Every finding on record at Madison Co NH

Based on interview, record review and facility policy review, the facility failed to ensure the resident's right to be free from abuse for one (1) of (20) sampled residents. Resident # 53Findings include:Record review of facility policy; Abuse Policy and Procedure , revision date April 2021 revealed, Residents have the right to be free from abuse. Policy interpretation and implementation: The resident abuse, neglect and exploitation prevention program consist of facility wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse. by anyone including but not necessarily limited to: a. facility staff . Record review of the facility investigation dated 4/21/26 revealed on 4/17/26 CNA # 1, Certified Nurse Aide (CNA), reported to Licensed Practical Nurse (LPN) # 4, that Resident #1 had a bruised left eye. Review revealed CNA # 1 reported the injury may have occurred while pushing Resident #53 to the dining table due to the resident's short, stooped posture. Record review further revealed the CNA reported Resident #53 used a racial slur toward her and she verbally responded but denied striking the resident.During an interview on 04/27/2026 at 11:30 AM, with Resident #53 she was unable to recall the incident in question. During an interview on 04/28/2026 at 2:00 PM, LPN #4 stated Resident #53 reported being hit in the eye by CNA #1. LPN#4 stated CNA # 2 reported she heard a commotion but did not witness the incident. She stated that when CNA #2 observed the resident's injury and asked what happened, Resident #53 reported she struck CNA #1 and was struck back in the eye, while making a motion consistent with a slap. She stated the resident provided a similar account to her. LPN # 4 revealed she reported the incident and removed CNA #1 from the unit with instructions not to return. During an interview on 04/28/2026 at 2:45 PM, CNA #2 stated she heard a commotion and later observed bruising to Resident #53's left eye. She stated that when she asked what happened, Resident #53 reported she hit CNA #1 and was hit back in the eye, while making a motion consistent with a slap.During an interview on 04/29/2026 at 11:00 AM, the Social Services Director stated she interviewed Resident #53 to assess psychosocial status following the incident. She reported the resident voiced no complaints and stated she felt safe. She stated the resident did not recall the incident, which she attributed to advanced dementia. She stated all residents assigned to the staff member involved were interviewed to assess any concerns related to abuse, neglect, or exploitation. She reported no additional allegations or concerns were identified. She stated she will continue to monitor Resident #53 for any changes in mood, behavior, or psychosocial well-being and will follow up as needed.During an interview on 04/29/2026 11:15 AM, the Director of Nurses (DON) revealed that following the investigation, it was determined that CNA # 1 struck Resident # 53 in the eye. She stated the staff member was removed from duty during the investigation and was subsequently terminated once the allegation was substantiated. The Administrator stated Resident # 53 was assessed by nursing the following day. On 04/21/2026, an emergency Quality Assurance and Performance Improvement meeting was conducted upon determination that abuse occurred. She stated Social Services interviewed the resident to assess psychosocial status. The resident voiced no additional complaints and did not recall the incident, which was attributed to advanced dementia. She further revealed that all residents assigned to CNA #1 were interviewed by Social Services, and no additional concerns were identified. The Resident Representative was notified by the Administrator and Director of Nursing regarding the investigation findings and cause of the injury. The Administrator stated a report was filed with the county police department. Written reports were submitted to the State Agency and the Attorney General's Office. She reported all staff received in service education on abuse, neglect, and exploitation, resident rights, recognizing and addressing burnout, and abuse prevention using Centers for Medicaid and Medicaid Services (CMS) Hand in Hand Module 5, as well as crisis intervention and de-escalation tools. She stated a memo was posted at the time clock directing staff to complete training at the start of their shift, and designated staff monitored compliance. All staff completed the required training by 04/22/2026.During an interview on 04/29/2026 at 11:38 AM, the Licensed Nursing Home Administrator (LNHA) stated that following the facility investigation, it was determined that CNA # 1 struck Resident #53 in the eye. He stated the staff member was immediately removed from duty during the investigation and was terminated upon confirmation of the allegation. He stated it was his decision to make the final determination to terminate CNA #1 even though it was not witnessed. He stated the resident was assessed by nursing the following day. He reported that on 04/21/2026, once the allegation was substantiated, the facility conducted an emergency Quality Assurance and Performance Improvement meeting. He stated Social Services interviewed the resident to assess psychosocial status. He reported the resident voiced no additional concerns and did not recall the incident, which he attributed to advanced dementia. He further stated all residents assigned to CNA #1 were interviewed by Social Services, and no additional concerns were identified. He confirmed the Resident Representative was notified by the Administrator and Director of Nursing regarding the findings of the investigation. He stated a report was filed with the county police department and written reports were submitted to the State Agency and the Attorney General's Office. He stated all staff received in service education on abuse, neglect, and exploitation, resident rights, recognizing and addressing burnout, and abuse prevention using CMS Hand in Hand Module 5, as well as crisis intervention and de-escalation techniques. He reported a memo was posted at the time clock directing staff to complete the training at the beginning of their shift, and staff compliance was monitored. He confirmed all staff completed the required training by 04/22/2026.Record review of the Face Sheet revealed Resident # 53 was admitted [DATE] to the Memory Care Unit with diagnoses including Alzheimer's disease, cognitive communication deficit, and unspecified dementia with behavioral disturbance. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/16/26 revealed a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment.Record review of the Social Services progress note dated 4/21/26 at 12:31 PM, revealed Social Services and the Assistant Administrator followed up with Resident #53 upon her return from a supervised joy ride and after lunch to assess emotional and psychosocial status related to the alleged abuse incident. Documentation revealed when asked how she was doing and if everything was going okay, Resident #53 stated, It's good. When asked if she felt safe, the resident responded, Yes. Record review revealed the resident was documented to be in a good mood, voiced no concerns, and expressed no issues at the time of the follow up.Record review of the facility's abuse investigation concluded Resident #53 did not sustain the injury by accidentally striking the dining table and the facility determined that CNA # 1 struck Resident #53 in the eye. CNA # 1 was suspended pending investigation and subsequently terminated. The facility reported the allegation to the State Agency, the Attorney General's Office, and local law enforcement. The facility conducted an emergency Quality Assurance Performance Improvement (QAPI) meeting, notified the Resident Representative, interviewed additional residents assigned to CNA #1 and educated staff regarding abuse prevention, resident rights, recognizing burnout, and preventing abuse.Record review of the progress note dated 4/17/26 at 1:39 AM revealed acute follow up assessment related to left orbital ecchymosis from an injury identified on the prior shift. Documentation revealed a dark red circular bruise to the left eye region, dark purple bruising along the lateral bridge of the nose extending to the superior left cheek, tenderness on palpation, minimal edema, and complaint of pain with the resident stating, It's sore. The residents' pupils were equal, round, and reactive to light and accommodation. Documentation noted due to advanced Alzheimer's disease, the resident was unable to reliably express symptoms such as blurred vision, double vision, dizziness, or headache, however nursing documented no apparent visual disturbance at that time. Interventions included staff assistance with transfers and toileting for safety, head of bed elevated to 45 degrees to reduce bruising, application of cold compresses to the eye area twice for ten minutes to reduce edema, and continued monitoring. Documentation revealed no acute distress, respirations even and unlabored, skin warm and dry, and resident resting quietly in bed. Vital signs were documented as temperature 97.5, pulse 79, respirations 16, and blood pressure 121/67. Further documentation revealed continued treatment and monitoring were implemented.

Based on observation, interview, facility policy review and record review, the facility failed to ensure staff followed infection prevention and control practices to prevent the spread of infection during resident care for two (2) of five (5) care observations. Resident #2 and Resident #82Findings Include: Record review of the facility policy Policy for Handwashing undated, revealed, Objective: To prevent and to control the spread of infectious disease.1. Appropriate 15 second hand washing with antimicrobial soap and water must be performed under the following conditions: a. when hands are visibly dirty or soiled with blood or other body fluids; b. after contact with blood, body fluids, secretions, mucous membranes or non-intact skin; c. after handling items potentially contaminated with blood, body fluids, or secretions; d. before eating; e. after using a restroom .3. If hands are not visibly soiled, use an alcohol-based hand rub for all the following situations: a. before direct contact with residents.f. after removing gloves. Record review of the facility policy Enhanced Barrier Precautions (EBP) dated 8/2022 revealed, . EBP are used as an infectious prevention and control interventions to reduce the spread of multi-drug-resistant organisms (MDROs) to residents . 2.a.Gloves and gowns are applied prior to performing the high contact resident care activity (as opposed to before entering the room).5. EBP are indicated (when contact precautions do not otherwise apply) for residents with wounds and or indwelling devise regardless of MDRO colonization .9. Staff are trained prior to caring for residents on EBP's . Resident # 2: In an interview with resident #2 at 2:08 PM on 4/28/26, he stated that he had been dealing with a urinary tract infection (UTI) in the past month requiring treatment with antibiotics. On 04/28/2026 at 2:17 PM, Registered Nurse (RN) #1 was observed performing catheter care. During the procedure, the nurse dropped a washcloth onto the bed linen, retrieved it, and used the same contaminated washcloth to cleanse the catheter site. The nurse then touched the bathroom door handle while wearing contaminated gloves after completing care. During an interview on 04/28/2026 at 2:21 PM, RN #1 stated she should have discarded the washcloth once contaminated and performed hand hygiene after removing gloves before touching environmental surfaces. She confirmed her actions created a risk for cross contamination. During an interview on 04/29/2026 at 2:31 PM, the Director of Nursing (DON) stated the nurse should have discarded the contaminated washcloth and performed hand hygiene after glove removal. She confirmed staff are expected to follow infection prevention policies. During an interview on 04/30/2026 at 11:01 AM, the Infection Preventionist (IP) stated proper catheter care requires discarding contaminated supplies and performing hand hygiene after glove removal to prevent cross contamination. Record review of the Face Sheet revealed Resident # 2 was admitted to the facility on [DATE] with a diagnoses that included central cord syndrome. Record review of the Minimum Data Set (MDS) section C with an Assessment Review Date (ARD) of 4/14/26 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact. Record review of the Physician Order Report dated 3/28/26-4/28/26 revealed an order dated 2/10/25 Record catheter output q (every) shift. Resident # 82: On 04/28/2026 at 3:20 PM, Licensed Practical Nurse (LPN) #1 was observed administering medications via Percutaneous Endoscopic Gastrostomy (peg) tube to Resident #82. The nurse entered the room and donned (put on) gloves without performing hand hygiene. While wearing the same gloves, the nurse touched multiple surfaces including the faucet, medication cart, computer mouse, privacy curtain, and bed controls prior to initiating care. The nurse did not don a gown. The nurse administered medications via peg tube without changing gloves or performing hand hygiene during the process. After completing the procedure, the nurse removed gloves and exited the room without performing hand hygiene. During an interview on 04/28/2026 at 3:40 PM, LPN#1 stated she had not received training on Enhanced Barrier Precautions (EBP) and acknowledged she failed to perform hand hygiene, wear a gown, and change gloves. She confirmed this created a risk for cross contamination. During an interview on 04/29/2026 at 3:12 PM, the IP stated LPN #1 had not completed required infection control training. She stated the nurse should have performed hand hygiene upon entry, worn a gown, and changed gloves after contact with environmental surfaces. She confirmed the observed practice exposed the resident to infection risk. During an interview on 04/29/2026 at 3:38 PM, the DON stated LPN#1 should have completed required training, performed hand hygiene, and worn a gown during peg tube medication administration. She confirmed failure to follow these practices increased the risk of infection. Record review of Resident #82 Face Sheet revealed an admission date of 11/11/20 with diagnoses that included Hemiplegia, unspecified affecting right dominant side and cerebral palsy, unspecified. Record use of the Physician Order Report revealed orders dated 6/6/23 for Calcium 500 plus D (calcium carbonate-vitamin d), phenobarbital 64.8 mg (milligrams) and an additional order dated 7/24/25 for phenytoin tablet chewable via peg tube. Record review of the MDS with an ARD of 2/23/26 revealed a BIMS score of (3) indicating the resident had severe cognitive impairment.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure other alternatives were implemented prior to the installation of bed rails and failed to assess and monitor the use of bed rails as a restraint and ensure they were medically necessary and the least restrictive intervention for one (1) of five (5) resident reviewed for restraints. Resident #42Findings Include: Record review of the facility policy Use of Side Rails revealed, The resident should be observed and assessed daily in order to assure the maintaining of his/her practicable physical, mental, and psychosocial well-being .Record review of the facility policy, Restraint Policy undated revealed, .It is the objective of this facility for each resident to be free from any physical restraint to maintain the highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances to which the resident has medical symptoms that warrant the use of restraints .On 04/27/2026 at 12:26 PM, Resident #42 was observed lying in bed with both side rails in the full up position, functioning as full length side rails.During an interview on 4/29/2026 at 1:15 PM, Licensed Practical Nurse (LPN) #2 confirmed the resident had full side rails in use. She stated she did not consider them a restraint and was unsure of the clinical justification. She reported the resident was total care and unable to reposition independently. She confirmed staff do not assess or document the side rails as a restraint and do not monitor their continued necessity. She acknowledged the rails could restrict movement and require a resident to climb over them to exit the bed.During an interview on 04/29/2026 at 1:30 PM, Registered Nurse (RN) #2 stated a pre-restraint evaluation should be completed prior to initiation but was unable to provide documentation. She stated the side rails were used at the request of the family following a prior fall. She confirmed less restrictive alternatives were not implemented prior to initiating side rails. She acknowledged risks associated with full length side rails, including entrapment and injury from attempting to climb over them.During an interview on 04/29/2026 at 2:30 PM, the Director of Nursing (DON) stated side rails were in place due to family requests to prevent falls. She confirmed the facility does not assess restraints daily and documentation is not completed each shift. She stated weekly notes are entered, but no consistent monitoring process is in place. She confirmed limited documentation of entrapment monitoring and stated failure to assess restraints appropriately could place residents at risk for injury.Record review of the physician orders revealed an order dated 4/15/25 for Full 3/4 bilateral rails to prevent leaning and falling out of bed.Record review of the Physical Restraint Elimination Evaluation form revealed the form was not dated with evaluation dates but included an evaluation with numbers. The form did not have the residents' name on it.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/18/26 revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated severely impaired mental status.Record review of the Face Sheet revealed Resident # 42 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke).

Based on staff interviews, record review, and facility policy review, the facility failed to ensure a resident was free from a significant medication error resulting in harm for one (1) of (6) six residents reviewed for narcotic medication administration (Resident #2). Findings include: A review of the facility policy titled, Adverse Consequences and Medication Errors, revealed under Policy Interpretation and Implementation: 5.) A Medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with physician's orders, manufacturer specifications, or accepted standards and principles of the professional providing services. Section 6 listed wrong dose as an example of a medication error. During an interview with the Director of Nursing (DON) on 5/12/25 at 11:30 AM regarding a facility-reported significant medication error, she stated that on 4/23/25 at 10:00 PM, Resident #2 was administered the incorrect dosage of morphine sulfate. The DON reported receiving a call at approximately 11:00 PM when the end-of-shift narcotic count was found to be incorrect. She stated Licensed Practical Nurse (LPN) #3 reported that the morphine sulfate was delivered without a syringe, so she used a plastic medication cup to administer the dose. The DON stated the medication cup had the lowest measurable line of 2.5 ml (milliliter), while the prescribed dose was only 0.25 ml. She reported that LPN #3 was asked to mark on the cup where she had poured the dose, and the mark was at the 2.5 ml line. The DON confirmed the resident required Narcan (a medication primarily used to reverse opioid overdoses) due to a significant change in condition and respiratory status following the medication error. She stated the Narcan was effective, and the residents' vital signs began to recover. The DON reported that the day prior to receiving the morphine, Resident #2 had attended bingo activities twice. An observation of the plastic medication cup with the DON on 5/12/25 at 11:45 AM confirmed a black line marked at the 2.5 ml level, which LPN #3 had indicated was the amount she administered. During an interview with LPN #4 on 5/12/25 at 1:20 PM, she stated that at the start of her shift on 4/23/25 at 11:00 PM, she and LPN #3 completed the narcotic count and found the morphine sulfate count was incorrect. She stated that LPN #3 reported the pharmacy did not send a syringe, so she used a medication cup and indicated the 2.5 ml line as the amount given. LPN #4 confirmed the medication cup's lowest measurement line was 2.5 ml. She stated she immediately reported the error to the provider, Hospice, and the DON, and monitored the resident closely due to observed changes in respiratory status. During a phone interview with LPN #3 on 5/12/25 at 3:33 PM, she confirmed she worked the 3:00 PM-11:00 PM shift on 4/23/25 and administered the first dose of morphine sulfate to Resident #2 from the new bottle. She confirmed the pharmacy did not send a syringe and she could not locate one, so she used a plastic medication cup. When asked how she measured the dose, she stated she poured to the lowest line on the cup. LPN #3 confirmed she again she did not locate a syringe or call for direction before administering the medication. During an interview with the Pharmacy Consultant on 5/12/25 at 3:40 PM, he confirmed he was aware of the significant medication error involving Resident #2. He stated that morphine sulfate should never be administered without a calibrated measuring syringe and that the use of an inaccurate measuring device increases the risk for overdose, sedation, respiratory depression, and other complications. Record review of the Physician Order Report dated 4/1/25 through 4/30/25 revealed an order dated 4/22/25 for morphine concentrate 100 mg (milligrams)/5 ml (20 mg/ml), to administer 0.25 ml every hour as needed by mouth (PO) or sublingually (SL) for pain or air hunger. A subsequent order dated 4/24/25 directed Narcan (naloxone) nasal spray 2 mg to be administered one time now. Record review of the Medication Administration Record for Resident #2 revealed morphine concentrate was signed off as administered on 4/23/25 at 10:20 PM by Licensed Practical Nurse (LPN) #3. Record review of the Progress Notes dated 4/23/25 at 3:33 PM for Resident #2 documented that the resident was alert, awake, and responsive to verbal and physical stimuli. On 4/24/25 at 2:01 AM, progress notes documented oxygen saturation at 81%, heart rate of 55, and respiratory rate of 12. Despite cueing to breathe deeply and continued oxygen use, the resident's saturation levels did not improve. Record review of the Progress Notes for Resident #2 dated 4/24/25 at 10:14 AM documented that the resident had an altered mental status and was difficult to arouse. At 10:21 AM, the resident was noted to be unresponsive. The medical doctor was notified and gave a now order for Narcan. Vital signs at that time included a blood pressure of 131/78, heart rate of 33, respiratory rate of 11, and oxygen saturation of 68%. Emergency services were contacted, and Narcan was administered. Post-administration vital signs showed improvement: BP 131/78, HR 111, RR 16, O2 79%. Review of a document from the Food and Drug Administration (FDA), last revised 12/2023, titled Morphine Sulfate Oral Solution under Warnings and Precautions, stated: Instruct caregivers to always use the enclosed calibrated oral syringe when administering morphine oral concentrate to ensure the dose is measured and administered accurately. Under Use in Specific Populations: Renal Impairment, the document stated that morphine pharmacokinetics are altered in patients with renal failure, with increased exposure and reduced clearance, and that metabolites may accumulate to higher plasma levels. Review of a document from the FDA, last revised 11/2015, titled NARCAN Nasal Spray described Narcan as an opioid antagonist indicated for the emergency treatment of known or suspected opioid overdose, as manifested by respiratory and/or central nervous system depression. Record review of the Face Sheet revealed that Resident #2 was admitted to the facility on [DATE] with medical diagnoses that included Chronic Kidney Disease, Stage 3. Record review of Resident #2's Minimum Data Set (MDS), Section C, with an Assessment Reference Date (ARD) of 4/7/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #2 was cognitively intact.

Based on staff interview, record review, and facility policy review the facility failed to ensure a resident was free from abuse and misappropriation of resident property when a resident was found to have 36 oxycodone pain pills missing from the narcotic box for (1) one of (6) six residents narcotics reviewed. (Resident #1) Findings include: Review of the facility policy titled, Abuse Policy & Procedure, with no revision date, revealed that each resident of the facility has the right to be free from misappropriation of property. The policy further defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident's belongings without the resident's consent. During an interview on 5/12/25 at 11:30 AM with the Director of Nursing (DON) related to a facility reported incident of drug diversion, she confirmed that narcotic drug diversion occurred involving Resident #1. The DON reported that on the morning of 2/13/25, staff notified her that a card of oxycodone 10 mg, delivered on 2/3/25, was missing from the medication cart. Staff indicated that it was unlikely the resident had taken 60 pills in a week's time. Upon investigation, it was discovered that 120 pills of oxycodone were delivered for Resident #1 on 2/3/25. On 2/12/25, a card of oxycodone was deducted from the Controlled Drug Record for Resident #1. However, upon reviewing the Medication Administration Record for Resident #1, it was noted that only 24 oxycodone pills had been signed out as administered between the time the Oxycodone card was added and removed from the medication cart. The DON revealed she questioned Licensed Practical Nurse (LPN) #1, who had removed the card from the count. She stated that LPN #1 verbalized that she administered the last dose of oxycodone, deducted the card from the count, and placed the narcotic card in the shred box, with the completed narcotic sheet placed in the medical record's box. The DON confirmed that she holds the only key to the shred box and was unable to locate the medication card for Resident #1 in the box. Additionally, no narcotic sheet for the oxycodone was found in the medical record box. The DON confirmed that upon completing the investigation, she validated there was a narcotic diversion because 36 of the 120 oxycodone pills delivered on 2/3/25 for Resident #1 were unaccounted for. Record review of the Physician's Order Report for Resident #1 from 2/1/25-2/28/25 revealed an order dated 12/30/24 for oxycodone 10 mg, one tablet by mouth every six (6) hours as needed for pain. Record review of a written statement from LPN #2 revealed that on the morning of 2/13/25, she noticed that the first card of 120 oxycodone pills was missing from the medication cart. LPN #2 reported the missing medication to the DON because the medication was ordered every six hours, and the calculation did not add up. Record review of a written statement from LPN #1 indicated that she worked on the medication cart from 7:00 AM to 3:00 PM, Monday through Friday, and dosed Resident #1 with oxycodone daily. On 2/12/25, she administered the last two pills from the card and placed the card in the shred box. Record review of the pharmacy receipt dated 2/3/25 revealed Resident #1 had prescription (RX) # N803917 two cards of oxycodone 10 mg with a total quantity of 120 pills delivered to the facility. Record review of the Controlled Drug Record revealed that on 2/3/25, 120 pills (two cards of 60 pills) of oxycodone, RX #N8039713, were added to the narcotic count form on the dayshift. On 2/12/25, a card of oxycodone, RX #N8039713, was deducted from the narcotic count form on the dayshift. Record review of the 'Medication Record' for Resident #1 with the DON on 5/12/25 at 12:10 PM revealed that, from 2/3/25-2/12/25, during the time oxycodone for Resident #1 was added and removed from the narcotic count, 24 pills were documented as administered. Review of the Face Sheet revealed that Resident #1 was admitted to the facility on [DATE] with diagnoses that included Unspecified Pain. Record review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/13/25 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.

Based on observation, staff interview and facility policy review the facility failed to ensure a resident's dignity as evidenced by allowing the resident to sit in a public area with a private body part exposed for one (1) of 21 residents sampled. Resident #85 Findings include: Review of the facility policy titled, Dignity with no revision date revealed under, Policy Interpretation and Implementation .#11. Staff promote, maintain and protect resident privacy, including bodily privacy . An observation on 7/8/24 at 12:10 PM revealed Resident #85 sitting in a reclined wheelchair across from the centralized nurse's station wearing a tank top that had fell from her left shoulder exposing her breast. At this time there were approximately 10 other residents sitting in the area of the nurse's station and day room with staff and visitors walking past the resident. An interview and observation on 7/8/24 at 12:15 PM with Licensed Practical Nurse (LPN) #1 revealed she is Resident #85's nurse and confirmed that the resident needed to be covered. She stated they were having trouble keeping the resident covered today. This observation revealed LPN #1 pulled the residents tank top strap up and began tucking a fleece blanket around the residents' shoulders then stated, I should've gone and got her something else to wear. An interview and observation on 7/9/24 at 10:30 AM, with Certified Nurse Assistant (CNA) #2 revealed that Resident #85's closet had approximately 4 shirts with sleeves, two long sleeve gowns, 4 pairs of pants and a robe. She stated the CNA's dress the resident and the resident should always have clothes that fit her and do not expose her breast for the resident's dignity. An interview on 7/9/24 at 11:00 AM, with LPN #1 confirmed that Resident #85 should have had better clothes on yesterday that did not expose her for the resident's dignity. An interview on 7/9/24 at 1:30 PM, with the Director of Nurses (DON) confirmed that her expectation is that residents should be dressed in a manner that would keep them from exposing private body parts. She stated that Resident #85 having a breast exposed due to an ill-fitting tank top while sitting in the area near the nurses' desk would have been a dignity issue for the resident. Record review of Resident #85's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Senile Degeneration of Brain.

Based on observations, staff interview, record review, and facility policy review, the facility failed to provide assistance with activities of daily living (ADLs) for a resident dependent on staff for shaving and changing visibly soiled clothing for two (2) of 21 sampled residents. Resident #20 and Resident #44 Findings Include: Review of the facility policy titled Activities of Daily Living undated, revealed, Policy Statement: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Resident #20 An observation on 7/8/2024 at 11:44 AM, revealed Resident #20 lying in bed, non-communicative with grayish-black facial hair observed above the upper lip, under the lower lip, and to her chin, measuring approximately 1/4 (one-fourth) inch in length. The resident was wearing a hospital gown and had a tan colored liquid substance spread across the chest area of the gown and two (2) small, cubed pieces of carrot. Review of the lunch menu for 7/8/2024 revealed lunch included a hamburger steak with brown gravy over white rice with sliced cooked carrots. An observation and interview with Registered Nurse (RN) #1 on 7/9/2024 at 10:15 AM, confirmed the presence of Resident #20's facial hair and revealed the aides were responsible for shaving the female residents when it was noticeable. RN #1 explained that she glanced into the resident's room daily to ensure her care was completed, and stated she just overlooked the facial hair. She acknowledged that when a resident had soiled clothing, it should be changed immediately. An interview with the Director of Nursing (DON) on 7/9/2024 at 10:21 AM, revealed the aides were responsible for shaving the female residents on their designated bath day. She explained Resident #20 was able to feed herself but was a messy eater. She revealed her expectations were for staff to check for soiled clothing and immediately changed it when needed. Record review of the Face Sheet revealed the facility admitted Resident #20 on 6/29/2023 with medical diagnoses that included Hemiplegia following Nontraumatic Intracerebral Hemorrhage affecting right dominant side. 44804 Resident #44 An observation on 07/08/24 at 2:06 PM revealed Resident #44 sitting in the day room dressed in personal clothes, with a sliced piece of carrot, approximately six (6) pieces of rice and a nickel size amount of a brown substance on her shirt around her chest area. Review of the lunch menu for 7/8/24 revealed lunch included a hamburger steak with brown gravy over white rice with sliced cooked carrots. An interview on 7/9/24 at 11:00 AM with Certified Nurse Assistant (CNA) #1 revealed that Resident #44 has to be fed by the staff and the resident should always be cleaned up after feeding because this resident cannot clean herself. She stated lunch is served around 11 AM and they should always make sure there is no food left on the resident's clothes after meal time. An interview on 7/9/24 at 11:22 AM with Licensed Practical Nurse (LPN) #1 confirmed that Resident #44 has to be fed by staff and would have been fed by her CNA yesterday. She stated she expects the CNA that feeds the resident to clean the resident up and make sure there is no food left on their clothes from the meal. An interview on 7/9/24 at 1:20 PM with the DON confirmed that Resident #44 has to be fed by the staff and that she normally wears a bib, but she should be checked before leaving the dining room and cleaned to make sure food is not left on the resident. She revealed it was her expectation that would be done for residents. Record review of Resident #44's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus. Record review of Resident #44's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/3/24 revealed in Section GG that the resident was dependent on staff for eating.

Based on observation, staff interview, record review and facility policy review, the facility failed to provide services to assure a resident maintained the level of range of motion (ROM) for one (1) of three (3) residents positioning and mobility. Resident # 68 Findings include: Review of the policy titled, Contracture Prevention Protocol, revealed Policy: .A resident with a limited ROM (Range of Motion) receives appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM, thus preventing contracture formation . An observation of Resident #68 on 7/8/24 at 11:00 AM revealed the resident's left hand/wrist to be contracted, a splinting device was observed lying on the counter next to the sink. An observation of Resident #68 on 7/8/24 at 2:45 PM revealed a hand splint laying on the counter next to the sink, resident observed with no splinting devices observed on left hand. Interview with Licensed Practical Nurse (LPN) #2 on 7/9/24 at 10:30 AM, confirmed Resident #68 should have been wearing the resting left-hand splint on 7/8/24 but confirmed she did not check to see if the resident was wearing the splint. She then revealed, after reviewing the Treatment Administration Records (TAR) and the physician's orders for Resident #68, that she did not see the order for the splint. An interview with the Occupational Therapist (OT) on 7/9/24 at 10:35 AM, revealed she has not had Resident #68 on case load for a while but confirmed that Resident #68 should be wearing her left-hand splint to prevent worsening of contractures, and she confirmed she had not discontinued the device. Record review of OT notes for Resident #68 revealed she began OT services on 1/2/2022 for functional decline with left-hand contracture, muscle wasting and atrophy after a hospital stay. OT services were discontinued on 2/10/22 related to goals met. Record review of a written Physician's Order for Resident #68 provided by the facility dated 2/10/22 revealed, resident to wear (L) left resting hand splint four (4) hours per day with staff monitoring skin for irritation to decrease risk of worsening joint deformity with no discontinue date. Record review of the July 2024 Physician's Orders for Resident #68 revealed no order for a left resting hand splint. Interview with Restorative Nurse on 7/9/24 at 10:40 AM, she revealed after review of Resident #68's physician's orders, she confirmed she was unable to find the splinting device for the left hand listed at all, and the purpose of the left-hand splint was to prevent worsening of the contracture. An interview with the Director of Nursing (DON) on 7/10/24 at 8:30 AM, revealed after further investigation it was found that the order for the left-hand splint was entered into the computer system to alert staff on 2/10/22 when Resident #68 was discharged from OT, but for some reason dropped off in May 2022 and was never re-entered in the computer system. Record review of the Face Sheet revealed Resident #68 was admitted by the facility on 11/11/20 with diagnoses including Cerebral Palsy and Hemiplegia. Record review of Resident #68's Section C of the Minimum Data Set (MDS) revealed that on 6/14/24 the Brief Interview for Mental Status (BIMS) score was 0, indicating the resident was severely cognitively impaired. Section GG0115: Functional Limitation in Range of Motion was coded 1. Impairment on one side to upper extremity.

Based on observations, staff interviews, record review and facility policy review, the facility failed to prevent the possibility of infection as evidenced by failing to cleanse and properly store a Percutaneous Endoscopic Gastrostomy (PEG) tube syringe for (1) one of (5) five resident care observations. Resident # 68 Findings include: Review of the facility policy titled, Standard Precaution, revealed, .Policy Interpretation: Any equipment or items that may be suspected of contamination with body fluids must be handled in a manner to prevent possible transmission of infectious agents . Review of the facility policy titled, Feeding Syringe Policy, revealed, Our policy for the cleanliness of syringes is they are dated and stored on a pole bag. Syringes are stored separated after use. An observation of Resident #68's room on 7/8/24 at 11:00 AM, revealed a PEG tube syringe separated and laying on the bedside table, with no clean barrier or storage bag observed on the table. Interview with Licensed Practical Nurse (LPN) #2 on 7/9/24 at 10:30 AM revealed she was assigned to Resident #68 and confirmed she left the PEG tube syringe laying on the bedside table. She revealed she should have cleansed the syringe, dried it and placed it in a clean storage bag. She then stated that by not cleaning and storing the PEG tube syringe correctly, it placed Resident #68 at increased risk for transmission of bacteria and infection into the gastric site. Interview with the Infection Control Nurse on 7/09/24 at 10:40 AM, revealed that the PEG tube syringe should have been cleaned and dried and stored in a clean storage bag. She stated by not cleaning and storing the PEG tube syringe appropriately, Resident #68 was placed at increased risk for transmission of infection or bacteria and germs to the PEG site. A record review of the July 2024 Physician's Orders for Resident #68 revealed she received all medications, nutrition, and fluid requirements via the PEG tube. Record review of the Face Sheet revealed Resident #68 was admitted by the facility on 11/11/20 with diagnoses including Cerebral Palsy and Encounter for Attention to Gastrostomy.

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement a comprehensive person-centered care plan for a resident requiring grooming and personal hygiene and failed to develop a care plan for splint/mobility devices for three (3) of 21 care plans reviewed. Resident #20, Resident #44 and Resident #68 Findings Include: Review of the facility policy titled, Care Plans-Comprehensive with no revision date revealed under the Policy Statement .A comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs shall be developed for each resident. Resident #20 Review of Resident #20's Care Plan revealed, ADLS (activities of daily living): Requires assistance with ADLS related to impaired functional ability/right sided hemiplegia, and cognitive impairment. Also revealed under, Approaches: . Hygiene and grooming daily . shave daily if facial hair is present . On 7/8/2024 at 11:44 AM, an observation revealed, Resident #20 lying in bed, non-communicative with grayish-black facial hair observed above the upper lip, under the lower lip, and to her chin, measuring approximately 1/4 (one-fourth) inch in length. The resident was wearing a hospital gown and had a tan colored liquid substance spread across the chest area of the gown and two (2) small, cubed pieces of carrot. An observation and interview with Registered Nurse (RN) #1 on 7/9/2024 at 10:15 AM, confirmed Resident #20's facial hair and acknowledged that when a resident had soiled clothing, it should be changed immediately. An interview with the Director of Nursing (DON) on 7/10/2024 at 8:25 AM, confirmed the ADL care plan was not followed and revealed the importance of following the plan of care was to provide the necessary care for Resident #20. Record review of the Face Sheet revealed the facility admitted Resident #20 on 6/29/2023 with medical diagnoses which included Hemiplegia following Nontraumatic Intracerebral Hemorrhage affecting right dominant side. 44804 Resident #44 Record review of Resident #44's care plans revealed the resident has a care plan regarding needing assistance with Activities of Daily Living (ADL) related to muscle weakness, occasional incontinence and cognitive impairment with interventions that include assist with grooming and spoon-feed all meals (CNA). On 07/08/24 at 2:06 PM, an observation revealed Resident #44 sitting in the day room dressed in personal clothes, with a sliced piece of carrot, approximately six (6) pieces of rice and a nickel size amount of a brown substance on her shirt around her chest area. On 7/9/24 at 1:20 PM, during an interview with the DON, she stated Resident #44 has to be fed by the staff and that she normally wears a bib, but she should be checked before leaving the dining room and cleaned to make sure food is not left on the resident. She revealed it was her expectation that this would be done for all residents. Record review of Resident #44's Face Sheet revealed the resident was admitted to the facility on [DATE]. Record review of Resident #44's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/3/24 revealed in Section GG that the resident was dependent on staff for eating. Resident #68 Review of a written physician's order for Resident #68 provided by the facility dated 2/10/22 revealed, resident to wear (L) left resting hand splint time four (4) hours per day with staff monitoring skin for irritation to decrease risk of worsening joint deformity with no discontinue date. Review of the Electronic Care Guide (ECARE) Care Plan for Resident #68 revealed no resting left-hand splint intervention listed. Review of the Comprehensive Care Plans for Resident #68 revealed no resting left-hand splint listed on any of the care plans. On 7/9/24 at 10:40 AM, during an interview with Restorative Nurse, she revealed after review of Resident #68's care plans and the ECARE guide for the Certified Nurse Assistants (CNAs), she confirmed she was unable to find the splinting device for the left hand listed on any of the care plans. Interview with the Minimum Data Set (MDS) Coordinator on 7/09/24 at 12:59 PM, she revealed the purpose of the comprehensive care plan is to direct resident specific care needs to staff. She then confirmed, if a resident had an order for a splinting device, the device should be a care-planned to reflect the resident's specific need. She confirmed, after review of Resident #68's care plans, they were not revised to reflect the left-hand resting splint. Interview with the Director of Nursing (DON) on 7/09/24 at 1:32 PM, she revealed the physician's order for the resting left-hand splint was never added to the ECARE care guide for the resident when she was discharged from Occupational Therapy (OT). Interview with Certified Nursing Assistant (CNA) #3 on 07/09/24 at 2:02 PM, she revealed if a resident has a splint or other device ordered, it would trigger the CNA ECARE guide. She stated Resident #68 used to have a splint triggering to the ECARE, but it dropped off a while back. Review of the Face Sheet revealed Resident #68 was admitted by the facility on 11/11/20 with diagnoses including Cerebral Palsy and Hemiplegia.

Based on staff interview, record review and facility policy review the facility failed to develop a comprehensive care plan for physical restraints for one (1) of eighteen residents sampled. Resident #25 Findings include: Record review of the facility policy Care Plans-Comprehensive undated, revealed Policy Statement: A comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs shall be developed for each resident. Policy Interpretation and Implementation .2. The comprehensive care plan has been designed to: a. Incorporate identified problem areas. b. Incorporate risk actors associated with identified problems .d. Reflect treatment goals and objectives in measurable outcomes.e. Identiy the professional services that are responsible for each element of care .3.The resident's comprehensive care plan is developed with seven (7) days of the completion of the resident's comprehensive assessment . 46013 Resident #25 An interview and observation on 01/25/23 at 9:38 AM, the Director of Nurses (DON) confirmed that Resident # 25 had a lap belt in place. The DON revealed she's not even supposed to have this waist belt on. I don't know why she has it on. An interview on 01/25/23 at 11:16 AM, with the DON revealed there was not a care plan because she wasn't aware it was being used. An interview on 01/26/23 at 11:40 AM, the Minimum Data Set (MDS) nurse confirmed that the care plan was not reflective of the waist belt. She revealed I just found out about the belt. An interview on 01/26/23 at 12:45 PM, the DON revealed upon admission the admitting nurse or the Minimum Data Set (MDS) nurse completes the 24-hour baseline care plan then the MDS nurse does the updating of any changes to their care plan. She revealed that she wasn't aware that Resident #25 was using the seat belt and that's why she didn't have a care plan. She revealed she was aware that the resident has been here for a long time and that the staff should have communicated that the waist belt was being used and revealed it was just bad communication. Record review of Resident #25's Care plan Problem Onset: dated 11/17/2006 Falls: At risk for falls/injury and further contractures related to impaired mobility. Approaches: geri-chair primary mode of locomotion. No care plan developed addressing the lap belt or the use of a restraint. Review of Resident #25's Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses that include Hemiplegia following nontraumatic intracerebral hemorrhage affecting the right dominant side.

Based on observation, staff interview, record review and facility policy review the facility failed to prevent the misappropriation of medication for one (1) of eighteen residents sampled. Resident #79 Findings include: Record review of facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, undated, revealed, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, any physical or chemical restraint not required to treat the resident's symptoms. The policy also revealed, The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff .e. staff from other agencies. 2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; b. neglect of residents; and/or c. theft, exploitation or misappropriation of resident property. An interview with the Director of Nursing (DON) on 1/24/23 at 3:00 PM, revealed a drug diversion occurred at the facility on 12/31/22, and through their investigation, it was determined that an agency nurse, Licensed Practical Nurse (LPN) #6, was the one that diverted the drugs. She stated LPN #6 signed out a narcotic card on the narcotic card count log and decreased the number by one on the card log, but did not put the resident information on the card. This made the numbers of narcotic cards and sheets on the medicine cart match the number on the card log, and it was not detected until the next day on 1/1/23, when Registered Nurse (RN) #2 noticed that the card count log was not filled out properly or completely and she notified the DON. A phone interview with RN #2 on 1/26/23 at 9:50 AM, revealed she worked on Saturday 12/31/23 and counted at 7 AM with the nurse leaving and the card count was 30 at that time. She stated LPN #6 came into work approximately 8:30 AM, so she counted with her and handed the keys and cart to her for her shift and at that time the card count and paper log remained at 30. She stated on Sunday morning at 7 AM she came in to work and she counted with the nurse going home and the card count and the paper log were both 29. She stated she realized shortly after that the card count log count was correct, but it was not filled out completely with the resident's name and medication that was removed from the cart. She stated the only information present was the date of 12/31/22 and the count of 29 and the signature of LPN #6. Stated at that point they tried to locate the medication and sheet and she contacted the DON to inform her of this incident. She stated all medication carts were checked and the card of medication and sheet could not be located. An interview with the DON on 1/26/23 at 2:30 PM, revealed the drug diversion at the facility occurred and she confirmed the facility failed to prevent the misappropriation of a resident's medication. Record review of Resident #79's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses of Adjustment Disorder with Mixed Anxiety and Depressed Mood, Dementia, Major Depressive Disorder, Opioid Dependence with unspecified Opioid Induced Disorder. Record review of Physician Orders revealed an order dated 11/22/22 for Hydrocodone-Acetaminophen 10-325 milligrams (mg), give one tablet by mouth three (3) times a day every eight (8) hours for pain. Record review of the Minimum Data Set with an Assessment Reference Date of 11/8/22 revealed a Brief Interview for Mental Status score of nine (9) which indicated moderate cognitive impairment.

Based on observation, staff/resident interview, record review and facility policy review the facility failed to provide a safe, clean environment for three (3) of the eighteen residents sampled. Resident Resident #25, Resident# 49 and Resident #65. Findings include: Record review of the facility policy titled, Resident Equipment Cleaning and Disinfection, undated revealed, . All equipment used for resident care shall be kept clean and in proper working condition . Resident #25 An observation on 01/24/23 at 9:51 AM, revealed Resident #25 sitting in a geriatric-chair (geri-chair), the footrest noted with torn vinyl on both sides exposing tattered foam padding. A further observation on 01/24/23 at 4:40 PM, of Resident #25's geri-chair revealed the footrest vinyl was peeled back on both sides exposing tattered foam padding. The bilateral armrest was loose and moved back and forth when touched. A tan-colored substance was noted on the left armrest with a dried light brownish substance down both sides of the chair. The back of the chair was tattered at the top seam with foam exposed. In an interview on 01/25/23 at 9:20 AM, Licensed Practical Nurse (LPN) #1 confirmed the footrest vinyl was torn, the foam padding was exposed and the armrests were loose and needed to be fixed on Resident #25's geri-chair. She stated the resident could get a skin tear from the vinyl sticking up. She revealed the resident eats sitting up in her chair and the substance on the armrest was probably dried food. She reported that on Wednesdays, all equipment is cleaned on the 11-7 PM shift, but it doesn't look like this chair had been cleaned in a while. An interview and observation on 01/25/23 at 09:38 AM, the Director of Nursing (DON) confirmed Resident #25's geri-chair was tattered and could cause a skin tear. She revealed the resident's husband brought that chair from home. She confirmed that it was the facility's responsibility to ensure the equipment was in good repair and she would see if they could order a new footrest. She confirmed that the geri-chair was dirty and attempted to scratch off the brown substance on the left armrest. She stated the chair was supposed to be kept clean. An interview on 01/26/23 at 10:35 AM, with Resident #25's Resident Representative (RR) revealed he purchased her the geri-chair sometime after she was admitted to the facility. He revealed he has had it worked on before but couldn't afford a new chair and is ashamed of how the chair looks with all the food on it and how it is torn up. He revealed about three months ago he took it out of the facility one evening and cleaned it and when the weather warms up, he will take it outside and give it a good cleaning again. In an interview on 01/26/23 at 12:05 PM, the DON revealed the Certified Nursing Assistants (CNAs) on the 11-7 PM shift are responsible for cleaning the geri-chairs. She revealed there is no sheet for the aides to sign off that the cleaning has been completed and sometimes they just initial a sheet by the room number. She confirmed that nothing had been signed on it and she wasn't sure of when the equipment had been cleaned. Review of the 11-7 Shift Wheelchair/Geri-Chair Washing Schedule, undated, revealed there were no staff initials by any of the room numbers. Record review of Resident #25's Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses that include Hemiplegia following nontraumatic intracerebral hemorrhage affecting the right dominant side. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 10/6/22 revealed a Brief Interview for Mental Status (BIMS) score of 00 which indicated Resident #25 had severe cognitive impairment. Resident #49 An observation on 01/24/23 at 3:33 PM, revealed Resident #49 in bed with four side rails up with full-length side rail pads on each side of the bed. The pads were torn with foam exposed in the middle area of the pads. The torn edges were rough to the touch. An observation on 01/25/23 at 9:00 AM, revealed Resident #49 in bed with four side rails up with torn side rail pads. An observation and interview on 1/25/23 at 2:15 PM, with the DON confirmed Resident #49 had side rails up times four (4) with blue plastic covered foam pads the full length of both sides of the bed. The DON confirmed the pads were torn with rough edges at the middle section and stated she knew they needed to get new ones. The DON declined to feel the rough torn areas on the side rail pads. Review of the facility Face Sheet for Resident #49 revealed an admitted [DATE] with diagnoses that include Vascular Dementia, Unspecified Lack of Coordination and Unspecified Convulsions. Review of the MDS Section C with an ARD of 11/30/22 revealed a BIMS score of 00 which indicated Resident #49 had severe cognitive impairment. 41878 Resident #65 An observation on 1/24/23 at 9:30 AM, revealed Resident #65 was sitting in a geriatric chair in the lobby area near the nurses' station. Resident #65 was moving her arms and legs freely and it was noted that the cushion to the right chair arm had moved towards the center of the chair exposing the metal part of the arm rest. The resident's right arm was noted to be near the metal area and occasionally rested on the unpadded area. An interview and observation of Resident #65's geriatric chair with Licensed Practical Nurse (LPN) #3 on 1/25/23 at 9:35 AM, revealed the area of exposed metal on the arm of the chair was due to a loose screw that held the cushion pad onto the metal arm. She stated she would ask maintenance to repair this to prevent an injury. An interview with the DON on 1/25/23 at 9:45 AM, revealed the metal on the chair arm was exposed due to the cushion being loose and repair was necessary. She stated all staff were responsible to monitor equipment for safety when being used. She confirmed the facility failed to properly maintain the resident's equipment and this could lead to a skin tear injury to the resident. Record review of Resident #65's Face Sheet revealed she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's Disease and Dementia with Behavioral Disturbances. Record review of Resident #65's MDS with an ARD dated 10/18/22 revealed a BIMS score of zero (0) indicating severe cognitive impairment. 46013

Based on observation, staff and resident representative interview, record review and facility policy review the facility failed to ensure residents were free from physical restraints for three (3) of eighteen residents on sample. Resident #25, #31, and #72. Findings include: Record review of the facility policy titled, Guidelines and Policy with no revision date revealed under, Purpose .Physical restraints are defined as any manual method, physical or mechanical device, material or equipment attached to the resident's body that the resident cannot remove easily which restricts freedom of movement or normal access to one's body. The resident must be physically and cognitively able to self-release device such as Velcro lap-trays or tables, seat belt with Velcro, or snap seat belts, if a resident cannot mentally and physically self-release, then the device is considered a restraint . 44804 Resident #31 An observation on 01/23/23 at 9:00 AM, revealed Resident #31 lying in bed with eyes closed, and three quarter (3/4) siderails up on both sides of the resident's bed with the bed in the lowest position. An interview on 01/25/23 at 8:15 AM, with Certified Nurse Assistant (CNA) #2 revealed she always works the Alzheimer/dementia care unit. She revealed that she thinks all of the residents need side rails to prevent them from falling. She revealed the facility has in-services about siderails and they have told us to make sure they are up and she believes they all need them for safety. She revealed Resident #31 has full side rails up when she is in bed, and she is unaware of any care plan that she is supposed to look at or orders to know who needs full side rails and who does not. An interview on 01/25/23 at 8:25 AM, with Licensed Practical Nurse (LPN) #2 revealed she is the nurse on the Alzheimer's/Dementia care unit. She revealed that full siderails are considered all four (4) split rails and if the bed only has long single rails on each side, then both sides up would be considered full rails. She revealed that the resident's that can let their own siderails down can get full siderails if they request them and they or the family signs a consent. She revealed she is aware that siderails could be considered a restraint, a siderail assessment is completed by the Registered Nurse (RN) and LPN on admission and if the resident has any changes in condition. She revealed that if the resident is a fall risk or cannot define the perimeters of the bed, then the staff talk to the resident's family, and if they want full side rails they sign a consent. She revealed that Resident #31 has a long side rail on each side of her bed and both are up when this resident is in the bed. An interview on 01/25/23 at 8:57 AM, with CNA #3 revealed that some residents have two (2) full rails, and some have 4 half rails. She revealed she does not work the floor often, but when she does, and she sees that a resident has full side rails up then she leaves them up. She revealed if she had to put the resident to bed she determines if the resident needs full side rails based on if the resident can move around by their self. She revealed if the resident can move around on their own, they are at a higher risk of falling out of the bed, so in her judgement they need full side rails. An interview and observation on 01/25/23 at 11:00 AM, with the Director of Nurses (DON) revealed there were 13 beds with 3/4 siderails and one (1) bed with full side rails on the 100 hall with 22 total beds. She revealed the facility has been trying to get all new beds with just the upper half rails. She revealed that if a resident's bed had both 3/4 side rails up then the resident could not let them down on their own and it could be considered a restraint. An interview on 01/26/23 at 11:35 AM, with Registered Nurse-Minimum Data Set (RN-MDS) confirmed that Resident #31 has both 3/4 side rails up while she is in bed to help with bed mobility. She revealed the resident is able to move herself in the bed independently and needs limited assistance with walking. When the SA asked why the resident would need both 3/4 side rails up while in bed if the resident is able to move herself independently in bed, RN-MDS stated, I see your point. She confirmed that if a resident had both 3/4 side rails up then the resident could not let them down or get out of their bed. Record review of the facility restraint in-services revealed CNA #2 and CNA #3 and LPN #1 and LPN #2 had completed restraint in-services in 08/2022. Record review of Resident #31's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified dementia, unspecified severity with behavioral disturbance. Record review of Resident #31's Physician's Orders revealed an order dated 4/20/21- Siderails, necessary to serve as an enabler to promote independence. Record review of Resident #31's Side Rail Consent revealed that left and right upper side rails were to be used and was signed by a resident representative on 4/19/21. Record review of Resident #31's Bedrail/Assist Bar evaluation competed on 01/03/23 revealed that bed rails are 3/4 rails and are only utilized when resident is in bed for promotion of bed mobility independence. Resident can reposition self in bed. Record review of Resident #31's MDS with an AR of 01/03/23 revealed under Section C a BIMS score of 00 which indicates the resident is severely cognitively impaired, under Section G indicated the resident needed limited assistance with bed mobility, transfer, moving from seated to standing position, walking, moving on and off toilet and surface-to-surface transfer and in Section P that bed rails were not being used, Resident #72 An observation on 01/23/23 at 7:20 PM, revealed Resident #72 lying in bed with a wood head and foot board and full wooden siderails up. An observation on 01/24/23 at 8:50 AM, revealed Resident #72 lying in bed with full side rails up. An observation on 01/24/23 at 3:00 PM, revealed Resident #72 lying in bed with full side rails up. An observation on 01/24/23 at 5:00 PM, revealed Resident #72 lying in bed with full side rails up and with eyes closed. An interview on 01/24/23 at 5:10 PM, with Resident #72's Resident Representative revealed she guesses she is ok with the siderails and revealed the staff may have discussed the risk and benefits of side rails, but she cannot remember. An interview and observation on 01/25/23 at 9:00 AM, with LPN #1 revealed she is the nurse for Resident #72. She revealed that full side rails are a precaution to keep them from falling out of the bed. She revealed if the resident moves a lot in the bed, then they have full side rails. She revealed that Resident #72 does not walk, but she can stand and pivot. An observation at this time with LPN #1 confirmed that Resident #72 has 4 split rails up. She revealed that she is not sure why Resident #72 has full side rails, because she should not need them. An interview and observation on 01/25/23 at 9:15 AM, with CNA #4 confirmed that Resident #72 has full side rails up on her bed. She revealed that Resident #72 has just come out of the stage of walking on her own and now she does not, so she might think she can still get up and that is why her full siderails are up. She revealed that Resident #72 has never tried to get out of bed as far as she knows. She revealed that residents that are total care all have full side rails to keep them from falling. She revealed that siderails can be considered a restraint. An interview and observation on 01/25/23 at 10:20 AM, with LPN-MDS with RN-MDS present revealed that Resident #72 has a consent on her record for left and right upper rails, signed by her resident representative on admission 11/3/22. An observation with LPN-MDS confirmed that Resident #72 has a bed with 4 half rails and all 4 rails were up. She revealed she would consider the resident a fall risk, but she has never known her to try and get out of the bed. She revealed Resident #72 needs a new bed that goes lower to the floor, and she plans to have it replaced. She revealed that Resident #72's siderail consent does not match what the resident has in use. An interview on 01/25/23 at 10:30 AM, with RN-MDS revealed that she and LPN-MDS does the bedrail assessments on everyone. She revealed that Resident #72 had a bedrail assessment on 12/22/22 due to a significant change in the same bed she currently is in. She confirmed that Resident #72's consent indicates left and right upper side rails and that did not match what the resident currently had in use, which was 4 half rails. She revealed that after she completed her bedrail assessment on 12/22/22 she did not get a new consent signed for full side rails. An observation on 01/25/23 at 1:00 PM, revealed that Resident #72's bed had been changed to a bed that goes lower and has bilateral 3/4 rails and the resident is sitting up in a reclining mobile chair out by the nurse's desk. An interview on 01/26/23 at 10:35 AM, with the DON revealed that Resident # 72 did not have an order for side rails and if a resident has siderails in use they should have an order. An interview on 01/26/23 at 11:30 AM, with RN-MDS confirmed that Resident #72's bed was changed and stated, Her bed was changed because apparently it was not a suitable bed. She also confirmed that the resident did not have an order for siderails but should have. Record review of Resident #72's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Chronic obstructive pulmonary disease. Record review of Resident #72's Physician's Orders revealed there was no order for side rail use. Record review of Resident #72's Bedrail/Assist Bar Evaluation completed 12/22/22 by RN-MDS revealed the assessment was completed due to a significant change. This assessment indicated that the resident had not expressed a desire to have side rails raised and is unable to release bed rails. This assessment revealed under Evaluation Factors .Bilateral upper and lower rails are needed for resident's bed mobility independence and for safety to prevent resident from slipping or rolling onto floor with the diagnosis to be considered with bed rails/assist bar being Unspecified Dementia. Record review of Resident #72's Side Rail Consent dated 11/3/22 revealed it read Prior to the completion of the side rail assessment I request the staff of Madison County Nursing Home to raise the protective side rails indicated below for my safety and the indicated side rails were marked as left and right upper side rail. Record review of Resident #72's MDS with an ARD dated of 12/22/22 revealed under Section C that there was a BIMS score of 00 which indicates the resident is severely cognitively impaired; Section G indicated the resident needed limited assistance for moving from seated to standing position and surface to surface transfer and in Section P indicated bed rails were not in use. 46013 Resident #25 An observation on 01/24/23 at 9:51 AM, of Resident #25 sitting in a Geri chair with a black lap belt fastened around her waist. An observation on 01/24/23 at 11:26 AM, of Resident #25 sitting in a Geri-chair with a black waist belt in place. An interview and observation on 01/25/23 at 9:20 AM, with LPN #1 confirmed Resident #25 had a lap belt on and was unable to unfasten it. She revealed it's used so she won't slide out of the chair. She revealed she has never witnessed her sliding down in the chair. An interview and observation on 01/25/23 at 9:38 AM, the DON confirmed that Resident #25 had a lap belt in place. The DON encouraged Resident #25 to release the belt and Resident #25 was unable to release the belt. The DON then revealed she's not supposed to have this waist belt on. I don't know why she has it on. An interview on 01/25/23 at 10:56 AM, with CNA #1 revealed they have been using the waist belt while the resident was up in the Geri chair to aid in her not sliding down and have been using the belt for a long time. An interview on 01/25/23 at 11:16 AM, with the DON revealed there was no restraint assessment for the waist belt or physician's order or care plan because she wasn't aware it was being used. An interview on 01/25/23 at 2:30 PM, with LPN #1 revealed Resident #25's husband was in today and signed a restraint consent form and wanted to keep the seat belt on her. An interview on 01/26/23 at 10:00 AM, with Resident #25's husband/Resident Representative revealed I'm the one who bought the geriatric chair for her, he revealed the staff would put her safety belt on her to keep her from sliding out of the chair. He revealed he never signed a consent for the belt until he came in yesterday and the nurse told him he needed to sign the form. An interview on 01/26/23 at 12:08 PM, with CNA #1 revealed she has been working in the facility for seven years and the resident has always had the lap belt and everyone knows that she has it. She revealed when I came to work here the aide training me told me the belt needed to be on her when she is up in the chair, so she doesn't slide out. Review of Resident #25's Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses that include Hemiplegia following nontraumatic intracerebral hemorrhage affecting the right dominant side. Review of the MDS Section C with an ARD of 10/6/22 revealed a BIMS score of 00 which indicated Resident #25 had severe cognitive impairment.

Based on staff interviews and record review the facility failed to accurately code the Minimum Data Set (MDS) for one (1) of eighteen residents sampled. Resident #25 Findings include: Record review of an unsigned, undated statement on facility letterhead revealed, It is Madison County Nursing home protocol to follow the Resident Assessment Instrument (RAI) Manual for MDS's and Care Plans. 46013 Resident #25 An interview and observation on 01/25/23 at 9:38 AM, the Director of Nurses (DON) confirmed that Resident # 25 had a lap belt in place. The DON encouraged Resident # 25 to release the belt and Resident # 25 was unable to release the belt. The DON revealed she's not even supposed to have this waist belt on. I don't know why she has it on. An interview on 01/25/23 at 11:16 AM, with the DON revealed there was no restraint assessment for the waist belt or physician's order or care plan because she wasn't aware it was being used. An interview on 01/26/23 at 11:40 AM, the Minimum Data Set (MDS) nurse confirmed that the MDS Section P was not coded correctly and the careplan was not reflective of the waist belt. An interview on 01/26/23 at 12:45 PM, the DON revealed upon admission the admitting nurse or the Minimum Data Set (MDS) nurse completes the 24-hour baseline care plan then the MDS nurse does the updating of any changes to their care plan. She revealed that she wasn't aware that Resident #25 was using the seat belt and that's why she didn't have a care plan. She revealed she was aware that the resident has been here for a long time and that the staff should have communicated that the waist belt was being used and revealed it was just bad communication. Review of the MDS Section P (Restraints) with an Assessment Reference Date (ARD) of 10/6/22 Coding: (0. Not Used) Review of Resident #25's Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses that include Hemiplegia following nontraumatic intracerebral hemorrhage affecting the right dominant side. Review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 10/6/22 revealed a Brief Interview for Mental Status (BIMS) score of 00 which indicated Resident #25 had severe cognitive impairment.

Based on record review, staff interview, and facility policy review, the facility failed to provide the bed hold policy to the resident and/or resident representative at the time of transfer for an acute care stay for four (4) of four (4) residents reviewed for transfer to the hospital (Resident #31, #50, #60, and #71). Findings Include: A review of the facility's Bed-hold and Readmission Policy revealed, The nursing home is required to provide written information to the resident and or the responsible party . Resident #31 On 07/24/19 at 09:46 AM, an interview with Resident #31 revealed she had a recent hospital stay. Review of the physician's orders [REDACTED]. A review of Resident #31's medical record revealed no indication of the bed-hold policy being provided to the resident or resident's representative upon transfer to the hospital. Resident #50 A review of nurse's notes for Resident #50 revealed the resident had transfers to the hospital on [DATE], and on 07/01/19. A review of Resident #50's medical record revealed no indication that the resident and/or the resident representative were notified of the bed-hold policy at the time of transfers to the hospital. Resident #60 A review of Resident #60's medical record revealed the resident had been transferred for acute care stays to the hospital on [DATE], 06/01/19, and on 06/20/19. There was no indication that the resident and/or the resident representative were notified of the bed-hold policy at the time of transfers to the hospital. Resident #71 A review of Resident # 71's medical record revealed the resident had been sent to the hospital from 06/06/19 through 6/9/19, due to altered mental status. There was no evidence in chart of notification in writing of the bed-hold notice to the resident or resident's representative. On 7/24/19 at 2:00 PM, an interview with the Licensed Social Worker (LSW) revealed she was not aware that the facility should be issuing the bed hold policy to the resident and/or resident representative at the time of transfer. The LSW stated the bed-hold policy was signed at admission but was not being signed upon transfer. On 7/25/19 at 8:14 AM, an interview with the Director of Nursing (DON) confirmed she was unaware of the regulation to provide the bed-hold policy at the time of transfer for an acute care stay. The DON stated the bed-hold policy is only being signed on admission.

Based on record review, staff interview, and facility policy review, the facility failed to notify the resident and/or the resident's Responsible Party (RP)/representative, in writing, of transfers to the hospital for four (4) of four (4) residents reviewed for transfer to the hospital (Resident #31, #50, #60, and #71). Findings Include: Review of the facility's Bed-hold and Readmission Policy revealed in part: The nursing home is required to provide written information to the resident and or the responsible party for residents transferred from the facility. Resident #71 A review of Resident #71's medical record revealed the resident had been sent to the hospital from 6/06/19 through 6/9/19, due to altered mental status. There was no evidence in the medical record of written notification of transfer to the hospital to the resident or resident's representative. Resident #31 On 07/24/19 at 9:46 AM, an interview with Resident #31 revealed she had a recent hospital stay. A review of the physician's orders [REDACTED]. A review of Resident #31's medical record revealed no indication of written notice being given to the resident or resident's representative of transfer to the hospital. On 7/24/19 at 2:00 PM, an interview with Licensed Social Worker (LSW) confirmed Resident #31 was transferred to the hospital two (2) times in the month of (MONTH) (2019) and no written notice was sent to the responsible party informing them of the transfer. On 7/25/19 at 8:14 AM, an interview with the Director of Nursing (DON) confirmed no written notice was sent to Resident #31's Responsible Party when the resident was transferred to the hospital. Resident #60 A review of nurse's notes for Resident #50 revealed the resident had transferred to the hospital on [DATE], and on 07/01/19. A review of Resident #50's medical record revealed no documentation that the resident and/or the resident representative was notified in writing of the transfers to the hospital. Resident #60 A review of Resident #60's medical record revealed the resident had been transferred for acute care stays to the hospital on [DATE], 06/01/19, and 06/20/19. There was no documentation that the resident or the resident representative were notified in writing of the transfers to the hospital. On 7/24/19 at 2:00 PM, an interview with the Licensed Social Worker revealed she was not aware that the facility should be sending a written notice to the responsible party when the facility sends a resident to the hospital, the reason why, where the resident was transferred, and the bed hold information. On 7/25/19 at 8:14 AM, an interview with the Director of Nursing (DON) confirmed she was unaware of the regulation for sending a written notice to the responsible party, of why the resident was being transferred and to where. The DON revealed we just call the RP with transfers and the bed hold form is signed on admission.

Based on observation, record review, interview, and facility policy review, the facility failed to revise the care plan related to an intervention to help prevent injury (use of padding for a bed rail) for one (1) of 19 care plans reviewed (Resident #88). Findings include: A review of the facility's Care Plans - Comprehensive Person-Centered policy, with a revision date of (MONTH) (YEAR), revealed the comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs shall be developed for each resident. The Interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative were to develop and implement a comprehensive, person-centered care plan for each resident. The policy further included the care plan was designed to incorporate identified problem areas and risk factors associated with identified problems and should be revised as information about the resident and resident condition changes. A review of Resident #88's Comprehensive Care Plan revealed a care plan with a problem onset date of 07/03/19, addressing the fracture of her left radius. The approaches were not revised to include using padding on the side rails. An observation on 07/24/19 at 08:30 AM, revealed Resident #88's bed had no padding on the side rails. A review of a facility reported incident dated 07/09/19, revealed Resident #88 sustained an injury of a subtle [MEDICAL CONDITION] radius of her left hand. The facility's investigation concluded it was unknown exactly how the injury occurred, but it was possibly during care, due to the resident's history of kicking, hitting and spitting. The resident also had [DIAGNOSES REDACTED]. The report documented the care plan was going to be revised and there would be padding put on the side rail of the bed. An observation of Resident #88, and an interview on 07/23/19 at 3:42 PM, with Resident #88's daughter, (FM #3), revealed FM #3 was generally pleased with the resident's care. FM #3 stated her sister (FM #4) was notified of an injury to Resident #88's wrist on 07/02/19, and an X-ray was done on 07/03/19, that revealed a fracture. FM #3 stated the facility investigated the incident and she and FM #4 met with the facility Administrator, Director or Nursing (DON), and a nurse from the hospice care provider on (MONTH) 9, 2019. FM #3 stated they were told by the facility that after completing their investigation, they were unsure what happened, but suspected she hit her wrist on something. They determined in the meeting that, as precaution to prevent any further injury, they would pad the side rail. FM #3 stated the side rail had not been padded yet, and it was now 07/23/19. There were 1/2 side rails observed on the resident's bed, with no padding, and Resident #88 was periodically using side rails to move around in the bed. Resident #88 had a splint on her left hand. The bed was positioned against the wall with approximately four (4) inches of space between the wall and bed rail. An interview on 07/24/19 at 05:00 PM, with the DON, revealed she was unable to determine the exact cause of Resident #88's injury. The DON stated she couldn't recall how or when the facility decided to put padding on the side rails, but did add padding to the rail today. The DON stated she attempted to pad the rails with sheepskin padding yesterday, but it wasn't adequate and could not be secured to the rail. The DON stated the padding should have been added sooner, and the care plan revised, as an intervention to prevent further injury. An interview with the DON and the Administrator on 07/25/19 at 3:03 PM, revealed there had been a meeting with Resident #88's family on 07/09/19, and discussed the injury. They did recall the discussion of placing padding on the side rails, but were not sure it was during the meeting with the family. They confirmed there were no minutes of the meeting. The DON confirmed the care plan did not include use of padding for bed rails and should have been revised to include use of padding sooner.

Based on observation, staff interview, family interview, resident interview, record review, and facility document review, the facility failed to provide nail care for Resident #25, and #71, and shave facial hair for Resident #36 and #59, for four (4) of 19 sampled residents. Findings include: A review of an untitled document provided by the facility on 07/25/19, revealed it was the protocol of the facility to have personal care, hygiene, and grooming needs met for all residents to include caring for fingernails and shaving. Resident #36 An observation and interview on 07/23/19 at 10:15 AM, revealed Resident #36 in her room lying in bed watching television. The resident appeared clean but had visible patches of chin hair curled up that extended approximately one (1) centimeter (cm) from the surface of her face. Resident #36 stated she liked for the chin hair to be shaved off. She stated the staff had shaved the chin hair in the past. She stated she could not recall when it was last done, but guessed it was more than two (2) weeks ago. An observation on 07/23/19 at 4:16 PM, revealed Resident #36 in her room in bed with chin hair present. Resident's eyes were closed and she was breathing deeply. An observation and interview on 07/24/19 at 08:39 AM, revealed Resident #36 sitting up in bed in her room. Resident #36 stated the chin hair was bothersome to her and she preferred for it to be shaved. Resident #36 stated she had never refused it to be shaved and staff had never asked her if she wanted it shaved. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/08/19, revealed resident had a Brief Interview of Mental Status (BIMS) of 12, indicating she had moderate cognitive impairment, and needed extensive assistance with one (1) person physically assisting her with personal hygiene. An interview on 07/24/19 at 03:43 PM, with Licensed Practical Nurse (LPN) #2, revealed all residents in the facility received a bed bath everyday if they didn't have a shower/whirlpool bath. LPN #2 stated during baths all personal hygiene needs should be completed including nail care, grooming, and shaving. LPN #2 stated the Certified Nursing Assistants (CNAs) should record tasks performed on the Activities of Daily Living (ADL) sheet electronically. LPN #2 stated the CNA Coordinator was responsible for checking to make sure the tasks were completed. An interview and observation on 07/25/19 at 09:18 AM, with CNA #1, of Resident #36, revealed the resident had curled chin hair. With Resident #36's permission, CNA #1 extended the chin hairs from the curled position to straight. The chin hair was estimated to be approximately one (1) inch long. CNA #1 stated the hair appeared to not have been shaved for at least two (2) weeks. CNA #1 stated that she had been regularly assigned to Resident #36, but had not really paid attention to the resident's chin hair. CNA #1 confirmed it was her responsibility to assist the resident with bathing and personal hygiene which would include shaving. CNA #1 stated she didn't remember doing it, but if she had she would have recorded it on the kiosk (electronic documentation instrument). CNA #1 demonstrated on the kiosk how the tasks performed were recorded, and the tasks did include an area to mark for shaving. There was no shaving recorded for the months of (MONTH) 2019, or (MONTH) 2019. A review of a print out, provided by the facility, titled Nail Care Report, revealed a column under Personal Hygiene with a task of shaving/hair removal. The column did not have any mark to indicate completion of shaving/hair removal from 06/01/19 through 07/24/19 for Resident #36. Resident #59 An observation on 07/23/19 at 09:58 AM, revealed Resident #59 in her room lying in bed. The resident was not verbally responsive. The resident had a patch of curled hair visible on the right side of her chin, approximately one (1) cm from the surface of her chin. A review of Resident #59's most recent quarterly MDS, with an ARD of 5/28/19, revealed Resident #59 was totally dependent on staff to take care of personal hygiene needs. An observation on 07/24/19 at 10:09 AM, revealed Resident #59 sitting in the dayroom near the nurse's station in a Ger-chair. The resident's chin hair glistened in the sunlight as it shone through the window, visible from the nurse's station, approximately 20 feet away. An interview and observation on 07/25/19 at 09:23 AM, with CNA #1, of Resident #59, revealed the resident had curled chin hair. In order to measure the hair, CNA #1 extended the chin hairs from the curled position to straight and estimated the hairs to be approximately one (1) inch long. CNA #1 stated it had probably been at least a couple of weeks since the hair had been shaved, but she was unsure. CNA #1 stated that she had been regularly assigned to Resident #59 and had not noticed the chin hair. CNA #1 stated that she really hadn't paid attention. CNA #1 confirmed it was her responsibility to assist the resident with bathing and personal hygiene, which would include shaving. CNA #1 stated she didn't remember doing it, but if she had, she would have recorded it on the kiosk. An interview on 07/25/19 at 03:50 PM, with Resident #59's brother (FM #2), revealed before Resident #59 got sick she was a person who prided herself on her appearance. FM #2 stated the resident would not want to have facial hair present and would want it to be shaved or plucked out. A review of a print out, provided by the facility, titled Nail Care Report, revealed a column under Personal Hygiene with a task of shaving/hair removal. The column did not have any mark to indicate completion of shaving/hair removal from 06/01/19 through 07/24/19. Resident #71 An observation and interview on 07/24/19 at 03:25 PM, revealed Resident #71 lying on his left side in bed. The resident's fingernails appeared approximately 0.75 cm from the nail bed, with build up of brown and reddish brown substance under the nails of both hands. Resident #71 stated the CNA told the nurse that his nails needed to be cut this morning, but the nurse came in and said she didn't think they needed to be cut. Resident #71 stated the substance was food built up. The resident stated he wasn't sure how long it had been since they had been cleaned, but buildup was thick and hard. A review of Resident #71's Quarterly MDS, with an ARD of 06/07/19, revealed the resident had a BIMS score of 9, which indicated the resident had moderate cognitive impairment and the resident was totally dependent on staff to complete personal hygiene needs. The resident required the assistance of 1 (one) staff person to assist with personal hygiene. An observation and interview on 07/25/19 at 09:13 AM, with the resident's sister (FM #1), and Resident #71, revealed the resident's sister often found the resident's fingernails to be dirty when she visited. FM #1 stated she usually tried to clean the nails when she was here. FM #1 stated the build up under the nails was so thick now the resident complained they hurt when she attempted to clean them. FM #1 stated the right hand was more of an issue than the left, because the resident ate with that hand. Resident #71 stated food gets caught under his nails, because his nails are long. Resident #71's nails had dirt under all nails. The resident stated a nurse came to look at the nails and said they didn't need cutting, so he just went along with it. Resident #71 stated if the nails were shorter they wouldn't pick up as much food under them. Resident #71 stated the nails were sore. An interview on 07/25/19 at 09:32 AM, with CNA #2, revealed she was regularly assigned to Resident #71. CNA #2 stated she had attempted to clean the resident's fingernails this morning, but the resident complained they hurt and so she stopped. CNA #2 stated she reported to the nurse and had told the nurse the resident wanted his nails trimmed. CNA #2 declined to answer if she believed the resident's nails should be trimmed, but stated the resident liked to eat finger foods that tended to get under his fingernails. CNA #2 stated she did think if the resident's nails were shorter, they would stay cleaner and be easier to clean. An interview with the CNA Supervisor (LPN #3) on 07/25/19 at 9:51 AM, revealed she expected CNAs to shave hair, clean nails, and assist with all hygiene needs during the resident's daily bath. LPN #3 stated CNAs were expected to shave any facial hair per the resident's preference or the preference of the resident representative if the resident could not speak for themselves. LPN #3 stated she did periodic spot checks to make sure hygiene tasks were being completed, but did not keep documentation of this. LPN #3 stated that regarding nail care, CNAs were expected to assist the residents in washing hands prior to meals and after meals, which included checking nails, and cleaning as needed, after meals and/or as they check people throughout the day. LPN #3 stated any nursing staff could complete hygiene tasks. LPN #3 stated she had not noticed chin hair on Resident #36 or Resident #59 and had not recently noticed residents having dirty or untrimmed nails. An interview on 07/25/19 at 2:52 PM, with the Administrator and the Director of Nursing (DON), revealed it was expected that staff complete all tasks assigned to them. The DON stated hygiene tasks should be completed during daily baths and as needed and she expected staff to do their job everyday. The DON stated it was the responsibility of nursing staff to complete hygiene tasks and it was expected the tasks be completed per resident preferences. Resident #25 During an interview and observation on /24/19 at 12:00 PM, Licensed Practical Nurse (LPN) #1 confirmed Resident #25 had long, rough, and dirty fingernails. She confirmed Resident #25's right hand index and middle finger had a dark brown substance under the nail. On 07/24/19 at 12:05 PM, an interview with Resident # 25 revealed she always does her own finger nails, the staff does not usually do them. Resident #25 revealed she tried to clean them when she notices they are dirty. On 07/24/19 at 12:10 PM, an interview with the LPN #1 confirmed Resident #25's fingernails were dirty, long, and rough. LPN #1 revealed that there is no excuse for not keeping her nails clean and smooth. LPN #1 revealed the resident just finished eating and her dirty fingernails could be a source of spreading an infection if not clean for meal times. LPN #1 revealed the Certified Nursing Assistants (CNA) clean and trim non-diabetic fingernails one (1) time a week and they should be cleaned on bath days. LPN #1 confirmed they look like they have not been cleaned or trimmed in a while. On 07/25/19 at 9:00 AM, an interview with the Director of Nursing (DON) revealed she was made aware of Resident #25's fingernails and confirmed they were long and dirty. The DON confirmed that it was everyone's responsibility to clean and trim resident's nails when they are dirty or long. Record review of Resident #25's nail care report revealed from 6/1/19 to 7/25/19, nail care (cleaning/trimming ) was provided only one (1) time on 6/20/19. Record review of the MDS for Significant Change, dated 4/18/19, revealed Resident #25 required extensive assistance of one (1) staff for personal hygiene.

Based on observation, interview, record review, and facility policy review, the facility failed to develop the comprehensive care plan to address dental concerns for Resident #59; change in condition after hospitalization for Resident #31; and failed to implement the care plan related to Activity of Daily Living (ADL) care for Resident #36, #59, and #71, for four (4) of 19 sampled residents reviewed. Findings include: A review of the facility's Care Plans - Comprehensive Person-Centered policy, with a revision date of (MONTH) (YEAR), revealed the policy statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs shall be developed for each resident. The Interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative were to develop and implement a comprehensive, person-centered care plan for each resident. The policy further included the care plan was designed to incorporate identified problem areas and risk factors associated with identified problems. Resident #36 A review of Resident #36's Comprehensive care plan revealed a care plan with a problem/need dated 02/22/19, of ADL's: Requires staff assistance for ADLs related to impaired mobility and cognitive impairment, The care plan had an intervention to assist with bathing, dressing, and grooming with Certified Nursing Assistant (CNA) listed as staff to complete the intervention. An observation and interview on 07/23/19 at 10:15 AM, revealed Resident #36 lying in bed watching television in her room. The resident appeared clean but had visible patches of chin hair about one (1) centimeter (cm) in length from the surface of the chin, but curled upward. Resident #36 stated she likes for the chin hair to be shaved off, had not recently asked staff to do it, but they had done it in the past. She stated she couldn't recall when it was last done, but it was more than two (2) weeks ago. Resident #36 stated she received a daily bed bath and went to the shower about once a week. An observation and interview on 07/24/19 at 8:39 AM, revealed the resident with visible chin hair. Resident #36 stated the chin hair was bothersome to her and she preferred it be shaved and had not ever refused to be shaved. The resident stated staff had not asked her if she wanted it shaved. An interview and observation of Resident #36, on 07/25/19 at 9:18 AM, with CNA #1, revealed the resident had curled chin hair. With Resident #36's permission, CNA #1 extended the chin hairs from the curled position to straight and CNA #1 estimated the hairs to be approximately one (1) inch long. CNA #1 stated the hair appeared to not have been shaved for at least two (2) weeks. CNA #1 stated that she had been regularly assigned to Resident #36 and had not noticed the chin hair. CNA #1 stated that she really hadn't paid attention. CNA #1 confirmed it was her responsibility to assist the resident with bathing and personal hygiene, which would include shaving as needed. Resident #59 A review of Resident #59's comprehensive care plan revealed the resident had an ADL care plan with an onset date of 05/01/08, a goal and target date of 08/25/19, with an approach to dress, bathe, and groom daily, keep clean and neat. CNA was listed as staff responsible for completion of the approach. A review of Resident #59's current care plan revealed an ADL care plan with an onset date of 05/01/08, with an intervention to provide oral care every shift and observe for mouth pain/problems during oral care. There was no care plan addressing dental exams. An observation on 07/23/19 at 9:58 AM, revealed Resident #59 in her room lying in bed. The resident was not verbally responsive. The resident had a patch of hair visible on right side of chin approximately one (1) cm from the surface of her chin, curled. An observation on 07/24/19 at 10:09 AM, of Resident #59 in the day room area near the nurse's station, revealed Resident #59 seated in a Geri-chair. The resident's chin hair glistened as it caught the sunlight. A review of Resident #59's most recent quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/28/19, revealed Resident #59 is totally dependent on staff to take care of personal hygiene needs. An interview and observation on 07/25/19 at 09:23 AM, with CNA #1, revealed Resident #59 had curled chin hair. In order to measure the hair, CNA #1 extended the chin hairs from the curled position to straight and estimated the hairs to be approximately one (1) inch long. CNA #1 stated it had probably been at least a couple of weeks since the hair had been shaved, but she was unsure. CNA #1 stated that she had been regularly assigned to Resident #59 and really hadn't paid attention. CNA #1 confirmed it was her responsibility to assist the resident with bathing and personal hygiene, which would include shaving. An interview on 07/25/19 at 2:52 PM, with the Administrator and the Director of Nursing (DON) revealed it was expected that staff complete all tasks assigned to them. The DON stated hygiene tasks should be completed during daily baths and as needed and she expected staff to do their job everyday. The DON stated it was the responsibility of nursing staff to complete hygiene tasks and it was expected the tasks be completed per resident preferences. The DON stated grooming included shaving. The DON stated if residents were not shaved if it were their preference to be, the care plan was not followed. An interview on 07/25/19 at 03:50 PM, with Resident #59's brother, (FM #2), revealed before Resident #59 got sick she was a person who prided herself on her appearance. The brother stated the resident would not want to have facial hair present and would want the hair to be shaved or plucked out. An observation on 07/23/19 at 09:58 AM, revealed Resident #59 lying in bed in her room. The resident was not verbal and had dry, cracked skin on her lips, several teeth were missing, with her visible bottom teeth appearing jagged with dark areas of decay present. A review of Resident #59's record revealed no indication of a dental exam in the past year. A review of Resident #59's physician's orders [REDACTED]. On 7/25/19 at 04:51 PM, interview with DON revealed the resident had been seen by a dentist, taken by her son, but she couldn't remember when. The DON asked LPN #2 to call the resident's son to see when the resident went to the dentist. LPN #2 called the resident's son and he told her it was in (YEAR), and it was recommended some teeth be pulled and recommended the resident be sedated to do so, but the attending physician wouldn't approve the resident having the procedure due to her condition at the time, it was unsafe to sedate her. The DON stated the facility used to have a dentist who came in to the facility to examine teeth, but did not currently have anyone. The DON stated she didn't know if Resident #59 had a dental exam since (YEAR). Review of the archived medical record revealed Resident #59's dental visits dated 11/15/16 and 03/08/17. The 11/15/16 visit indicated the resident did not have a dental exam due to the resident refusing and being combative. The 03/08/17 visit indicated the resident was seen due to bleeding gums and had gingivitis. Plan was to re-evaluate wear, gingivitis, bleeding gums, and plaque during the next scheduled visit. The facility was unable to provide evidence that any visit had been scheduled since (YEAR). A review of Resident #59's most recent comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/18, revealed Resident #59 was assessed to have cavity or broken natural teeth, had a decreased ability to understand others or perform tasks, had poor dental health, obvious or likely cavities noted, and was dependent on staff for oral care. During an interview on 07/25/19 at 4:00 PM, the DON stated there was a care plan to provide oral care, but the care plan did not address dental visits or exams. The DON stated the care plan should be further developed to include regular dental exams for the resident to meet her needs. Resident #71 A review of Resident #71's comprehensive care plan revealed an ADL care plan with a problem onset date of 05/31/16, of Requires staff assistance for ADL's related to [MEDICAL CONDITION]/impaired mobility, contracted legs. Goals included Will be neat, clean, dressed, and groomed appropriately with an approach to be completed by the CNA of Bathe, dress, and groom. The care plan did not specifically address nails or nailcare. On 07/24/19 at 3:25 PM, Resident # 71 was observed in bed lying on the left side. The Resident's fingernails appeared approximately 0.75 cm from the nail bed and had build up of brown and reddish brown substances under the nails. Resident #71 stated the CNA told the nurse that his nails needed to be cut but the nurse came in and said she didn't think they needed to be cut. Resident #71 stated the substance was food built up. The resident stated he wasn't sure how long it had been since they had been cleaned, but buildup was thick and hard. On 07/25/19 at 9:13 AM, interview with Resident #71's sister revealed she often finds her brother's fingernails to be dirty and when she is here she usually tries to clean them. She stated the build up under the nails is so thick now he is complaining they hurt when she tried to clean them this morning. She stated the right hand is more of an issue than the left, because he eats with that hand. The resident stated because his nails are long, the food gets caught under them. The resident's fingernails were observed to have dirt under all nails. The resident stated a nurse came to look at the nails and said they didn't need cutting, so he just went along with it. He stated if they were shorter, they wouldn't pick up as much food under them. Resident #71 stated the nails were sore. An interview on 07/25/19 at 9:32 AM, with CNA #2, revealed she was regularly assigned to Resident #71. CNA #2 stated she had attempted to clean the resident's fingernails this morning but the resident complained they hurt, so she stopped. CNA #2 stated she reported it to the nurse and had told the nurse the resident wanted his nails trimmed. CNA #2 declined to answer if she believed the resident's nails should be trimmed but stated the resident liked to eat finger foods that tended to get under his fingernails. CNA #2 stated she did think if the resident's nails were shorter, they would stay cleaner and be easier to clean. An interview on 07/25/19 at 2:52 PM, with the Administrator and the Director of Nursing (DON), revealed it was expected that staff complete all tasks assigned to them. The DON stated grooming included cleaning nails. The DON stated if residents had dirty or long nails, the care plan was not followed. Resident #31 Record review of Resident #31's current comprehensive care plan revealed no care plan was developed for the change in medical condition which involved two (2) hospital transfers for vomiting blood and new MEDICATION ORDERS FOR [REDACTED] On 07/24/19 at 09:46 AM, an interview with Resident #31 revealed she had a recent hospital stay. On 7/24/19 at 4:01 PM, an interview with RN #1 confirmed there was no care plan developed for Resident #31 for the problem which resulted in hospital transfers and stays. RN # 1 confirmed Resident #31 has had episodes of vomiting blood and blood clots and should be care planned with interventions. RN #1 confirmed hand written orders were documented in the chart for two (2) transfers to the hospital for vomiting of blood. RN #1 revealed she is not sure if she every got a copy of the new orders or not. On 7/25/19 at 8:14 AM, an interview with the DON revealed the recent medical condition, where Resident #31 had episodes of vomiting blood clots and blood, should have been care planned, with interventions to address the change in condition. The DON revealed the nurses should update the paper care plans in the resident's charts with any changes or updates, then the Minimum Data Set (MDS) nurse updates the care plan in the computer. She stated that the MDS nurse should get the yellow copy of all new orders written and update the care plans from the new orders. Record review of the physician's orders [REDACTED]. Record review of the (MONTH) monthly physician's orders [REDACTED]. There was no care plan developed for the new orders and/or condition.

Based on observation, record review, resident trust fund review, cash transaction form review, receipt review, independent accountant report review, bank statement review, policy review, staff interviews, resident interviews, and responsible party (RP) interviews, the facility failed to hold, safeguard, manage and account for the personal funds of residents as evidenced by: (A.) the facility's failure to ensure resident funds were credited to the resident trust fund account when received, funds were withdrawn for credible resident needs, transaction forms were witnessed by persons at the time of the transaction, and resident accounts were audited for discrepancies for five (5) of 16 residents (Residents #1, #2, #6, #13, and #16) out of a total sample of 16 residents reviewed for misappropriation of Resident Trust Funds; and, (B.) the facility's failure to ensure resident funds were placed in an interest bearing account prior to June of 2013 for 16 of 16 residents reviewed (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16). This resulted in Immediate Jeopardy due to the likelihood of future personal financial loss and the associated mental anguish for residents. Findings include: A review of the facility's policy entitled "Resident Trust Fund Policies" stated, "1. Madison County Nursing Home (MCNH) will, upon written authorization by the resident or responsible party, accept responsibility for holding, safeguarding and accounting for the residents personal funds in an interest bearing account at a federally insured banking facility. The responsibility for the accuracy of the records remains with (facility initials)." Resident #6 Record review for Resident #6 revealed the resident was admitted on [DATE]. A review of Resident #6's Trust Fund Transaction List revealed there had been a withdrawal of $500.00 on 4/9/13 for "denture replacement". There was a withdrawal on 7/25/13 for $450.00 for "dentures and supplies". There was a withdrawal on 8/21/13 of $130.00 for "supplies clothing". There was a withdrawal on 8/26/13 for $290.00 for "dentures". There was a withdrawal of $240.00 for "hearing aid". Review of the report from the independent accounting firm revealed "11/2/12 - $10: ($10.00) Witnesses (names of two (2) facility staff persons) signatures are not consistent with master signature list." On 10/17/13 at 10:45 a.m., an observation and interview with Resident #6 revealed she was neat, clean and well groomed. The resident stated she had no problems with getting her money when she needed it. She stated she had taken some money out to get her bottom plate (bottom dentures) repaired and then again to get another bottom plate made. She stated she had taken out a little over $300.00 to get the bottom plate made, but the plate only cost $290.00, and she kept the rest of the money to buy some things she needed. She stated that her family buys all her clothes, and that she has never had a hearing aid. She revealed that someone had taken $450.00 out of her account, and she had never taken that amount out. When Resident # 6 was shown the Cash Transaction form dated 7/25/13 for the $450.00, she stated it was not her signature on the form. On 10/17/13 at 11:30 a.m., an interview with the facility's Administrator revealed Resident # 6's son had called on 10/15/13 asking about his mother's Trust Fund account. The son stated that things "just didn't look right". The Administrator stated when he looked at the account, he (Administrator) agreed that it did not look right. The Administrator then began an internal audit of the resident's trust fund which resulted in suspension of the Social Worker (SW) who was in charge of resident funds. The SW was subsequently terminated. On 10/23/13 at 10:05 a.m., an interview with Resident #6's son and Responsible Party (RP) revealed he had first noticed withdrawals from his mother's Trust Fund account which did not seem to be right on 10/15/13. He stated he had asked his mother about it, and they went to the bookkeeper to talk to him about it. Resident #6's son stated the Administrator told him the money in question would be returned to the Trust Fund. On 10/18/13 at 4:00 p.m., an interview with Licensed Practical Nurse (LPN) #1 revealed the Social Worker had requested her to sign on 10/14/13 as one of two needed witnesses a transaction form in the amount of $450.00 (which was dated 7/25/13) for Resident #6. She stated that she never saw the money change hands, but she did see the Social Worker coming from the hallway on 10/14/13 where Resident #6 lived and assumed the Social Worker had given the money to the resident at that time. LPN #1 stated it was the first time she had ever been a witness on a transaction form. When shown the form dated 7/25/13, she confirmed it was her signature but stated she doesn't remember signing anything prior to 10/14/13. The facility's policy at the time of the incident stated two (2) witness signatures were required for transactions but did not specify who could witness. On 10/22/13 at 1:30 p.m., an interview with the Social Worker revealed she had gone to work for the Nursing Home on November 1, 2011. She stated it was in her job description to manage the Resident Trust Fund. She stated that she had never been properly trained on the trust fund and just did the best that she knew how. She stated no one had ever told her that she had to have receipts for money she gave to the resident's families or for what the facility spent on residents out of their personal funds. She stated she had always had a witness for the actual exchange of money and she had never given money to cognitively impaired residents. She stated she had never given Resident #6 money for a hearing aid. At the end of the interview, the Social Worker gave a conflicting statement that not all transactions were witnessed. She stated she would find staff members to sign the witness portion of the Transaction form after she had already given money to the residents and/or family members. She stated she didn't know she was supposed to have a witness for each transaction. On 10/23/13 at 10:40 a.m., an interview with the Office Manager revealed when the Social Worker was hired, she (Office Manager) was the one to show the now terminated Social Worker how to manage the trust fund. She stated she told the previous Social Worker that she had to keep all receipts, even if it was for just a penny, and to make copies of everything she did associated with the trust fund. The Office Manager stated she would never give large amounts of cash to a resident without first talking to the resident's Responsible Party or their Power of Attorney to make sure it was okay for the resident to have the money. The Office Manager stated that from time to time, when the facility was between Social Workers, she had been responsible for the resident trust funds. On 10/24/13 at 10:30 a.m., an interview with the Bookkeeper confirmed that on 10/14/13, the Social Worker had approached him to sign as a second witness, a Cash Transaction Form in the amount of $450.00 for cash she stated that she had already given to Resident #6 on 7/25/13. He stated he did sign the form which was not the right thing to do. Resident #1 Record review for Resident #1 revealed the resident was admitted to the facility on [DATE]. A review of the Trust Fund Transaction List revealed a withdrawal on 7/29/13 in the amount of $100.00 with no documented purpose of why the money was withdrawn. On 10/14/13 at 2:35 p.m., an interview with LPN # 2 revealed Resident #1 does not get up anymore related to a recent decline. LPN #2 explained that the resident had previously handled his own money, but due to the decline he was no longer able to do so. She stated the resident has been bed bound since early July 2013, ate all meals in his room, and was fed by staff. The resident had good family support. A face to face interview attempted at the Attorney General's Office with the Attorney General (AG) Representative, the surveyor, and the Social Worker present on 10/22/13 at 1:30 p.m. revealed that after the AG Representative explained the consequences of any falsification, the Social Worker became defensive. The Social Worker's father entered and stated "This interview is over". The father of the social worker then told the social worker to get her "stuff" and leave. The surveyor was unable to interview the Social Worker any further related to any resident concerns. On 10/23/13 at 10:45 a.m., a telephone interview with Resident #1's family member revealed the withdrawal of $100.00 from the trust fund on 7/29/13 was not right. She stated to her knowledge, the resident had never received the $100.00. The RP was notified of the withdrawal of $100.00 from the trust fund on 7/29/13 during this interview. The RP stated the resident had not been able to manage his money since his decline four months ago. She stated that before the resident declined, he would ask for his $44.00 every month, but had no reason to get $100.00. She stated the facility did not give money to her, but would reimburse her for things she bought for the resident if she brought in a receipt. Resident #2 Record review for Resident #2 revealed the resident was admitted to the facility on [DATE]. A review of the Trust Fund Transaction List had a withdrawal on 8/21/13 of $55.00 for "supplies". There was no documentation of what supplies had been purchased with the funds. On 10/14/13 at 6:15 p.m., an interview with LPN # 3 revealed Resident #2 was not able to keep up with money due to her cognitive status. On 10/17/13 at 9:30 a.m., an interview with the Director of Nursing (DON) confirmed the resident lived on the Alzheimer's unit. The DON stated Resident #2 would not be able to request or to handle any money due to her cognitive impairment. On 10/18/13 at 3:15 p.m., an interview with the Activity Director revealed Resident #2 had gone on outings but she (Activity Director) only requested $25.00 for any resident outings. The Activity Director stated she had never requested $55.00 for Resident #2. When shown the Cash Transaction Form, dated 8/21/13, she stated "That's not my signature. I don't sign like that". On 10/18/13 at 3:45 p.m., an interview with the Activity Assistant revealed the signature on the Cash Transaction form dated 8/21/13 was not her signature. She stated she was left handed, and it didn't look anything like the way she signed. On 10/23/13 at 11:00 a.m., an interview with the family member of Resident #2 revealed she had been unaware of the withdrawal on 8/21/13. She stated she received the statements, but does not look at them closely. She stated that she had not requested any money or had not been reimbursed for any items she might have purchased for the resident. Resident #13 Record review for Resident #13 revealed the resident was admitted on [DATE]. A review of the Trust Fund Transaction List showed a withdrawal on 8/7/13 in the amount of $55.00. There was no documentation stating the reason for the withdrawal. On 10/18/13 at 2:45 p.m., a telephone interview with Resident #13's family member confirmed the facility does send him quarterly statements for the trust fund account for the resident. He stated on 8/7/13 the facility had reimbursed him $37.40 for shoes he had purchased for Resident #13. He stated he had noticed on the statement that on that same day, there had been a withdrawal of $55.00. He stated the $55.00 was not given to him. He stated he had wondered what it had been used for since he did not request it but he did not notify the facility of the questionable amount prior to the survey. On 10/18/13 at 4:30 p.m., an interview with the Director of Nursing confirmed Resident #13 would not be able to request or handle money due to her cognitive status. Resident #16 Record review for Resident #16 revealed the resident was admitted to the facility on [DATE]. A review of the Trust Fund Transaction List shows a withdrawal of $100.00 on 8/12/13. There was no supporting documentation stating the purpose for the withdrawal. On 10/17/13 at 2:00 p.m., an interview with Resident #16's Responsible Party (RP) revealed the resident has no family available to act as his contact. When he became unable to manage his money, she started helping him. She stated she had been his RP for quite a while. She stated she does receive his quarterly statements and had noticed a withdrawal on 8/12/13 for $100.00. She stated she had no idea what the money could have been used to purchase, but did not contact the facility. On 10/17/13 at 5:00 p.m., an interview with the DON revealed Resident #16 had cognitive deficits and would not be able to handle his own money. On 10/18/13 at 3:15 p.m. an interview with the Activity Director revealed Resident #16 did not go on outings. She stated she had never requested any money for him. A review of the "Independent Accountants' Report" completed on 10/18/13 revealed procedures had been performed to assist the facility in evaluating the compliance of the facility ' s policy and procedures with respect to expenditure transactions from the Resident Trust Fund. Problems identified were as follows: "We found there were numerous disbursements with insufficient or no supporting documentation." "Our inspection found numerous instances of inconsistent signatures by the residents and witnesses when compared to the master list and other disbursements." "We found a few expenditures and disbursements were not posted correctly. We also found a few disbursements that were posted to the residents' accounts that did not have any supporting documentation." Review of Resident Trust Fund Interest Payments: Review of the Resident Trust Fund Transaction List revealed there had been no interest payments credited to any of the 16 sampled residents' account until June of 2013, which included Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16. On 10/17/13 at 11:30 a.m., an interview with the facility's Administrator revealed the trust fund account used to be in an interest bearing account until the bank had called him and notified him that the bank would no longer pay interest on the account. He stated this was around September 1, 2011. He stated when he found out during the most recent Medicaid audit in May 2013 that the trust fund had to be in an interest bearing account he called the bank and told them the funds had to be in an interest bearing account. He stated the bank then started paying interest in June of 2013. The facility did not reimburse the residents for the lost interest from September 2011 through May 2013. A review of a statement the bank issued on 10/18/13 stated: "To whom it may concern: The above referenced checking account did not receive any interest from September 1, 2011 through May 31, 2013." The facility submitted an Acceptable Credible Allegation of Compliance on 10/23/13 which alleged removal of the Immediate Jeopardy on 10/23/13 at 12:00 p.m. "Credible Allegation of Compliance Resident Trust Fund Suspicious entries were noted by the Administrator in Resident #6's resident trust fund account on 10/16/13. An investigation was immediately opened by the Administrator on 10/16/13 and the Attorney General's Office and the MS State Department of Health (MSDH) were contacted by the Administrator that same day, 10/16/13. The Madison County Sheriff's Department was contacted by the Administrator on 10/18/13. The Social Worker who had operated the account from February 2012 to September 2013 was asked for a statement by the Administrator on 10/16/13. The Social Worker was suspended effective 10/16/13 due to suspicion of resident abuse, more specifically, exploitation. The Social Worker was terminated on 10/18/13. The facility completed and filed its written report detailing the results of its investigation regarding Resident #6 to the Attorney General's office and the MSDH at approximately 9 a.m. on 10/21/13. An outside, independent accounting firm not related to the facility was called in by the Administrator on 10/16/13 to review all Resident Trust Fund transactions from the last 12 months. A 100% audit of Resident #6's resident trust fund account was performed by the accounting firm on 10/16/13 through 10/18/13. A 100% audit of all Resident Fund cash transaction (RFCT) forms for Resident #6 from 2012 and 2013 was performed by the Administrator on 10/20/13 to verify the presence and authenticity of resident and witness signatures. The suspicious activity as to Resident #6's account appears to have begun in December 2012. Suspicious RFCT forms were pulled by the Administrator and reviewed with Resident #6 to verify authenticity. The facility issued a reimbursement to Resident #6's Resident Trust Fund account on 10/22/13 in the amount of $1,310 representing all transactions determined to be of suspicious nature or that could not be verified. All residents maintaining a resident trust fund account with the facility have the potential to be affected by this matter. A 100% audit of all resident trust fund account transactions dating back the past 12 months was performed by the outside, independent accounting firm on 10/16/13 through 10/18/13. The suspicious activity appears limited to the time period when the Social Worker was responsible for the Resident Trust Fund account, February 2012 through August 31, 2013. On 10/17/13, the Administrator and Director of Nursing began in-servicing all facility staff and contract employees on Resident Abuse with a focus on exploitation. This in-service covered Resident Abuse in general, the facility's abuse policy and the Mississippi Vulnerable Adults Act with focus given on exploitation. Any staff or contract employees that have not been in-serviced as of 10/18/13 will not be allowed to report to their work area until they have completed the in-service by the Administrator or DON. All staff and contract employees were in-serviced by the Administrator, Director of Nursing and Compliance Officer on 10/21/13 regarding corporate compliance, fraud and abuse, including recognizing and reporting fraud and abuse and the updated Resident Trust Fund Policy. Any staff or contract employees that have not been in-serviced as of 10/21/13 will not be allowed to report to their work area until they have completed the in-service. A new Resident Trust Fund Manager (RTFM) was appointed by the Administrator effective immediately on 10/21/13. A criminal background check on the RTFM was performed on 10/21/13. The Administrator instructed the RTFM on the new Resident Trust Fund policy and RFCT form requirements on 10/21/13. A copy of the new policy and RFCT form are attached hereto. The updated Resident Trust Fund Policy was completed and implemented effective immediately on 10/21/13 to show that the Resident Trust Fund Manager (RTFM) is responsible for the Resident Trust Fund. Any time a Resident Fund cash transaction (RFCT) is made, a written authorization must be signed by the RTFM, the resident and/or power of attorney, and two witnesses from the facility's approved resident trust fund witness list who will witness the RFCT. Only designated witnesses may witness RFCT. On 10/21/13, the Administrator designated three individuals as weekday designated witnesses and 3 individuals as weekend designated witnesses. Effective 10/21/13, the Administrator will send a written statement reflecting any resident funds that the facility has deposited in an interest bearing account to each resident's responsible party on a quarterly basis. Effective 10/21/13, the Administrator will also balance the Resident Trust Fund to the bank statement monthly. Effective 10/21/13, the Compliance Officer at MCNH (initials for the name of the facility) will perform monthly random audits of Resident Trust Fund accounts to verify the authenticity of all disbursements and verify the presence and authenticity of all required signatures on disbursement authorization forms, receipts, and/or any other documentation involved in RFCT. Any problems noted will be immediately reported to the Quality Assurance Committee (QAC). All other audit findings will be reported to the QAC at least quarterly. All staff was in-serviced on the new revised policy by the Administrator on 10/21/13. Any staff or contract employees that have not been in-serviced on the new policy as of 10/21/13 will not be allowed to report to their work area until they have completed the in-service by the Administrator or DON. The Resident Fund Cash Transaction Form (RFCT) was updated on 10/21/13. A list of approved RFCT witnesses for the day shift and weekends was created by the Administrator on 10/21/13. The Administrator obtained a signature list with each designated RFCT witness on 10/21/13. Effective 10/21/13, the signature list shall be maintained in the RTFM's office. All members of the Quality Assurance Committee (QAC) met on 10/18/13 and on 10/21/13 to review and discuss the matter and all proposed corrective actions. The QAC has reviewed and approved the updated Resident Trust Fund policy and RFCT form on 10/21/13. On 10/23/13, I (Administrator) spoke to a representative with the Division of Medicaid to inform him that there were discrepancies in our Resident Trust Fund and a completed report would be filed with him. The Immediate Jeopardy was removed on 10/23/13 at noon." State Agency Validation - On 10/24/13, the surveyor validated that as of 10/23/13, the facility had implemented the following measures to remove the immediate jeopardy: 1. Reviewed documentation where the facility had refunded back to the trust fund for Resident #6 in the amount of $1,310.00 on 10/22/13. 2. Reviewed documentation that the facility suspended the Social Worker on 10/15/13 and terminated the Social Worker on 10/18/13. 3. Reviewed documentation that the facility notified the Mississippi State Department of Health and the State Attorney General's office on 10/16/13 of the misappropriation of resident funds and to meet the 24 hour reporting requirement. 4. Reviewed documentation that the facility notified the County Sheriff's department on 10/18/13 of the misappropriation of resident funds and to meet the 24 hour reporting requirement. 5. Reviewed documentation that the facility contracted with an independent accounting firm to review all trust fund transactions for the last 12 months. 6. Reviewed the documentation that the facility in-serviced facility staff and contract staff on 10/17/13 and 10/21/13 regarding corporate compliance, fraud and abuse, including recognizing and reporting fraud and abuse and the updated Resident Trust Fund Policy. No staffs were allowed to work until in-serviced. 7. The surveyor interviewed 50 staff members from all disciplines to validate the content of the in-service presented on 10/17/13 and 10/21/13. 8. The surveyor reviewed and evaluated the following policies: 1) Revised Trust Fund Policy; 2) Resident Rights; 3) Abuse, Neglect and Misappropriation. 9. Reviewed documentation that the facility appointed a new Trust Fund Manager on 10/21/13 and designated specific staff members who would be allowed to sign as witnesses for future transactions of the trust fund. 10. Reviewed documentation that the Trust Fund Accounts had been audited by the Bookkeeper with the discrepancies identified and reported. 11. Reviewed documentation that the facility held an emergency meeting of the Quality Assurance Committee on 10/18/13 and 10/21/13 to review and discuss the matter and all proposed corrective actions. The facility reported that the QA Committee approved the updated Resident Trust Fund policy on 10/21/13. 12. Reviewed documentation that the facility spoke with a representative with the Division of Medicaid on 10/23/13 to inform the agency of the discrepancies in the Resident Trust Fund.

Based on observation, record review, resident trust fund review, cash transaction form review, receipt review, independent accountant report review, bank statement review, policy review, staff interviews, resident interviews, and responsible party (RP) interviews, the facility failed to protect residents from misappropriation of their funds by failing to properly manage Resident Trust Fund Accounts for five (5) of 16 residents (Resident #1, #2, #6, #13, and #16) reviewed for misappropriation out of a total sample of 16. This resulted in Immediate Jeopardy due to the likelihood of mental anguish associated with this loss of resident funds. Findings include: Review of the facility's policy entitled "Abuse Policy & Procedure" (no date) revealed "All Employees will be TRAINED through orientation and periodic in-services about: What constitutes abuse, neglect, and misappropriation of resident property." The facility's "Abuse Policy & Procedure" included a page summarizing "Vulnerable Adults Act" which stated, "Per Mississippi law, the following situations are considered CRIMES OF ABUSE against vulnerable adults. This list is not all inclusive: 5. Theft or misuse of a resident's personal belongings, personal funds, or bank accounts". Resident #6 Upon review of Resident #6's Trust Fund Transaction List, it was discovered that there had been the following withdrawals made to the account: $500.00 on 4/9/13 for "denture replacement", $450.00 on 7/25/13 for "dentures and supplies", $130.00 on 8/21/13 for "supplies clothing", $290.00 on 8/26/13 for "dentures", and another $240.00 on 8/26/13 for "hearing aid". Investigation revealed the resident does not wear hearing aids. Upon review of the report from the independent accounting firm it was noted that on 11/2/12, two (2) witness signatures for $10.00 taken from Resident #6's account were not consistent with the master signature list. An interview and observation on 10/17/13 at 10:45 a.m., revealed Resident #6 stated she had taken some money out to get her bottom plate (denture) repaired and then again to get another bottom plate made. She stated she had taken out a little over $300.00 to get the bottom plate made but the plate only cost $290.00. She stated she kept the remaining $10 to buy some things she needed. She stated that her family buys all her clothes and that she has never had a hearing aid. She revealed that someone had taken $450.00 out of her account and that she had never taken that amount out. Resident #6 stated it was not her signature on the Cash Transaction form dated 7/25/13 for the $450.00. During an interview with the facility's Administrator on 10/17/13 at 11:30 a.m., it was revealed the facility was notified on 10/15/13 by Resident #6's son that his mother's Trust Fund Account just didn't look right. The Administrator stated he began an investigation and agreed that it did not look right. The Administrator stated an audit was initiated at that time. An interview on 10/23/13 at 10:05 a.m., with Resident #6's son and Responsible Party revealed he noticed withdrawals from his mother's Trust Fund account which did not seem to be right. He stated he had asked his mother about it, and they went to the Bookkeeper to talk to him about it on 10/15/13. Resident #6's son stated the Administrator told him the money would be returned to the Trust Fund. Record review revealed Resident #6 was admitted on [DATE]. A review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/25/13, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. This MDS coded that Resident #6 did not require the use of a hearing aid. Resident # 1 A review of the Trust Fund Transaction Lists revealed a withdrawal on 7/29/13 in the amount of $100.00 with no documentation of the purpose of the withdrawal. LPN #2 revealed in an interview on 10/14/13 at 2:35 p.m. that Resident #1 does not get out of bed anymore related to a recent decline. She stated the resident had been bed bound since early July 2013 and required total care. On 10/23/13 at 10:45 a.m. a telephone interview with Resident #1's family member revealed the withdrawal of $100.00 from the resident's trust fund on 7/29/13 was not right since the resident had not been able to manage his money since his decline four (4) months ago. She stated that before the decline, the resident would ask for $44.00 every month, but had no reason to get $100.00. She stated to her knowledge, the resident had never received the $100.00. Record review for Resident #1 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 had been placed on hospice services. A review of the current Minimum Data Set, with an Assessment Reference Date of 9/16/13, showed the resident had a Brief Interview for Mental Status score of 7, which indicated Resident #1 had moderate cognitive impairment due to a decline in health status. Resident #2 A review of Resident #2's Trust Fund Transaction List revealed a withdrawal on 8/21/13 of $55.00 for "supplies". There was no documentation of supplies being purchased. An interview on 10/14/13 at 6:15 p.m. with LPN # 3 revealed Resident #2 was not able to keep up with money due to cognitive status. The Director of Nursing (DON) confirmed in an interview on 10/17/13 at 9:30 a.m. that the Resident #2 would not be able to request or to handle any money due to her cognitive impairment. An interview with the Activity Director on 10/18/13 at 3:15 p.m. revealed Resident # 2 had gone on outings where $25.00 was requested for any resident outings. She stated she had never requested $55.00 for Resident #2's outings. An interview with the family member of Resident #2 on 10/23/13 at 11:00 a.m. revealed the family member had been unaware of the withdrawal on 8/21/13. She stated she received the statements but did not look at them closely. She denied that she had requested any money or had been reimbursed for any items she might have purchased for the resident. Record review for Resident #2 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the current Minimum Data Set, with an Assessment Reference Date of 8/27/13, revealed a Brief Interview for Mental Status score of 8, which indicated the resident had moderate cognitive impairment. Resident #2 resided on the Alzheimer's Unit. Resident #13 Review of the Trust Fund Transaction List showed a fund withdrawal on 8/7/13 in the amount of $55.00 without documentation to support the withdrawal. A telephone interview with Resident #13's family member on 10/18/13 at 2:45 p.m. confirmed that he had noticed on the statement that on that same day (8/7/13), there had been a withdrawal of $55.00. He stated the $55.00 was not given to him, and he had wondered what it had been used for since he did not request it. An interview on 10/18/13 at 4:30 p.m. with the DON confirmed Resident #13 would not be able to request or handle money due to her cognitive status. Record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the current Minimum Data Set, with an Assessment Reference Date of 8/23/13, had a Brief Interview for Mental Status score of 5, which indicated severe cognitive impairment. Resident #13 resided on the Alzheimer's Unit. Resident # 16 A review of the Trust Fund Transaction List showed a withdrawal of $100.00 on 8/12/13 from Resident #16's account with no supporting documentation for the withdrawal. On 10/17/13 at 2:00 p.m., an interview with Resident #16's Responsible Party (RP) revealed the resident has no family available to act as his contact. She stated she had been his RP for quite a while when he became unable to manage his money she started helping him. She stated she received his quarterly statements and had noticed a withdrawal on 8/12/13 for $100.00, but she did not know why the withdrawal was made. She confirmed the resident was not able to handle his money and had not been able to for a long time. The DON revealed on 10/17/13 at 5:00 p.m. in an interview that Resident #16 had cognitive deficits and would not be able to handle his own money. During an interview with the Activity Director on 10/18/13 at 3:15 p.m., she revealed Resident #16 does not go on outings. She stated she had never requested any money be drawn out of his resident funds. Record review for Resident #16 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the current Minimum Data Set, with an Assessment Reference Date of 7/30/13, revealed a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. The facility submitted an Acceptable Credible Allegation of Compliance on 10/23/13 which alleged removal of the Immediate Jeopardy on 10/23/13 at 12:00 p.m. "Credible Allegation of Compliance Resident Trust Fund Suspicious entries were noted by the Administrator in Resident #6's resident trust fund account on 10/16/13. An investigation was immediately opened by the Administrator on 10/16/13 and the Attorney General's Office and the MS State Department of Health (MSDH) were contacted by the Administrator that same day, 10/16/13. The Madison County Sheriff's Department was contacted by the Administrator on 10/18/13. The Social Worker who had operated the account from February 2012 to September 2013 was asked for a statement by the Administrator on 10/16/13. The Social Worker was suspended effective 10/16/13 due to suspicion of resident abuse, more specifically, exploitation. The Social Worker was terminated on 10/18/13. The facility completed and filed its written report detailing the results of its investigation regarding Resident #6 to the Attorney General's office and the MSDH at approximately 9 a.m. on 10/21/13. An outside, independent accounting firm not related to the facility was called in by the Administrator on 10/16/13 to review all Resident Trust Fund transactions from the last 12 months. A 100% audit of Resident #6's resident trust fund account was performed by the accounting firm on 10/16/13 through 10/18/13. A 100% audit of all Resident Fund cash transaction (RFCT) forms for Resident #6 from 2012 and 2013 was performed by the Administrator on 10/20/13 to verify the presence and authenticity of resident and witness signatures. The suspicious activity as to Resident #6's account appears to have begun in December 2012. Suspicious RFCT forms were pulled by the Administrator and reviewed with Resident #6 to verify authenticity. The facility issued a reimbursement to Resident #6's Resident Trust Fund account on 10/22/13 in the amount of $1,310 representing all transactions determined to be of suspicious nature or that could not be verified. All residents maintaining a resident trust fund account with the facility have the potential to be affected by this matter. A 100% audit of all resident trust fund account transactions dating back the past 12 months was performed by the outside, independent accounting firm on 10/16/13 through 10/18/13. The suspicious activity appears limited to the time period when the Social Worker was responsible for the Resident Trust Fund account, February 2012 through August 31, 2013. On 10/17/13, the Administrator and Director of Nursing began in-servicing all facility staff and contract employees on Resident Abuse with a focus on exploitation. This in-service covered Resident Abuse in general, the facility's abuse policy and the Mississippi Vulnerable Adults Act with focus given on exploitation. Any staff or contract employees that have not been in-serviced as of 10/18/13 will not be allowed to report to their work area until they have completed the in-service by the Administrator or DON. All staff and contract employees were in-serviced by the Administrator, Director of Nursing and Compliance Officer on 10/21/13 regarding corporate compliance, fraud and abuse, including recognizing and reporting fraud and abuse and the updated Resident Trust Fund Policy. Any staff or contract employees that have not been in-serviced as of 10/21/13 will not be allowed to report to their work area until they have completed the in-service. A new Resident Trust Fund Manager (RTFM) was appointed by the Administrator effective immediately on 10/21/13. A criminal background check on the RTFM was performed on 10/21/13. The Administrator instructed the RTFM on the new Resident Trust Fund policy and RFCT form requirements on 10/21/13. A copy of the new policy and RFCT form are attached hereto. The updated Resident Trust Fund Policy was completed and implemented effective immediately on 10/21/13 to show that the Resident Trust Fund Manager (RTFM) is responsible for the Resident Trust Fund. Any time a Resident Fund cash transaction (RFCT) is made, a written authorization must be signed by the RTFM, the resident and/or power of attorney, and two witnesses from the facility's approved resident trust fund witness list who will witness the RFCT. Only designated witnesses may witness RFCT. On 10/21/13, the Administrator designated three individuals as weekday designated witnesses and 3 individuals as weekend designated witnesses. Effective 10/21/13, the Administrator will send a written statement reflecting any resident funds that the facility has deposited in an interest bearing account to each resident's responsible party on a quarterly basis. Effective 10/21/13, the Administrator will also balance the Resident Trust Fund to the bank statement monthly. Effective 10/21/13, the Compliance Officer at MCNH (initials for the name of the facility) will perform monthly random audits of Resident Trust Fund accounts to verify the authenticity of all disbursements and verify the presence and authenticity of all required signatures on disbursement authorization forms, receipts, and/or any other documentation involved in RFCT. Any problems noted will be immediately reported to the Quality Assurance Committee (QAC). All other audit findings will be reported to the QAC at least quarterly. All staff was in-serviced on the new revised policy by the Administrator on 10/21/13. Any staff or contract employees that have not been in-serviced on the new policy as of 10/21/13 will not be allowed to report to their work area until they have completed the in-service by the Administrator or DON. The Resident Fund Cash Transaction Form (RFCT) was updated on 10/21/13. A list of approved RFCT witnesses for the day shift and weekends was created by the Administrator on 10/21/13. The Administrator obtained a signature list with each designated RFCT witness on 10/21/13. Effective 10/21/13, the signature list shall be maintained in the RTFM's office. All members of the Quality Assurance Committee (QAC) met on 10/18/13 and on 10/21/13 to review and discuss the matter and all proposed corrective actions. The QAC has reviewed and approved the updated Resident Trust Fund policy and RFCT form on 10/21/13. On 10/23/13, I (Administrator) spoke to a representative with the Division of Medicaid to inform him that there were discrepancies in our Resident Trust Fund and a completed report would be filed with him. The Immediate Jeopardy was removed on 10/23/13 at noon." State Agency Validation - On 10/24/13, the surveyor validated that as of 10/23/13, the facility had implemented the following measures to remove the immediate jeopardy: State Agency Validation - On 10/24/13, the surveyor validated that as of 10/23/13, the facility had implemented the following measures to remove the immediate jeopardy: 1. Reviewed documentation where the facility had refunded back to the trust fund for Resident #6 in the amount of $1,310.00 on 10/22/13. 2. Reviewed documentation that the facility suspended the Social Worker on 10/15/13 and terminated the Social Worker on 10/18/13. 3. Reviewed documentation that the facility notified the Mississippi State Department of Health and the State Attorney General's office on 10/16/13 of the misappropriation of resident funds and to meet the 24 hour reporting requirement. 4. Reviewed documentation that the facility notified the County Sheriff's department on 10/18/13 of the misappropriation of resident funds and to meet the 24 hour reporting requirement. 5. Reviewed documentation that the facility contracted with an independent accounting firm to review all trust fund transactions for the last 12 months. 6. Reviewed the documentation that the facility in-serviced facility staff and contract staff on 10/17/13 and 10/21/13 regarding corporate compliance, fraud and abuse, including recognizing and reporting fraud and abuse and the updated Resident Trust Fund Policy. No staffs were allowed to work until in-serviced. 7. The surveyor interviewed 50 staff members from all disciplines to validate the content of the in-service presented on 10/17/13 and 10/21/13. 8. The surveyor reviewed and evaluated the following policies: 1) Revised Trust Fund Policy; 2) Resident Rights; 3) Abuse, Neglect and Misappropriation. 9. Reviewed documentation that the facility appointed a new Trust Fund Manager on 10/21/13 and designated specific staff members who would be allowed to sign as witnesses for future transactions of the trust fund. 10. Reviewed documentation that the Trust Fund Accounts had been audited by the Bookkeeper with the discrepancies identified and reported. 11. Reviewed documentation that the facility held an emergency meeting of the Quality Assurance Committee on 10/18/13 and 10/21/13 to review and discuss the matter and all proposed corrective actions. The facility reported that the QA Committee approved the updated Resident Trust Fund policy on 10/21/13. 12. Reviewed documentation that the facility spoke with a representative with the Division of Medicaid on 10/23/13 to inform the agency of the discrepancies in the Resident Trust Fund.

Based on observation, resident trust fund review, cash transaction form review, independent accountant report review, bank statement review, and staff interview, the facility failed to be administered in a manner to maintain the highest practicable mental and psychosocial well-being of the residents as evidenced by the failure to ensure resident funds were credited to the resident trust fund account and withdrawn for credible resident needs, transaction forms were witnessed by persons at the time of the transaction, and resident accounts were audited for discrepancies for five (5) of 16 residents (Residents #1, #2, #6, #13, and #16), and for 16 of 16 residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16) for not having interest bearing accounts between September 2011 to June 2013 out of a total sample of 16 residents. This resulted in Immediate Jeopardy due to the likelihood of mental and psychosocial anguish associated with the loss of funds. Findings include: Cross refer to F-159 for failure of the facility to ensure that the Resident Trust Fund was properly managed to prevent the misappropriation of resident funds for five (5) of 16 sampled residents (Residents #1, #2, #6, #13 and #16) and not having interest bearing accounts prior to June 2013 (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16). Cross refer to F-224 for failure of the facility to protect residents from misappropriation of funds by failing to properly manage the Resident Trust Fund for five (5) of 16 sampled residents (Residents #1, #2, #6, #13 and #16). Review of the Trust Fund policy revealed proper procedures were not followed in regard to having two witnesses sign at the time of withdrawal to ensure cash disbursements were given to the resident and for failure to obtain receipts of items purchased by the facility and/or family member for the residents. A review of the "Independent Accountants' Report" revealed procedures had been performed to assist the facility in evaluating the compliance of policy and procedures with respect to expenditure transactions from the Resident Trust Fund. Problems found were as follows: "We found there were numerous disbursements with insufficient or no supporting documentation. Our inspection found numerous instances of inconsistent signatures by the resident and the witness signatures. We found several disbursements where proper procedures were proper procedures were not adhered to. We found a few expenditures and disbursements were not posted correctly. We also found a few disbursements that were posted to the residents account, but did not have any supporting documentation." Review of the Resident Trust Fund Transaction List revealed no interest payments were credited until June of 2013 to any resident's account which included sampled residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16). An interview with the facility's Administrator on 10/17/13 at 11:30 a.m. revealed the residents' accounts were in an interest bearing account until the bank informed him in September 2011 that the bank would no longer pay interest on the account. He stated that he found out in May 2013 during a Medicaid audit that the trust fund had to be in an interest bearing account. The Administrator stated he called the bank at that time to explain the funds had to be in an interest bearing account. He revealed the bank started paying interest again in June of 2013. During the Administrator interview on 10/17/13 at 11:30 a.m., the Administrator stated he was unaware of the missing funds until the surveyor arrived to investigate the complaint. He stated that he then "immediately" started an internal audit and when he discovered inconsistencies with resident funds, he called for an external audit. The Administrator then stated he reported to the appropriate entities after the results of the audit. The Administrator stated he was in charge of reconciling the bank statements with the checkbook every month, but he never audited the Social Worker's transactions to ensure she was properly managing the Residents' Trust Fund Account. Interview with the Administrator by phone on 11/12/13 at 1:54 p.m. revealed he and the Bookkeeper were responsible for overseeing and balancing the resident trust fund account. The Administrator confirmed there was no consultant to perform external audits. A review of a statement issued on 10/18/13 by the bank stated: "To whom it may concern: The above referenced checking account did not receive any interest from September 1, 2011 through May 31, 2013." The facility did not reimburse the residents for the lost interest. A review of the facility's document entitled "Resident Trust Fund Policies" stated "1. Madison County Nursing Home (MCNH) will, upon written authorization by the resident or responsible party, accept responsibility for holding, safeguarding and accounting for the residents personal funds in an interest bearing account at a federally insured banking facility. The responsibility for the accuracy of the records remains with MCNH." "Credible Allegation of Compliance Resident Trust Fund Suspicious entries were noted by the Administrator in Resident #6's resident trust fund account on 10/16/13. An investigation was immediately opened by the Administrator on 10/16/13 and the Attorney General's Office and the MS State Department of Health (MSDH) were contacted by the Administrator that same day, 10/16/13. The Madison County Sheriff's Department was contacted by the Administrator on 10/18/13. The Social Worker who had operated the account from February 2012 to September 2013 was asked for a statement by the Administrator on 10/16/13. The Social Worker was suspended effective 10/16/13 due to suspicion of resident abuse, more specifically, exploitation. The Social Worker was terminated on 10/18/13. The facility completed and filed its written report detailing the results of its investigation regarding Resident #6 to the Attorney General's office and the MSDH at approximately 9 a.m. on 10/21/13. An outside, independent accounting firm not related to the facility was called in by the Administrator on 10/16/13 to review all Resident Trust Fund transactions from the last 12 months. A 100% audit of Resident #6's resident trust fund account was performed by the accounting firm on 10/16/13 through 10/18/13. A 100% audit of all Resident Fund cash transaction (RFCT) forms for Resident #6 from 2012 and 2013 was performed by the Administrator on 10/20/13 to verify the presence and authenticity of resident and witness signatures. The suspicious activity as to Resident #6's account appears to have begun in December 2012. Suspicious RFCT forms were pulled by the Administrator and reviewed with Resident #6 to verify authenticity. The facility issued a reimbursement to Resident #6's Resident Trust Fund account on 10/22/13 in the amount of $1,310 representing all transactions determined to be of suspicious nature or that could not be verified. All residents maintaining a resident trust fund account with the facility have the potential to be affected by this matter. A 100% audit of all resident trust fund account transactions dating back the past 12 months was performed by the outside, independent accounting firm on 10/16/13 through 10/18/13. The suspicious activity appears limited to the time period when the Social Worker was responsible for the Resident Trust Fund account, February 2012 through August 31, 2013. On 10/17/13, the Administrator and Director of Nursing began in-servicing all facility staff and contract employees on Resident Abuse with a focus on exploitation. This in-service covered Resident Abuse in general, the facility's abuse policy and the Mississippi Vulnerable Adults Act with focus given on exploitation. Any staff or contract employees that have not been in-serviced as of 10/18/13 will not be allowed to report to their work area until they have completed the in-service by the Administrator or DON. All staff and contract employees were in-serviced by the Administrator, Director of Nursing and Compliance Officer on 10/21/13 regarding corporate compliance, fraud and abuse, including recognizing and reporting fraud and abuse and the updated Resident Trust Fund Policy. Any staff or contract employees that have not been in-serviced as of 10/21/13 will not be allowed to report to their work area until they have completed the in-service. A new Resident Trust Fund Manager (RTFM) was appointed by the Administrator effective immediately on 10/21/13. A criminal background check on the RTFM was performed on 10/21/13. The Administrator instructed the RTFM on the new Resident Trust Fund policy and RFCT form requirements on 10/21/13. A copy of the new policy and RFCT form are attached hereto. The updated Resident Trust Fund Policy was completed and implemented effective immediately on 10/21/13 to show that the Resident Trust Fund Manager (RTFM) is responsible for the Resident Trust Fund. Any time a Resident Fund cash transaction (RFCT) is made, a written authorization must be signed by the RTFM, the resident and/or power of attorney, and two witnesses from the facility's approved resident trust fund witness list who will witness the RFCT. Only designated witnesses may witness RFCT. On 10/21/13, the Administrator designated three individuals as weekday designated witnesses and 3 individuals as weekend designated witnesses. Effective 10/21/13, the Administrator will send a written statement reflecting any resident funds that the facility has deposited in an interest bearing account to each resident's responsible party on a quarterly basis. Effective 10/21/13, the Administrator will also balance the Resident Trust Fund to the bank statement monthly. Effective 10/21/13, the Compliance Officer at MCNH (initials for the name of the facility) will perform monthly random audits of Resident Trust Fund accounts to verify the authenticity of all disbursements and verify the presence and authenticity of all required signatures on disbursement authorization forms, receipts, and/or any other documentation involved in RFCT. Any problems noted will be immediately reported to the Quality Assurance Committee (QAC). All other audit findings will be reported to the QAC at least quarterly. All staff was in-serviced on the new revised policy by the Administrator on 10/21/13. Any staff or contract employees that have not been in-serviced on the new policy as of 10/21/13 will not be allowed to report to their work area until they have completed the in-service by the Administrator or DON. The Resident Fund Cash Transaction Form (RFCT) was updated on 10/21/13. A list of approved RFCT witnesses for the day shift and weekends was created by the Administrator on 10/21/13. The Administrator obtained a signature list with each designated RFCT witness on 10/21/13. Effective 10/21/13, the signature list shall be maintained in the RTFM's office. All members of the Quality Assurance Committee (QAC) met on 10/18/13 and on 10/21/13 to review and discuss the matter and all proposed corrective actions. The QAC has reviewed and approved the updated Resident Trust Fund policy and RFCT form on 10/21/13. On 10/23/13, I (Administrator) spoke to a representative with the Division of Medicaid to inform him that there were discrepancies in our Resident Trust Fund and a completed report would be filed with him. The Immediate Jeopardy was removed on 10/23/13 at noon." State Agency Validation - On 10/24/13, the surveyor validated that as of 10/23/13, the facility had implemented the following measures to remove the immediate jeopardy: State Agency Validation - On 10/24/13, the surveyor validated that as of 10/23/13, the facility had implemented the following measures to remove the immediate jeopardy: 1. Reviewed documentation where the facility had refunded back to the trust fund for Resident #6 in the amount of $1,310.00 on 10/22/13. 2. Reviewed documentation that the facility suspended the Social Worker on 10/15/13 and terminated the Social Worker on 10/18/13. 3. Reviewed documentation that the facility notified the Mississippi State Department of Health and the State Attorney General's office on 10/16/13 of the misappropriation of resident funds and to meet the 24 hour reporting requirement. 4. Reviewed documentation that the facility notified the County Sheriff's department on 10/18/13 of the misappropriation of resident funds and to meet the 24 hour reporting requirement. 5. Reviewed documentation that the facility contracted with an independent accounting firm to review all trust fund transactions for the last 12 months. 6. Reviewed the documentation that the facility in-serviced facility staff and contract staff on 10/17/13 and 10/21/13 regarding corporate compliance, fraud and abuse, including recognizing and reporting fraud and abuse and the updated Resident Trust Fund Policy. No staffs were allowed to work until in-serviced. 7. The surveyor interviewed 50 staff members from all disciplines to validate the content of the in-service presented on 10/17/13 and 10/21/13. 8. The surveyor reviewed and evaluated the following policies: 1) Revised Trust Fund Policy; 2) Resident Rights; 3) Abuse, Neglect and Misappropriation. 9. Reviewed documentation that the facility appointed a new Trust Fund Manager on 10/21/13 and designated specific staff members who would be allowed to sign as witnesses for future transactions of the trust fund. 10. Reviewed documentation that the Trust Fund Accounts had been audited by the Bookkeeper with the discrepancies identified and reported. 11. Reviewed documentation that the facility held an emergency meeting of the Quality Assurance Committee on 10/18/13 and 10/21/13 to review and discuss the matter and all proposed corrective actions. The facility reported that the QA Committee approved the updated Resident Trust Fund policy on 10/21/13. 12. Reviewed documentation that the facility spoke with a representative with the Division of Medicaid on 10/23/13 to inform the agency of the discrepancies in the Resident Trust Fund.