but not later than: Two (2) hours if the alleged violation involves abuse . Resident #1 A review of the facility's Face Sheet for Resident #1 revealed the facility admitted the resident on 6/4/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/25/21, revealed Resident #1 had no Brief Interview for Mental Status (BIMS)score, which indicated the resident had significant cognitive impairment. A review of Resident #1's Medical Record revealed no documentation related to an allegation of abuse, and no notification to the physician, practitioner, or Responsible Party (RP) regarding an allegation of abuse. An interview on 9/21/21 at 11:10 AM with the Administrator and the Director of Nurses (DON) revealed they had not had any recent complaints or incidents reported to them. In an interview on 9/21/21 at 12:51 PM with the DON she stated There was a thing between two staff not getting along. Certified Nurse Assistant (CNA) #2 wrote a note and gave it to someone but not me. As soon as I found out I did an investigation. The SA requested a copy of the investigation. A review of the facility's investigation revealed a note written by CNA#2 alleging verbal and physical abuse of Resident #1 by CNA#1. On 9/21/21 at 12:55 PM an interview with the Director of Nursing (DON) revealed she did not report the written allegation of verbal and physical abuse to the State Agency (SA) or any other entity as she determined the allegation to be false based on her investigation. An observation on 9/21/21 at 12:59 PM revealed Resident #1 in the common area seated in a Geri chair. The resident responded when spoken to but was unable to engage in conversation beyond her immediate self. Resident responded she felt ok and responded no when asked if she was hurting anywhere. When asked other questions she had no response. An observation on 9/21/21 at 2:15 PM of Resident #1 revealed her resting quietly in her bed in her room with her eyes open. Resident #1 was able to respond when spoken to and when asked if she was comfortable responded We're alright. She did not answer any other questions. She appeared comfortable with no indication of distress. On 9/21/21 at 2:18 PM an interview with CNA #1 revealed she had been called in to the DON's office on the afternoon of 9/17/21 regarding an allegation of abuse against her related to Resident #1. CNA #1 stated she had written and submitted a statement denying all allegations. CNA #1 stated she worked fast but was not abusive and denied verbally or physically abusing Resident #1. On 9/21/21 at 2:40 PM an interview with CNA #2 revealed she had worked at the facility a little over a year. She confirmed she had worked Friday 9/17/21. She stated she went into the room with Resident #1 and CNA #1 at approximately 10:00 AM to help get the resident dressed for a visit. CNA #2 stated she had witnessed what she considered an act of verbal and physical abuse against Resident #1 by CNA #1. CNA #2 stated she spoke to the MDS Nurse and told her what happened. CNA #2 stated she was advised to write a statement and give it to her (the MDS Nurse), and it would be given to the DON. CNA #2 stated she followed the instructions of the MDS Nurse immediately and wrote a statement and gave it to the MDS Nurse around lunch time. CNA #2 stated that she also learned there had been another incident involving CNA #2 on 9/17/21 in which Resident #2 had reported CNA #2 for being rough with her. An interview on 9/21/21 at 3:00 PM with the MDS nurse revealed on the morning of 9/17/21 CNA #2 reported an incident that morning at approximately 11:00 AM involving CNA #1 being rough with Resident #1 and saying things she shouldn't in front of the resident. The MDS Nurse stated her instructions to CNA #2 were to write a statement and give it to the DON, in accordance with facility policy and procedure. The MDS Nurse stated CNA #2 did write a statement and gave it to her, (the MDS Nurse) and she in turn gave the statement to the DON around lunch time. Resident #2 A review Resident #2's Face Sheet revealed Resident #2 was admitted by the facility on 8/27/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #2's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/3/21 revealed the resident had a Brief Interview for Mental Status (BIMS) indicated moderate cognitive impairment. An interview on 9/21/21 at 3:17 PM with RN#1 revealed she was the RN supervisor on the 9/17/21 day shift. RN #1 denied being notified by CNA #2 of any alleged abuse of Resident #1 but stated she had been made aware that a complaint had been voiced regarding alleged abuse against Resident #2 by CNA #1 and went to check on Resident #2 along with the RN #2. RN #1 stated Resident #2 confirmed that she felt that CNA #1, who was assigned to assist her on 9/17/21, had moved too fast while providing care. RN #1 stated she and RN #2 assessed Resident #2 and noted no signs of injury or abuse, and Resident #2 denied pain or injury. RN #1 stated she reassigned Resident #2 to CNA #3. RN #1 stated I let the DON know as well. On 9/21/21 at 3:45 PM an interview with Resident #2 revealed she was alert, oriented, and able to communicate well. Resident #3 stated CNA #1 was her CNA on 9/17/21 during the 7-3 shift. Resident #2 stated she had suffered a stroke which left her unable to use her right side including her right arm and right leg. Resident #2 stated that on 9/17/21 she reported to RN #1, RN #2, and the DON that She (CNA #1) was moving too fast. Resident #2 stated she did not intend to report it because I didn't want to make a big deal out of anything. Resident #2 denied pain and stated, I wasn't hurt, she was just moving too fast, and I didn't like it. Resident #2 stated she had never had any problem or conflict of any kind with CNA #2 prior or since the 9/17/21 incident. Resident #2 confirmed she reported the incident to RN #1 and the RN #2 but had not reported it to anyone else, until the DON came and asked her about it the same day. On 9/21/21 at 5:12 PM the DON confirmed she was aware of both complaints about CNA #1 on Friday 9/17/21. She stated she received and read the statement written by CNA #2 around 4:50 PM. The DON stated she had not notified the families or RPs of the allegations of abuse. The DON stated the physician, nor the facility's Medical Director had been notified. The DON stated she and the Administrator spoke about the allegation on 9/17/21 and the Administrator read both the statement written by CNA #2 and a statement of response written by CNA #1. The DON stated RN #1 brought to her attention another, separate report concerning CNA #1 and she interviewed Resident #2 (who the DON described as alert and oriented). The DON stated Resident #2 reported she didn't like the way CNA #1 handled her. Resident #2 said CNA #2 just works fast. I concluded on the allegations of abuse that there was no harm to the residents. She stated she did not attempt to notify Resident #1's Responsible Party (RP), nor Resident #2's RP because she did not want to start conflict. She stated she did not notify the state agency of survey and certification, or any other external entity of the allegations. On 9/21/21 at 6:00 PM an interview with the Administrator revealed the DON notified him of the allegations made in CNA #2's written statement and he read the statement. He stated he was notified about the allegations made by Resident #2 on 9/20/21(not the date it was reported). He stated the facility did not report the allegations to the SA. The Administrator stated he thought CNA #2 was not trustworthy and she misinforms. He stated when he was made aware of the 9/17/21 allegations, he had to consider the source. When asked if he considered CNA #2's statement an allegation of abuse, the Administrator responded CNA #2 is not trustworthy and she doesn't tell the whole truth. The Administrator stated the allegation by CNA #2 was deemed false. The Administrator stated his impression of the allegation made by Resident #2 wasn't abuse. When asked why the facility had not followed its own policy and procedure for abuse allegation, the Administrator stated, I don't know. We should have done that. He confirmed the allegation had not been reported to state agency. An interview on 9/22/21 at 6:32PM with Resident #2's Responsible Party (RP) revealed the facility did not notify him of any allegation of abuse.

Based on interview, receipt review, ledger review, records review and policy review, the facility failed to ensure each residents personal property in the form of money, was protected for seven (7) of 13 sampled residents (Residents #1, #2, #3, #4, #5, #8 and #9) and three (3) of five (5) unsampled residents (Unsampled Residents B, C, D), from a total sample of 13, resulting in Immediate Jeopardy that began on [DATE], when without authorization staff received cash payments from Resident #1's Responsible Party (RP) but did not credit them to the resident's accounts, altered payment receipts, altered deposit slips, altered postings, redistributed trust funds, and redistributed Social Security checks, resulting in the misappropriation of resident funds in excess of $9701.17 with the likelihood of ongoing financial loss, associated hardship, and the accompanying mental anguish. The misappropriation involving cash received for a resident trust fund account was determined to begin initially on [DATE]. This was first identified when a cash payment to the facility for $465.00 by Resident #1's Responsible Party (RP), was not posted to Resident #1's trust fund account and/or the resident's room/board account. Findings Include: Review of the facility's document entitled Mississippi Vulnerable Persons Act (dated [DATE]) read under Section 7: the exploitation of a vulnerable person was prohibited and unlawful. Further, the policy defined exploitation as "the illegal or improper use of a vulnerable person or the improper use of, or theft of his/her money, property, assets or other resources for another person's profit or advantage." During an interview [DATE] at 9:10 AM, ADM #1 said Resident #1's RP notified him of financial discrepancies in the resident's room /board account on [DATE]. The following day, the RP provided original receipts. ADM #1 said he called CPA #1 and began an investigation on [DATE], because the RP's original receipts did not match the corresponding carbon copies retained by the facility. The administrator revealed according to the CPA #1 investigation initiated [DATE], the CPA identified more than $9701.17 of resident funds had been misappropriated. CPA #1 documented his findings in a report dated [DATE]. The facility, following the CPA review, contracted a forensic accountant on [DATE] to further investigate the resident accounts. ADM #1 confirmed prior to Bookkeeper #1's resignation, all transactions connected with the misappropriation were independently initialed, signed, or electronically stamped by Bookkeeper #1. CPA #1 verified during an interview on [DATE] at 1:20 PM, the resident fund review revealed room and board payments submitted in cash funds through Bookkeeper #1 were never posted to the intended accounts established for Resident #1. CPA #1 said he assumed these cash funds were "pocketed" by Bookkeeper #1, which caused a mounting bill for Resident #1's room and board. CPA #1 explained to avoid detection Bookkeeper #1 made unauthorized payments to Resident #1's room and board account, by altering payment receipts, altering bank recipients, redirecting funds, and posting false deposits and withdrawals to various accounts. This practice negatively impacted the trust funds of five (5) vulnerable residents (Residents #2, #3, #4, and #5), but involved misappropriation from a total of nine (9) trust fund accounts (Residents #1, #2, #3, #4, #5, #8, Unsampled Residents B, C, and D). CPA #1 was unable to calculate the losses incurred by Resident #1, saying the total losses and reimbursement for Resident #1's account would be based on findings in the pending forensic accountant's report. On [DATE] at 9:30 AM during an interview, Bookkeeper #2 said receiving, depositing, and posting financial transactions required a receipt, with the original copy going to the payer, and all carbon copies retained by the facility. She said, Bookkeeper #1 conducted these transactions prior to her resignation. Additionally, payments for room and board generated a different receipt form, than those of the trust fund. Bookkeeper #2 stated, often the two (2) types of receipts were interchanged by Bookkeeper #1. Resident #1 During the interview on [DATE] at 1:20 PM, CPA #1 said large credits and debits applied to the trust fund account established for Resident #1 were not expected, because her social security check and bill payment were handled by her RP. Review of her trust fund statement revealed Resident #1 had an active account from [DATE] through [DATE], with relatively small cash deposits and withdrawals. However, the following transactions appeared random and based on interviews, they were unexpected: 1) a $1253.00 deposit on [DATE]; 2) a $1253.00 room and board withdrawal on [DATE]; 3) a $1315.00 deposit on [DATE]; 4) a $1315.00 room and board withdrawal on [DATE]; 5) a $1315.00 deposit on [DATE]; 6) a $465.00 room and board withdrawal on [DATE]; 7) an $840.00 room and board withdrawal on [DATE]. The facility was unable to provide a valid receipt for any of these transactions. During an observation on [DATE] at 12:00 PM, Resident #2 reported she did not want to be interviewed. Though she reported feeling safe at the facility and free to speak her mind without reprisal, she did not want to be bothered by details of the ongoing investigation. Record review revealed the facility admitted Resident #1 on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) revealed Resident #1 had no cognitive impairments, but required minimally one staff member to assist with all activities of daily living. During the same interview on [DATE] at 1:20 PM, CPA #1 said when Bookkeeper #1 excepted cash payments from Resident #1's responsible party (RP), they were not always posted to the intended account, as evidenced by the following: Review of receipt # 7, revealed on [DATE] Bookkeeper #1 issued a cash receipt in the amount of $465.00 to Resident #1's RP. Review of monthly statements for Resident #1's trust fund and room/board account revealed, the cash payment for $465.00 was not posted to either of her accounts. Review of receipt # 9, revealed on [DATE] Bookkeeper #1 issued a cash receipt in the amount of $465.00 to Resident #1's RP. Review of monthly statements for Resident #1's trust fund and room/board account revealed, the cash payment for $465.00 was not posted to either of her accounts. Review of receipt # 0, revealed on [DATE] Bookkeeper #1 issued a cash receipt in the amount of $465.00 to Resident #1's RP. Review of monthly statements for Resident #1's trust fund and room/board account revealed, the cash payment for $465.00 was not posted to either of her accounts. Review of receipt # 2, revealed on [DATE] Bookkeeper #1 issued a cash receipt in the amount of$465.00 to Resident #1's RP. Review of monthly statements for Resident #1's trust fund and room/board account revealed, the cash payment for $465.00 was not posted to either of her accounts. Review of receipt # 9, revealed on [DATE] Bookkeeper #1 issued a cash receipt in the amount of $465.00 to Resident #1's RP. Review of monthly statements for Resident #1's trust fund and room/board account revealed, the cash payment for $465.00 was not posted to either of her accounts. Review of receipt # 1, revealed on [DATE] Bookkeeper #1 issued a cash receipt in the amount of $450.00 to Resident #1's RP. Review of monthly statements for Resident #1's trust fund and room/board account revealed, the cash payment for $450.00 was not posted to either of her accounts. Review of receipt # 3, revealed on [DATE] Bookkeeper #1 issued a cash receipt in the amount of $465.00 to Resident #1's RP. Review of monthly statements for Resident #1's trust fund and room/board account revealed, the cash payment for $465.00 was not posted to either of her accounts. Review of the operating account receipt #9154, against the carbon copy for the same receipt, revealed the carbon copy receipt/ledger had been altered. The original #9154 receipt read "450.00" dollars in the cash column, "450.00" dollars in the net column, "[DATE]" in the date column, with Resident #1's name written in the name column, and Bookkeeper #1's initials in the received column. However, the carbon copy ledger for receipt #9154 documented "289.30" dollars in the checks column, nothing in the cash column, "289.30" dollars in the net column, "[DATE]" in the date column, with Unsampled Resident F's name written in the name column, "medical records" documented in the description column, with Bookkeeper #1's initials in the received by column. During the interview on [DATE] at 1:20 PM, CPA #1 reviewed the operations account receipt #9040 and said Bookkeeper #1 used the same receipt number twice to hide the cash payment she received from Resident #1's RP. Review of the operations account receipt #9436, revealed on [DATE] Bookkeeper #1 issued a cash receipt in the amount of $840.00 to Resident #1's RP. Review of monthly statements for Resident #1's trust fund and room/board account revealed, the cash payment for $840.00 was not posted to either of her accounts. Review of the operations account receipt #9437, revealed on [DATE] Bookkeeper #1 issued a cash receipt in the amount of $465.00 to Resident #1's RP. Review of monthly statements for Resident #1's trust fund and room/board account revealed, the cash payment for $465.00 was not posted to either of her accounts. Review of the operations account receipt #9500, revealed on [DATE] Bookkeeper #1 issued a cash receipt in the amount of $840.00 to Resident #1's RP. Review of monthly statements for Resident #1's trust fund and room/board account revealed, the cash payment for $840.00 was not posted to either of her accounts. Review of operations account receipt #9501, revealed on [DATE] Bookkeeper #1 issued a cash receipt in the amount of $465.00 to Resident #1's RP. Review of monthly statements for Resident #1's trust fund and room/board account revealed, the cash payment for $465.00 was not posted to either of her accounts. Review of operations account receipt #9614, revealed on [DATE] Bookkeeper #1 issued a cash receipt in the amount of $840.00 to Resident #1's RP. Review of monthly statements for Resident #1's trust fund and room/board account revealed, the cash payment for $840.00 was not posted to either of her accounts. Review of operations account receipt #9640, revealed on [DATE] Bookkeeper #1 issued a cash receipt in the amount of $465.00 to Resident #1's RP. Review of monthly statements for Resident #1's trust fund and room/board account revealed, the cash payment for $465.00 was not posted to either of her accounts. Review of operations account receipt #9671, revealed on [DATE] Bookkeeper #1 issued a cash receipt in the amount of $465.00 to Resident #1's RP. Review of monthly statements for Resident #1's trust fund and room/board account revealed, the cash payment for $465.00 was not posted to either of her accounts. Review of operations account receipt #9729, revealed on [DATE] Bookkeeper #1 issued a cash receipt in the amount of $840.00 to Resident #1's RP. Review of monthly statements for Resident #1's trust fund and room/board account revealed, the cash payment for $840.00 was not posted to either of her accounts. Review of operations account receipt #9730, revealed on [DATE] Bookkeeper #1 issued a cash receipt in the amount of $465.00 to Resident #1's RP. Review of monthly statements for Resident #1's trust fund and room/board account revealed, the cash payment for $465.00 was not posted to either of her accounts. Review of operations account receipt #9772, revealed on [DATE] Bookkeeper #1 issued a cash receipt in the amount of $840.00 to Resident #1's RP. Review of monthly statements for Resident #1's trust fund and room/board account revealed, the cash payment for $840.00 was not posted to either of her accounts. Review of operations account receipt #9773, revealed on [DATE] Bookkeeper #1 issued a cash receipt in the amount of $465.00 to Resident #1's RP. Review of monthly statements for Resident #1's trust fund and room/board account revealed, the cash payment for $465.00 was not posted to either of her accounts. Review of operations account receipt #9848, revealed on [DATE] Bookkeeper #1 issued a cash receipt in the amount of $840.00 to Resident #1's RP. Review of monthly statements for Resident #1's trust fund and room/board account revealed, the cash payment for $840.00 was not posted to either of her accounts. Review of operations account receipt #9849, revealed on [DATE] Bookkeeper #1 issued a cash receipt in the amount of $465.00 to Resident #1's RP. Review of monthly statements for Resident #1's trust fund and room/board account revealed, the cash payment for $465.00 was not posted to either of her accounts. Review of operations account receipt #9909, revealed on [DATE] Bookkeeper #1 issued a cash receipt in the amount of $840.00 to Resident #1's RP. Review of monthly statements for Resident #1's trust fund and room/board account revealed, the cash payment for $840.00 was not posted to either of her accounts. Review of operations account receipt #9640, revealed on [DATE] Bookkeeper #1 issued a cash receipt in the amount of $465.00 to Resident #1's RP. Review of monthly statements for Resident #1's trust fund and room/board account revealed, the cash payment for $465.00 was not posted to either of her accounts. Resident #2 Review of the room and board carbon copy ledger receipt #9564 dated [DATE], documented Resident #1 made a room and board payment for $1190.00. However, on the original copy of the receipt someone crossed Residents #1's name off and replaced it with Resident #2's name. Review of the trust fund statement for Resident #2 dated [DATE], revealed $1190.00 had been withdrawn for room and board, but the facility was unable to provide a valid receipt for this transaction. Review of the room and board statement for Resident #2 from the same month, revealed the $1190.00 was not credited to her room and board account. Review of the room and board statement for Resident #1 from the same month, revealed a credit for $1190.00 made on [DATE], but the facility was unable to provide a valid receipt for this transaction. Receipts issued to Resident #1's RP the same month, failed to reveal any payment made to the facility in the amount of $1190.00. Review of the room/board carbon copy receipt/ledger # 9660 dated [DATE], documented Resident #1 made a room and board payment for $1591.00. However, on the original copy of the receipt someone crossed Resident #1's name off and replaced it with Resident #2's name. Review of the trust fund statement for Resident #2 dated [DATE], revealed $1591.00 had been withdrawn for room and board, but the facility was unable to provide a valid receipt for this transaction. Review of the room and board statement for Resident #2 the same month, revealed a the$1591.00 was never credited to her room and board account. Review of the room and board statement for Resident #1 from the same month, revealed a credit for $1591.00 made on [DATE], but the facility was unable to provide a valid receipt for this transaction. Receipts issued to Resident #1's RP the same month, failed to reveal any payment made to the facility in the amount of $1591.00. During the same interview [DATE] at 1:20 PM, CPA #1 said changing the original receipt ensured each posted transaction was receipted if a second review was conducted. Only with the two receipts reviewed simultaneously, was the misappropriation visible. Review of the face sheet revealed the facility admitted Resident #2 on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #2 had moderately impaired cognition and required minimally one staff member to assist with all activities of daily living. Resident #3 Review of the room and board carbon copy receipt/ledger #9671 dated [DATE], documented Resident #1 made a room and board payment for $1383.00. However, on the original copy of the receipt someone scribbled Resident #3's name over, Resident #1's name. Review of the trust fund statement for Resident #3 revealed a withdrawal of $1383.00 from her account, but the facility was unable to provide a valid receipt for this transaction. Review of the room and board statement for Resident #3 the same month, revealed the $1383.00 was not credited to her account. Review of the room and board statement for Resident #1 revealed a credit for $1383.00 made on [DATE], but the facility was unable to provide a valid receipt for this transaction. Receipts issued to Resident #1's RP the same month, failed to reveal any payment made to the facility in the amount of $1383.00. During the same interview on [DATE] at 1:20 PM, CPA #1 explained the process when CPA #1 said changing the original receipt ensured each posted transaction was receipted if a second review was required. Only with the two receipts reviewed simultaneously, was the misappropriation visible. Review of the trust fund statement for Resident #3 revealed monthly Social Security Administration (SSA) checks in the amount of $1427.00 were routinely credited to her account, but no deposit was made in ,[DATE] or ,[DATE]. Review of the facility's bank deposit slip dated [DATE], revealed a SSA check for $1427.00 was issued to Resident #3, but the facility deposited $1315.00 into the trust fund account established for Resident #1, and $112.00 was deposited into the trust fund established for Resident #8. The facility was unable to provide a valid receipt for these transactions. Review of the account statements for Resident #3 the same month, revealed he was not credited for the $1427.00 payment. Review of the trust fund statement for Resident #1 revealed a credit for $1315.00 on [DATE], but the facility was unable to provide a valid receipt for this transaction. Receipts issued to Resident #1's RP the same month, failed to reveal any payment made to the facility in the amount of $1315.00. Review of the facility's bank deposit slip dated [DATE], revealed a SSA check for $1427.00 was issued to Resident #3, but the facility deposited $1315.00 into the trust fund account for Resident #1, $30.00 into the trust fund account for Unsampled Resident B, $30.00 into the trust fund account for Unsampled Resident C and $52.00 into the trust fund account for Unsampled Resident D. Review of the room and board statement for Resident #3 the same month, revealed the $1427.00 was not credited to her account. Review of the trust fund statement for Resident #1 revealed a credit for $1315.00, on [DATE], but the facility was unable to provide a valid receipt for this transaction. The room and board statement for Resident #1 the same month, revealed a credit for $1315.00, but the facility was unable to provide a valid receipt for this transaction. Receipts issued to Resident #1's RP the same month, failed to reveal any payment made to the facility in the amount of $1315.00. Review of the trust fund statement for Unsampled Resident B dated [DATE] revealed a credit for $30.00, but the facility was unable to provide a valid receipt for this transaction. Review of the undated face sheet revealed the facility admitted Resident #3 on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #3 had moderately impaired cognition and required minimally one staff member to assist with all activities of daily living. Resident #4 Review of the room/board carbon copy receipt/ledger # 9752 dated [DATE], documented Resident #1 made a room and board payment for $1400.71. However, the original copy of the receipt revealed someone scratched off Resident #1's name and replaced it with Resident #4's name. Resident #4's trust fund statement documented $1400.71 had been withdrawn for room and board, but the facility was unable to provide a valid receipt for this transaction. The room and board statement for Resident #4 the same month, revealed the $1400.71 was not credited to his account. Review of the room and board statement for Resident #1 revealed a credit for $1400.71 dated [DATE], but the facility was unable to provide a valid receipt for this transaction. Receipts issued to Resident #1's RP the same month, failed to reveal any payment made to the facility in the amount of $1400.71. Record review revealed the facility admitted Resident #4 on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #4 had moderately impaired cognition with both long and short term memory loss, which required minimally one staff member to assist with all activities of daily living. Resident #5 Review of the bank deposit slip dated [DATE], a check issued to Resident #5 in the amount of $1727.00. However, someone struck through the $1727.00 and altered the amount to $474.05. The same form documented a deposit to Resident #1's trust fund in the amount of $1253.00, but the facility was unable to provide valid receipt for this transactions. Review of the trust fund statement for Resident #5 the same month revealed a credit for only $474.05, but facility was unable to provide a valid receipt for this transaction. Review of the trust fund statement for Resident #1 revealed a credit for $1253.00 on [DATE], but the facility was unable to provide a valid receipt for this transaction. Receipts issued to Resident #1's RP the same month, failed to reveal any payment made to the facility in the amount of $1253.00 Record review revealed the facility admitted Resident #5 on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #5 had severely impaired cognition and required minimally one staff member to assist with all activities of daily living. Resident #8 Review of the trust fund statement for Resident #8 revealed a credit for $112.00 made on [DATE], but the facility was unable to provide a valid receipt for this transaction. Record review of the undated face sheet revealed the facility admitted Resident #8 on [DATE] and the resident died on [DATE]. [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #8 had no cognitive impairments, but required minimally one staff member to assist her with all activities of daily living. Resident #9 Review of the carbon copy receipt # 6, signed by both Bookkeeper #1 and Resident #9 revealed a trust fund withdrawal for six dollars dated [DATE]. However, someone altered the carbon copy to reflect a $16.00 withdrawal. Resident #9 trust fund the same month, revealed a withdrawal of $16.00 was made the same day. The facility was unable to provide a valid receipt for this transaction. Review of the undated face sheet revealed the facility admitted Resident #9 on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #9 had severely impaired cognition and required minimally one staff member to assist with all activities of daily living. Unsampled Resident B Review of the trust fund established for Unsampled Resident B revealed a $30.00 credit on [DATE]. The facility was unable to provide a valid receipt for this trust fund deposit. Unsampled Resident C Review of the trust fund established for Unsampled Resident C revealed a $30.00 credit on [DATE]. The facility was unable to provide a valid receipt for this trust fund deposit. Unsampled Resident D Review of the trust fund established for Unsampled Resident D revealed a $52.00 credit on [DATE]. The facility was unable to provide a valid receipt for this trust fund deposit. ADM #1 was informed on [DATE] at 4:30 PM, of the immediate jeopardy identified [DATE], that began [DATE] when the facility failed to prevent trust fund discrepancies. The facility submitted the following credible Allegation of Compliance (AoC) on [DATE] at 12:53 PM, summarized as follows: - [DATE] Bookkeeper #1 resigned and her last day worked was [DATE]. - [DATE], the facility implemented a new electronic resident trust accounting software system. - [DATE], the Administrator was notified of potential misappropriation in the room/board established for Resident #1. - [DATE], CPA #1 initiated account reviews to rule out misappropriation. - [DATE], ADM #1 notified the following agencies of the identified misappropriation: 1) The State Licensure and Certification Agency; 2) the Attorney General's Office; and 3) local law enforcement. - [DATE], ADM #1 notified the State Medicaid office of the identified misappropriation. - [DATE], the facility contracted with an independent forensic accounting firm, who reviewed the accounts [DATE]/2014. As of [DATE], the forensic accountants report was pending, with the tally of losses for Resident #1 yet to be established and reimbursed. - [DATE], CPA #1 documented 5 residents were adversely impacted in excess of $9701.17. Additionally, the review identified unauthorized deposits made to trust fund accounts established for Unsampled Resident B, C, and D. These unauthorized deposits were not reversed by the facility. - On [DATE] the facility reconciled the lost funds through reimbursements to the trust fund accounts for: 1) Resident #2 in the amount of $2786.00; 2) Resident #3 in the amount of $4252.00; 3) Resident #4 in the amount of $1405.71; and 4) Resident #5 in the amount of $1258.00. - On [DATE], letters were sent to the RP for Resident #2, #3, #4, #5, informing them of the discrepancy and adjustment made to reconcile the resident trust fund accounts. - On [DATE], ADM #1, CPA #1, and the facility's Corporate Regional Director developed a procedure that segregated duties between receipt, deposit, and posting of resident funds. QA members met the same day and approved the new procedure. - On [DATE], the facility implemented mandatory training for their new resident funds procedure. The facility made it mandatory for all staff involved with resident fund transactions to attend before their return to duty. - On [DATE], mandatory in-services for 100% of staff members began on the following topics: Vulnerable Persons Act, misappropriations of resident funds, Abuse, Neglect, Exploitation, Resident Identity Theft Prevention, Resident Rights, Elder Justice Act, and the Corporate Compliance Code of Conduct. No staff members were permitted to return to their duties until their education was completed. The facility alleged the immediate jeopardy was removed on [DATE]. On [DATE], the surveyor confirmed that as of [DATE], the facility had implemented the following measures to remove the Immediate Jeopardy. - The facility had implemented electronic software for their resident trust fund accounts. - Bookkeeper #1 had resigned [DATE] and her last day of work was [DATE]. - The following notifications were made on [DATE]: 1) the Attorney General's office; 2) the State Licensure and Certification Agency; and 3) local law enforcement. - Medicaid was notified of the misappropriation of resident trust funds on [DATE]. - CPA #1 conducted account reviews, that by [DATE] revealed in excess of $9701.71 were missing from Resident trust funds. - The following resident trust fund accounts had been reimbursed: 1) Resident #2 received $2786.00; 2) Resident #4 received 1405.71; and 3) Resident #5 received 1258.00. - The facility reimbursed the RP for Resident #3 who had since died with $4252.00, as evidenced a check payment and United Postal Service certified mail receipts. - The facility reversed the payment for $1230.00 from the accounts receivable for Resident #1. - Reimbursements to Resident #1 were pending and to be determined by results of a forensic accounting report, who conducted account reviews at the facility [DATE]. - The facility left the excess payments made into the resident trust fund accounts for Resident #8, Unsampled Resident B, Unsampled Resident C, and Unsampled Resident D. - Letters that outlined the account discrepancies and resulting adjustments were mailed on [DATE] to the RP for Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #8, Unsampled Resident B, Unsampled Resident C, and Unsampled Resident D. - A valid contract for a surety bond good through [DATE], for coverage up to $91,000.00, was held by the facility. - ADM#1, CPA #1, and the Corporate Director of Operations reviewed facility policy for resident trust funds and accounts receivable, based on a sign in record and direct observation. - ADM#1, CPA #1 and the Corporate Director of Operations established an "Immediate Plan and Procedure for the receipt, deposit, and posting of accounts receivable and resident trust funds" on [DATE]. - QA documented approval of the new "Immediate Plan and Procedure for the receipt, deposit, and posting of accounts receivable and resident trust funds" on [DATE]. - 4 of 4 business office staff signed in for education on misappropriation of resident funds, exploitation of resident funds or property, the Vulnerable Persons Act, the Elder Justice Act and the new "Immediate Plan and Procedure for the receipt, deposit, and posting of accounts receivable and resident trust funds". - 58 of 74 staff had signed in before they returned to work for education on misappropriation of resident funds, exploitation of resident funds or property, the Vulnerable Persons Act, and the Elder Justice Act. - Inservice content of abuse/misappropriation was validated by interview of random staff members across all disciplines. - The components of the facility's "Immediate Plan and Procedure for the receipt, deposit and posting of accounts receivable and resident trust funds" had been implemented. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of an "E" at 42 CFR 483.13 Resident Behavior and Facility Practice (F-224), which is no actual harm with potential for more than minimal harm that is not an immediate jeopardy, while the facility monitors the effectiveness of systemic changes and quality assurance activities.

Based on interview, facility ledger review, receipts review, resident records review, and policy review, the facility failed to hold, safeguard, manage, and protect resident trust funds for seven (7) of 13 sampled residents (Residents #1, #2, #3, #4, #5, #8, AND #9) and three (3) of five (5) unsampled residents (Unsampled Residents B, C, and D), from a total sample of 13. This resulted in immediate jeopardy that began on [DATE] when staff made unauthorized trust fund withdrawals from accounts belonging to Resident #2, Resident #3, Resident #4, and Resident #5, and made unauthorized deposits into the trust fund accounts established for Resident #1, Resident #8, Unsampled Resident B, Unsampled Resident C, and Unsampled Resident D, resulting in lost funds, and inaccurate trust fund balances, with the likelihood of ongoing mismanagement of resident trust funds and the associated financial losses. The misappropriation involving resident trust fund accounts was determined to begin on [DATE]. This was evidenced when Certified Public Accountant #1 CPA #1 found a social security check intended for deposit to the trust fund established for Resident #5, was instead credited to the trust fund established for Resident #1, and later withdrawn to pay Resident #1's room and board. Findings Include: Review of the facility's policy entitled "Corporate Compliance Code of Conduct" dated [DATE] revealed staff members were to ensure all financial records "accurately" reflected transactions, "in accordance with generally accepted accounting principles." The company's records were "not to contain any false or misleading information," with all payments applied to the appropriate accounts for their intended purpose. Additionally, billing was to be "only for services rendered". The Administrator's documented email dated [DATE] at 9:17 AM, for clarification of his job description, revealed his duties included monthly checks to: 1) Reconcile the facility trust fund; 2) Investigate and reconcile any discrepancies identified in balances; and 3) Review the petty cash balance. Additionally, his role included quarterly facility statement reviews for: 1) Negative balances; 2) Acceptable limits for Medicaid allowance; 3) Zero balance accounts; 4) Open accounts for discharged residents; and 5) Outstanding checks. During a follow up telephone interview [DATE] at 11:00 AM, Administrator #1 (ADM #1) said the facility's contracted Certified Public Accountant #1 (CPA #1) conducted resident trust fund reviews annually and when requested based on identified discrepancies. The last annual review CPA #1 conducted was in January of 2013, when the State Medicaid Agency sent a trust fund auditor to the facility. ADM #1 said, neither of these two audits revealed any evidence of misappropriation or resident trust fund discrepancies. ADM #1 said he provided monthly resident trust fund reviews, but never identified misappropriation despite its existence, because Bookkeeper #1 falsified the records he reviewed well enough to avoid detection. During a verification telephone interview with the State Medicaid Agency on [DATE] at 3:43 PM, the Performance Auditor for the Division of Medicaid verified the audits they had conducted on [DATE], [DATE], and [DATE], identified minimal random transaction errors that lacked receipts, but "no egregious findings" otherwise to conduct an extended review. During an interview [DATE] at 9:10 AM, ADM #1 said Resident #1's responsible party (RP) notified him of financial discrepancies in the resident's room /board account on [DATE]. The following day, the RP provided original receipts. ADM #1 said he called CPA #1 and began an investigation on [DATE], because the RP's original receipts did not match the corresponding carbon copies retained by the facility. The ADM #1 went on to say, CPA #1 arrived on [DATE], and identified in excess of $9701.17 was missing from the resident fund account on [DATE]. CPA #1 expanded his account review through [DATE], and documented his findings in a report dated [DATE]. A forensic accountant was secured on [DATE] by the facility. ADM #1 said, Bookkeeper #1 initialed, signed, or electronically stamped all transactions linked to the misappropriation. Further, he said Bookkeeper #1 worked unsupervised doing receipts, deposits, and postings of all resident trust fund and accounts receivable transactions (room/board) for the past three years. During an interview on [DATE] at 1:20 PM, CPA #1 verified the accuracy of his findings documented in the three page report dated [DATE]. The review conducted by CPA #1 revealed, many room/board payments submitted in cash funds through Bookkeeper #1, were never posted to intended accounts established for Resident #1. CPA #1 said he assumed these cash funds were pocketed by Bookkeeper #1, causing a mounting bill for Resident #1's room/board. He said to avoid detection from the unwarranted mounting charges incurred from the theft, Bookkeeper #1 made unauthorized payments to Resident #1's room/board account, by altering payment receipts and bank receipts intended for other residents and redirecting their funds to cover Resident #1's room/board bill. Bookkeeper #1 also posted charges to other resident trust fund accounts and redirected those funds to cover Resident #1's room/board bill. Review of the CPA #1's report dated [DATE], revealed misappropriation involving resident trust fund accounts began on [DATE]. CPA #1's findings revealed a social security check intended for deposit to the trust fund established for Resident #5, was instead credited to the trust fund established for Resident #1, and later withdrawn to pay Resident #1's room and board. CPA #1 went on to explain during the interview, this practice negatively impacted the trust funds of four (4) vulnerable residents (Resident #2, #3, #4, and #5), but involved misappropriation from a total of nine (9) trust fund accounts (Resident #1, #2, #3, #4, #5, #6, #8, Unsampled Resident B, C, and D). However, CPA #1 was unable to calculate the losses incurred by Resident #1, saying the total losses and reimbursement for her account would be based on finding in the pending forensic accountants report. An interview on [DATE] at 9:30 AM revealed Bookkeeper #2 assumed the role of bookkeeper on [DATE], following Bookkeeper #1's resignation. Bookkeeper #2 reported prior to taking on the bookkeeper responsibilities, he/she was a receptionist at the facility. Bookkeeper #2 stated she would intermediately fill in for Bookkeeper #1 during breaks. Bookkeeper #2 stated while working along side Bookkeeper #1, he/she had no suspicion of money being taken from the residents. During the interview on [DATE] at 9:30 AM, Bookkeeper #2 said the facility had always required their bookkeeper to receipt, deposit, and post all financial transactions made on behalf of residents at the facility. Prior to her assuming the role on [DATE], it was Bookkeeper #1 who completed these transactions. All financial transaction at the facility were required to generate a receipt, with the original copy going to the payer, and all carbon copies retained by the facility. Bookkeeper #2 said when the payment was made for room/board a receipt specific to the room/board was generated, with the original provided to the payer, and the carbon copy with subsequent carbon ledger, retained by the facility. When the payment was made to a resident trust fund a triplicate receipt book was used. However, it was not uncommon for the two receipts to be interchanged, when Bookkeeper #1 issued a receipt. Once the receipt was generated, but not always the same day depending on available time, the receipted transaction was transcribed onto a deposit slip. The deposit was then taken to the bank, where the aforementioned deposit slip generated by the facility, was used to allocate payments to the appropriate residents. Once the deposit was complete, but not always the same day depending on time available, the receipt transactions would be posted to the appropriate resident account. During an interview [DATE], Resident #1's responsible party (RP) verified since his mother's admission on [DATE], he paid all monthly bills for room/board in cash funds, for which he had kept receipts. However, when he noticed financial discrepancies with the room/board account on [DATE], he went to the facility and reported his concerns to the Administrator. Resident #1 Review of the closed trust fund accounts for Resident #1 revealed the resident's trust fund account was active since [DATE], but closed by the responsible party (RP) on [DATE], due to the fact the facility implemented electronic resident trust accounting practices and he only used cash for his financial transactions. During an interview on [DATE] at 1:20 PM, CPA #1 said the room/board charges applied to the trust fund account for Resident #1 were alarming, because her RP always paid the monthly room/board charges using cash funds. Additionally, the facility did not receive the resident's monthly Social Security Administration (SSA) treasure check; therefore the large deposits preceding the room/board charges were suspicious. Review of the trust fund statement revealed Resident #1 had an active account [DATE] through [DATE], with the following large transactions: 1) a $1253.00 deposit on [DATE]; 2) a $1253.00 room/board withdrawal on [DATE]; 3) a $1315.00 deposit on [DATE]; 4) a $1315.00 room/board withdrawal on [DATE]; 5) a $1315.00 deposit on [DATE]; 6) a $465.00 room/board withdrawal on [DATE]; and 7) an $840.00 room/board withdrawal on [DATE]. The facility was unable to provide a valid receipt for any of these transactions. During the interview on [DATE] at 1:20 PM, CPA #1 said unauthorized trust fund transactions occurred to cover Resident #1's room/board account, because often cash payments made by Resident #1's responsible party (RP) to Bookkeeper #1, were not posted to the intended account, as evidenced by the following: Review of receipt # 7, revealed on [DATE] Bookkeeper #1 issued a cash receipt for a facility payment in the amount of $465.00 to Resident #1's RP. Review of Resident #1's trust fund and room/board statements for the same month, revealed the cash payment for $465.00 was not posted to either of the resident's accounts (room and board account or trust fund account). Review of receipt # 9, revealed on [DATE], Bookkeeper #1 issued a cash receipt for a facility payment in the amount of $465.00 to Resident #1's RP. Review of Resident #1's trust fund and room/board statements for the same month, revealed the cash payment for $465.00 was not posted to either of the resident's accounts. Review of receipt # 0, revealed on [DATE], Bookkeeper #1 issued a cash receipt for a facility payment in the amount of $465.00 to Resident #1's RP. Review of Resident #1's trust fund and room/board statements for the same month, revealed the cash payment for $465.00 was not posted to either of the resident's accounts. Review of receipt # 2, revealed on [DATE] Bookkeeper #1 issued a cash receipt for a facility payment in the amount of $465.00 to Resident #1's RP. Review of Resident #1's trust fund and room/board statements for the same month, revealed the cash payment for $465.00 was not posted to either of the resident's accounts. Review of receipt # 9, revealed on [DATE] Bookkeeper #1 issued a cash receipt for a facility payment in the amount of $465.00 to Resident #1's RP. Review of Resident #1's trust fund and room/board statements for the same month, revealed the cash payment for $465.00 was not posted to either of the resident's accounts. Review of receipt # 1, revealed on [DATE], Bookkeeper #1 issued a cash receipt for a facility payment in the amount of $450.00 to Resident #1's RP. Review of Resident #1's trust fund and room/board statements for the same month, revealed the cash payment for $450.00 was not posted to either of the resident's accounts. Review of receipt # 3, revealed on [DATE], Bookkeeper #1 issued a cash receipt for a facility payment in the amount of $465.00 to Resident #1's RP. Review of Resident #1's trust fund and room/board statements for the same month, revealed the cash payment for $465.00 was not posted to either of the resident's accounts. Review of the operations account receipt #9436, revealed on [DATE], Bookkeeper #1 issued a cash receipt for a facility payment in the amount of $840.00 to Resident #1's RP. Review of Resident #1's trust fund and room/board statements for the same month, revealed the cash payment for $840.00 was not posted to either of the resident's accounts. Review of the operations account receipt #9437, revealed on [DATE], Bookkeeper #1 issued a cash receipt for a facility payment in the amount of $465.00 to Resident #1's RP. Review of Resident #1's trust fund and room/board statements for the same month, revealed the cash payment for $465.00 was not posted to either of the resident's accounts. Review of the operations account receipt #9500, revealed on [DATE] Bookkeeper #1 issued a cash receipt for a facility payment in the amount of $840.00 to Resident #1's RP. Review of Resident #1's trust fund and room/board statements for the same month, revealed the cash payment for $840.00 was not posted to either of the resident's accounts. Review of operations account receipt #9501, revealed on [DATE] Bookkeeper #1 issued a cash receipt for a facility payment in the amount of $465.00 to Resident #1's RP. Review of Resident #1's trust fund and room/board statements for the same month, revealed the cash payment for $465.00 was not posted to either of the resident's accounts. Review of operations account receipt #9614, revealed on [DATE] Bookkeeper #1 issued a cash receipt for a facility payment in the amount of $840.00 to Resident #1's RP. Review of Resident #1's trust fund and room/board statements for the same month, revealed the cash payment for $840.00 was not posted to either of the resident's accounts. Review of operations account receipt #9640, revealed on [DATE] Bookkeeper #1 issued a cash receipt for a facility payment in the amount of $465.00 to Resident #1's RP. Review of Resident #1's trust fund and room/board statements for the same month, revealed the cash payment for $465.00 was not posted to either of the resident's accounts. Review of operations account receipt #9671, revealed on [DATE] Bookkeeper #1 issued a cash receipt for a facility payment in the amount of $465.00 to Resident #1's RP. Review of Resident #1's trust fund and room/board statements for the same month, revealed the cash payment for $465.00 was not posted to either of the resident's accounts. Review of operations account receipt #9729, revealed on [DATE] Bookkeeper #1 issued a cash receipt for a facility payment in the amount of $840.00 to Resident #1's RP. Review of Resident #1's trust fund and room/board statements for the same month, revealed the cash payment for $840.00 was not posted to either of the resident's accounts. Review of operations account receipt #9730, revealed on [DATE] Bookkeeper #1 issued a cash receipt for a facility payment in the amount of $465.00 to Resident #1's RP. Review of Resident #1's trust fund and room/board statements for the same month, revealed the cash payment for $465.00 was not posted to either of these accounts. Review of operations account receipt #9772, revealed on [DATE] Bookkeeper #1 issued a cash receipt for a facility payment in the amount of $840.00 to Resident #1's RP. Review of Resident #1's trust fund and room/board statements for the same month, revealed the cash payment for $840.00 was not posted to either of these accounts. Review of operations account receipt #9773, revealed on [DATE] Bookkeeper #1 issued a cash receipt for a facility payment in the amount of $465.00 to Resident #1's RP. Review of Resident #1's trust fund and room/board statements for the same month, revealed the cash payment for $465.00 was not posted to either of these accounts. Review of operations account receipt #9848, revealed on [DATE] Bookkeeper #1 issued a cash receipt for a facility payment in the amount of $840.00 to Resident #1's RP. Review of Resident #1's trust fund and room/board statements for the same month, revealed the cash payment for $840.00 was not posted to either of these accounts. Review of operations account receipt #9849, revealed on [DATE] Bookkeeper #1 issued a cash receipt for a facility payment in the amount of $465.00 to Resident #1's RP. Review of Resident #1's trust fund and room/board statements for the same month, revealed the cash payment for $465.00 was not posted to either of these accounts. Review of operations account receipt #9909, revealed on [DATE] Bookkeeper #1 issued a cash receipt for a facility payment in the amount of $840.00 to Resident #1's RP. Review of Resident #1's trust fund and room/board statements for the same month, revealed the cash payment for $840.00 was not posted to either of these accounts. Review of operations account receipt #9640, revealed on [DATE] Bookkeeper #1 issued a cash receipt for a facility payment in the amount of $465.00 to Resident #1's RP. Review of Resident #1's trust fund and room/board statements for the same month, revealed the cash payment for $465.00 was not posted to either of these accounts. During an observation on [DATE] at 12:00 PM, Resident #1 declined an interview related to her trust fund account, saying her RP dealt with those matters. Review of the undated face sheet revealed the facility admitted Resident #1 on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) revealed she had no cognitive impairments, but required minimally one staff member to assist with all activities of daily living. Resident #2 During the interview on [DATE] at 1:20 PM, CPA #1 said when he traced suspicious check transactions for Resident #1, he identified unauthorized trust fund transactions in Resident #2's account. CPA #1 said the monthly room/board charges for Resident #2 were taken from her trust fund account, but never credited to her operating account. Instead, Bookkeeper #2 altered the receipt to avoid detection and then redirected the payment onto Resident #1's room/board account, as evidenced by the following: Review of the open trust fund for Resident #2 revealed her account was active since [DATE]. Review of the room and board carbon copy ledger receipt #9564 dated [DATE], documented a check payment for room and board, in the amount of $1190.00 was made by Resident #1. However, the original copy of the same receipt was altered, with Residents #1's name crossed of and replaced by Resident #2's name. Review of the trust fund statement for Resident #2 dated [DATE], revealed $1190.00 had been withdrawn for room and board. The facility was unable to provide a valid receipt for this transaction. Review of the room and board statement for Resident #2 from the same month, revealed the trust fund withdrawal for $1190.00 was not credited to the resident's room and board account. Review of the room and board statement for Resident #1 the same month, revealed a credit for $1190.00 was made on [DATE]. The facility was unable to provide a valid receipt for this transaction. Review of facility issued receipts made to Resident #1's RP the same month, failed to reveal any payment made to the facility in the amount of $1190.00. Review of the room/board carbon copy receipt/ledger #9660 dated [DATE], documented Resident #1 paid $1591.00. However, the original copy of the same receipt revealed Resident #1's name had been scratched out and replaced with Resident #2's name. Review of the trust fund statement for Resident #2 revealed on [DATE], $1591.00 had been withdrawn for room and board. The facility was unable to provide a valid receipt for this transaction. Review of the room and board statement for Resident #2 the same month, revealed the trust fund withdrawal for $1591.00 was not credited to her room and board. Review of the room and board statement for Resident #1 revealed a credit for $1591.00 on [DATE]. The facility was unable to provide a valid receipt for this transaction. Review of facility issued receipts made to Resident #1's RP the same month, failed to reveal any payment made to the facility in the amount of $1591.00. During the same interview [DATE] at 1:20 PM, CPA #1 said changing the original receipt ensured each posted transaction was receipted if a second staff members review was required. Only with the two receipts reviewed simultaneously, was the misappropriation visible. Review of the face sheet revealed the facility admitted Resident #2 on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #2 had moderately impaired cognition and required minimally one staff member to assist with all activities of daily living. Resident #3 During an interview on [DATE] at 1:20 PM, CPA #1 said when he traced suspicious check transactions for Resident #1, he identified unauthorized trust fund transactions in Resident #3's account as well. CPA #1 said the monthly room/board charges for Resident #3 in ,[DATE], were taken from her trust fund account, but not credited to her operating account. Instead, Bookkeeper #2 altered the receipt to avoid detection and then redirected the payment onto Resident #1's room/board account, as evidenced by the following: Review of the room/board carbon copy receipt/ledger #9671 dated [DATE], documented Resident #1 paid revealed $1383.00. However, the original copy of the same receipt revealed Resident #3's name had been scribbled over Resident #1's name. Review of the trust fund statement for Resident #3 revealed on [DATE], $1383.00 had been withdrawn for room and board. The facility was unable to provide a valid receipt for this transaction. Review of the room and board statement for Resident #3 the same month, revealed a trust fund withdrawal for $1383.00 was not credited to the room and board. Review of the room and board statement for Resident #1 revealed a credit for $1383.00 was made on [DATE]. The facility was unable to provide a valid receipt for this transaction. Review of facility issued receipts made to Resident #1's RP the same month, failed to reveal any payment made to the facility in the amount of $1383.00. During the interview on [DATE] at 1:20 PM, CPA #1 said upon further review he traced altered receipts and suspicious trust fund transactions for Resident #1, and found Social Security checks issued to Resident #3 for ,[DATE] and ,[DATE] where never credited to her account. Instead, a large portion of the funds were deposited into Resident #1's trust fund, with smaller portions applied to the trust funds established for Resident #8, Unsampled Resident B, Unsampled Resident C, and Unsampled Resident D. He said the deposit went through because Bookkeeper #1 had altered the deposit slip to ensure the funds were redistributed as she saw fit. After the funds were credited into the trust fund account for Resident #1, they were subsequently withdrawn by Bookkeeper #2 and applied to the room/board bill, as evidenced by the following: Review of the trust fund statement for Resident #3 revealed monthly Social Security Administration (SSA) checks in the amount of $1427.00 were routinely credited to her account. However, there were no similar deposits made in ,[DATE] or ,[DATE], despite her ongoing room charges. Review of the facility's bank deposit slip for [DATE], revealed Resident #3 had been issued a SSA check for $1427.00, which was deposited to resident trust fund accounts, but not the established account for Resident #3. Instead, the bank record revealed $1315.00 of these funds were deposited into the trust fund account established for Resident #1, and $112.00 was deposited into the trust fund established for Resident #8. The facility was unable to provide a valid receipt for these transactions. Review of the trust fund and room/board statements for Resident #3 the same month, revealed his check for $1427.00 was not credited to either of the resident's accounts. Review of the trust fund statement for Resident #1 revealed a credit for $1315.00 on [DATE]. The facility was unable to provide a valid receipt for this transaction. Review of the room/board account for Resident #1 revealed a credit for $1315.00 on [DATE]. The facility was unable to provide a valid receipt for this transaction. Review of receipts issued for payments to Resident #1's RP the same month, failed to reveal any payment made to the facility in the amount of $1315.00. Review of the facility's bank deposit slip for [DATE], revealed Resident #3 had been issued a SSA check for $1427.00, which was deposited to resident trust fund accounts, but not the established account for Resident #3. Instead, the bank record revealed $1315.00 was deposited into the trust fund account established for Resident #1. Further, the deposit slip revealed the trust funds for Unsampled Residents B received $30.00, Unsampled Resident C received $30.00, and Unsampled Resident D received $52.00. Review of the trust fund and room/board statements for Resident #3 the same month, revealed a check for $1427.00 was not credited to either of the resident's accounts. Review of the trust fund statement for Resident #1 revealed a credit for $1315.00 on [DATE]. The facility was unable to provide a valid receipt for this transaction. Review of the room and board statement for Resident #1 the same month, revealed a credit for $1315.00. The facility was unable to provide a valid receipt for this transaction. Review of receipts issued for payments to Resident #1's RP the same month, failed to reveal any payment made to the facility in the amount of $1315.00. Review of the trust fund statement for Unsampled Resident B dated [DATE] revealed a credit for $30.00. The facility was unable to provide a valid receipt for this transaction. Review of the undated face sheet revealed the facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #3 had moderately impaired cognition and required minimally one staff member to assist with all activities of daily living. Resident #4 During the interview [DATE] at 1:20 PM, CPA #1 said upon further review he traced altered receipts and check transactions for Resident #1, and found social security check issued to Resident #4 on ,[DATE], was deposited into his trust fund account, but then withdrawn for room/board. However, the payment was never credited to his account, because Bookkeeper #1 applied the funds to Resident #1's mounting bill, as evidenced by the following: Review of the open trust fund account for Resident #4 revealed the account was active since [DATE]. Review of the room/board carbon copy receipt/ledger # 9752 dated [DATE], revealed Resident #1 paid $1400.71. However, the original copy of the same receipt revealed Resident #1's name had been scratched out and placed with Resident #4's name. Review of the trust fund statement for Resident #4 revealed on [DATE], $1400.71 had been withdrawn for room and board. The facility was unable to provide a valid receipt for this transaction. Review of the room and board statement for Resident #4 the same month, revealed the trust fund withdrawal for $1400.71 was not credited to the resident's room/board account. Review of the room/board statement for Resident #1 revealed a credit for $1400.71 on [DATE]. The facility was unable to provide a valid receipt for this transaction. Review of facility issued receipts made to Resident #1's RP the same month, failed to reveal any payment made to the facility in the amount of $1400.71. Review of the undated face sheet revealed the facility admitted Resident #4 on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #4 had moderately impaired cognition with both long and short term memory loss, which required minimally one staff member to assist with all activities of daily living. Resident #5 During the interview on [DATE] at 1:20 PM, CPA #1 said when he traced suspicious check transactions for Resident #1, CPA #1 found a Social Security check issued to Resident #5 on ,[DATE] was never fully credited to her account. Instead, a large portion of the funds were deposited into Resident #1's trust fund, and Resident #5 only retained $474.05. He said the deposit went through undetected because Bookkeeper #1 had altered the deposit slip to ensure the funds were redistributed. After the funds were credited into the trust fund account for Resident #1, the funds were subsequently withdrawn by Bookkeeper #2 and applied to the room/board bill, as evidenced by the following: Review of the open trust fund account for Resident #5 revealed the account had been active since [DATE]. Review of the bank deposit slip dated [DATE], revealed original documentation of a check being issued for deposit to Resident #5's trust fund, in the amount of $1727.00. However, the $1727.00 was then stricken through and an alternative amount of $474.05 replaced the entry. Below that entry was a deposit to Resident #1's trust fund in the amount of $1253.00. The facility was unable to provide valid receipts for these transactions. Review of the resident trust fund statement for Resident #5 that same month, revealed only $474.05 had been credited to the resident's account. The facility was unable to provide a valid receipt for this transaction. Review of the trust fund statement for Resident #1 revealed a credit for $1253.00 on [DATE]. The facility was unable to provide a valid receipt for this transaction. Review of receipts issued for payments to Resident #1's RP the same month, failed to reveal any payment made to the facility in the amount of $1253.00. Review of the undated face sheet revealed, the facility admitted Resident #5 on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #5 had severely impaired cognition and required minimally one staff member to assist with all activities of daily living. Resident #8 During the interview on [DATE] at 1:20 PM, CPA #1 said upon further review of the missing Social Security funds for Resident #3, he traced an unauthorized trust fund deposit to Resident #8. He did not specify why the funds had been applied to this account. Review of the closed trust fund account for Resident #3 revealed the account was active since [DATE], but closed and dispersed to the RP on [DATE], within thirty days of the resident's death. Review of the trust fund statement for Resident #8 revealed a credit for $112.00 made on [DATE]. The facility was unable to provide a valid receipt for this transaction. Review of the undated face sheet revealed the facility admitted Resident #8 on [DATE] and the resident died on [DATE]. [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #8 had no cognitive impairments, but required minimally one staff member to assist her with all activities of daily living. Resident #9 Review of the closed trust fund account for Resident #9 revealed the account was active since [DATE], but closed and dispersed to the RP on [DATE], within thirty days of the resident's death. Review of the carbon copy receipt # 6, signed by both Bookkeeper #1 and Resident #9 revealed a trust fund withdrawal for six dollars dated [DATE]. Review of the carbon