Every finding on record at Murfreesboro Rehab and Nursing, Inc.

Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to ensure residents were protected from exploitation and failed to ensure resident funds were protected from misappropriation for four (Resident #5, #8, #9, and #10) of five residents reviewed for misappropriation of resident funds.It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The immediate Jeopardy (IJ) was related to CFR S483.12(Freedom from Abuse, Neglect, and Exploitation) at a scope and severity of K. The IJ began on 07/30/2025, when facility staff opened and deposited a check belonging to Resident #5 into a bank account belonging to the facility without the resident's knowledge or permission, and utilized the funds belonging to Resident #5 for facility purposes. The Administrator and Director of Nursing (DON) were notified of IJ on 05/06/2026 at 1:25 PM. A removal plan was requested, but an acceptable plan of removal has not been provided to the State Agency, and the facility remains in IJ status.The findings include: Resident #5 Review of a Clinical Resident Profile, indicated the facility admitted Resident #5 to the facility on [DATE] with diagnoses that included narrowing of the lumbar spinal canal with pain, weakness in the legs, incomplete spinal cord injury at the seventh cervical vertebrae, and adjustment disorder. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/18/2026, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #5 required set up and clean up assistance with eating and oral hygiene; was independent with toileting, bathing and upper body dressing; required partial to moderate assistance with lower body dressing and personal hygiene; required substantial to maximum assistance with putting on and taking off footwear. Resident #5 required substantial and maximum assistance to stand from a sitting position and transfer from chair to bed; required partial to moderate assistance transferring to and from toilet; was independent rolling left to right, sitting on side of bed to laying position, and moving from laying position to sitting on side of the bed. Resident #5 utilized a wheelchair for mobility.Review of Resident #5's Care Plan Report, initiated on 06/13/2025, revealed the resident was independent for meeting emotional, intellectual, physician and social needs. Interventions included: notifying resident of preferred activities, converse with resident to degree of intellectual functioning, and invite the resident to participate in all activities. Potential for adverse reaction to psychotropic medication. History of adjustment disorder with depressed mood. Monitor and document side effects including depression, hopelessness, negative statements, changes in appetite, and emotional distress. Notify MD of resident withdrawal from social interaction.Review of an attorney hearing reminder letter dated 07/10/2024, located in Resident #5's electronic health record, indicated Resident #5 had a Social Security Hearing scheduled for 10/22/2024 at 2:00 PM.Review of the front and back of a United States Treasury check, received by the facility, was dated 07/25/2025, payable to Resident #5 in care of the facility, in the amount of $56,481.00 dollars, had a notation in the bottom left that indicated SOC SEC FOR INS. The back of the check included an endorsement Pay to the Order of [name of bank with account number] For Deposit Only [facility name] [account number].Review of the facility's July 2025 Bank Statement [Name of Bank and account number] revealed a deposit on 07/30/2025 in the amount of $56,481.00. No image was shown. Account balance at the time of the deposit was $16.83. Overdraft item fees year to date for this period were $320.00, and Total Year to Date was $1984.00. Return fees to date for this period was $0.00, and Total Year to Date was $160.00.Review of a Progress Note dated 09/18/2025 at 1:53 PM, revealed Resident #5 felt depressed, and was concerned about their physical disability and felt as if social security was clueless.Review of a Progress Note, communication with physician, dated 09/23/2025 at 9:24 AM, indicated Resident #5 voiced and showed increased symptoms of depression. The physician increased Resident #5's antidepressant.Review of an Order Summary Report, revealed Resident #5 had medication that included [an antidepressant] 1 tablet by mouth daily related to adjustment disorder with depressed mood, with an end date of 03/04/2025. [An antidepressant] 1.5 tablet by mouth daily related to adjustment disorder with depressed mood, with an order date of 09/23/2025. Review of a Medication Administration Record, revealed Resident #5 had [an antidepressant] 1.5 tablets by mouth one time a day related to adjustment disorder with depressed mood, with a start date of 09/24/2025. Review of a Monthly Nursing Summary, dated 10/07/2025, indicated Resident #5 had a change in condition in the last 30 days that included Resident #5 was more isolated with a sleep pattern that was inconsistent. Review of a Progress Note, dated 03/24/2026, indicated Resident #5 is very sad and depressed, self-isolating, little interest in things that used to enjoy. Staff was unable to engage resident in activities or conversation.During an interview on 05/01/2026 at 12:44 PM, Resident #5 stated their money had gone missing, that they had applied for social security disability (SSD) in 2012, and were denied eight times, before being approved in 2025, and that they were waiting on the settlement check. Resident #5 was expecting the settlement to arrive by mail and asked the Administrator one to two times a week if the check had come in the mail or if they had seen a check for me. In February or March of 2026, Resident #5 reached out to the attorney who represented Resident #5 during the SSD hearing, and the attorney stated the settlement check should have been received because the attorney already received their portion of money. Social Security Disability said they sent a letter, but I never got the letter. I got ahold of the district representative for disability, cannot remember the name, and they emailed me saying that they had paid me. Resident #5 stated the Administrator apologized and said she had no idea a mistake was made, the check indicated, disability insurance, in the amount of $56,481.00, and the facility thought it was an insurance check and deposited the money into their (the facility's) account. The Administrator had voiced intent to pay back the money in increments of $1,000.00 per week, but there was no written agreement. Resident #5 stated, I do not want to get anyone in trouble, twice during this interview.During an interview on 05/01/2026 at 3:32 PM, the Administrator stated We got a check and I thought it was ours for insurance. I thought it was a back payment because [Resident #5] owes quite a bit and the check said insurance on it. We are paying [Resident #5] back $1000.00 a week. The Administrator stated there was a written agreement and would provide a copy.During an interview on 05/01/2026 at 3:50 PM, the Director of Nursing (DON) provided a copy of a typed statement showing Resident #5 was being paid $1000.00 weekly, with a copy of four checks made out to Resident #5 for $1000.00 each. The agreement was not dated and was not signed by Resident #5.During an interview on 05/01/2026 at 4:07 PM, the Administrator provided a copy of the agreement to pay back Resident #5, $1000.00 a week (SSD check was $56,481.00). The Administrator stated she was not the one that deposited the check and would not respond when asked who made the deposit. The Administrator stated there were no issues obtaining supplies, medications, food, or utilities for residents. The electronic heath records were not accessible due to a mix up on how the bill was paid, I thought payment was being taken from our bank account, access was restored when payment was made. This surveyor requested a general ledger for Resident #5 showing all charges and credits.During an interview on 05/04/2026 at 10:46 AM, the Administrator provided a facility document titled, Ledger Account Cash Journal dated from 07/01/2025 to 5/01/26. The Administrator stated Resident #5 owed around $39,000.00. The Administrator stated she had not discussed the $39,000.00 owed with Resident #5. The ledger did not reflect a debt of $39,000.00, or any balance owed. The Administrator stated the facility had not received a letter from SSD, for Resident #5. Resident #5 was, expecting this huge settlement in the hundreds of thousands of dollars, and I think that is another reason when we got the check, we thought it was our portion. The Administrator stated she handled the accounting and trust fund, and it was done on paper, (name of electronic health record) was never correct so we do it all on paper. During an interview on 05/05/2026 at 12:25 PM, the Administrator acknowledged Resident #5's settlement check was deposited into a facility account on 07/30/2025; and the funds were utilized for facility business. The facility did not have the funds to return Resident #5's money and continued to use the funds for the benefit of the facility. The Administrator stated this did constitute misappropriation of Resident #5's money.During a second interview on 05/05/2026 at 5:49 PM, Resident #5 stated upon learning four to five weeks ago the facility received the settlement check on 07/30/2025 and deposited the funds into a facility account, Resident #5 felt very surprised and depressed. Resident #5 described feelings of depression waxing and waning, which required increased antidepressants.During an interview on 05/05/2026 at 3:15 PM, LPN #3 stated she was aware of misappropriation of funds involving Resident #5's $56,481.00 dollars, and a lockbox with envelopes containing resident's money. When residents play bingo, they win a few dollars and the money goes into the envelope, and if family leaves money for the residents it is put in the envelope and the nurse writes the total on the outside of the envelope and initials the envelope. LPN #1 told LPN #3 money was missing from residents' envelopes, staff was paid incentive pay for working during a holiday and that was the only cash on hand. The nurse that removed the money should deduct the amount and write it on the outside of the envelope and the money was supposed to be replaced. LPN #3 was not aware of who was responsible to replace the funds in the envelopes.During a third interview on 05/05/2026 at 11:55 AM, Resident #5 stated the Administrator was told about the SSD check (being diverted to a facility account), and that to their knowledge no one had done an investigation, interviewed, or asked Resident #5 for a statement. During an interview on 05/05/2026 at 12:30 PM, the Administrator stated she was on vacation when she received a call from the Minimum Data Set (MDS) Coordinator asking about a check that was received and stated it had insurance on it. I thought that it was our payment. Resident #5 told me, The check was in the hundreds of thousands of dollars, I told the MDS Coordinator to deposit the check. The Administrator relayed that Resident #5 told LPN #15, The Administrator stole my money. The Administrator stated she told Resident #5 she could not just come up with fifty-six thousand dollars, and started paying $1,000.00 a week. I did not get the letter from disability; the letter did not have our address on it. It was not clear that the check was for disability. The Administrator did not know how long Resident #5 was waiting on the check, and stated Resident #5 had asked about the check arriving in the mail. We all knew Resident #5 was waiting for a check and thought it would be a huge lump sum. The way the check was presented I thought it was back pay that Resident #5 owed me.During a fourth interview on 05/05/2025 at 5:49 PM, Resident #5 stated the medication for their depression was increased, Yes, I was really stressed just from not knowing if I was going to get my money. I was depressed for several months, and it would come and go. It was just not knowing, and it bothered me. I was glad to hear I was getting a check, but then I was very surprised when I found out what happened to my check. I was depressed. Resident #5 learned and clarified the expected check had been received by the facility and cashed by the facility in July of 2025.During an interview on 05/06/2026 at 06:20AM, LPN #1 stated she was aware, we were all aware Resident #5 was waiting on money from Social Security Disability, it was just driving [Resident #5] crazy for months. Resident #5 was asking Activities, the MDS Coordinator, and the Administrator about receiving a letter or check, and they all said no. LPN #1 stated Resident #5 was down and depressed, gained weight, and talked about eating their feelings. Two to three months ago Resident #5 was down and depressed and was self-isolating and sleeping a lot. Medication for the resident's depression was increased, and after finding out what happened to the check/money, Resident # 5's depression was better. Not knowing was hard on the resident. LPN #1 stated she and RN #2 discussed the check, Resident #5 had shown her a copy of it, and the fact that the Administrator deposited the check into one of her accounts. It was like an open secret, and everyone was talking about it because Resident #5 was telling everyone.During an interview on 05/06/2026 at 08:38 AM, the Dietary Manager stated she was not left in charge during the Administrator's absence. The Dietary Manager stated, I have never stamped a check, but I have gone to the bank when they are busy, to make deposits.During an interview on 05/06/2026 08:46 AM, the MDS Coordinator stated she had covered for the Administrator during vacations. When checks are received, the MDS Coordinator stated, I always call or text her [Administrator] and tell her what check comes in and she will tell me to stamp it and what account to deposit it in. The deposit would be made by the Dietary Manager or the Activity Director. The MDS Coordinator recalled the Social Security Disability (SSD) check coming in, the Administrator was on vacation, and I called her and told her a check came in for Resident #5, and she told me to stamp it, make a copy and where to deposit it. The MDS coordinator stated, I vaguely remember it [the check] was made out to [the facility] and Resident #5. A copy of Resident #5's check was shown to the MDS Coordinator. The MDS Coordinator confirmed that was the check she was instructed, by the Administrator, to stamp for deposit, and deposit into a facility account. The MDS Coordinator confirmed the check was made out to Resident #5 in care of the facility. The MDS Coordinator did not tell Resident #5 the check came in because Resident #5 was telling people the expected check was a hundred thousand dollars from social security disability.During an interview on 05/06/2026 at 11:09 AM, Facility Staff #16 stated she worked at the facility and had gone to the bank for the Administrator to make deposits but did not pay attention to the checks being deposited. There were times when the Administrator was out of the office and checks would come in; Staff #16 would call the Administrator and would stamp and deposit the checks. Staff #16 stated she would stamp the back of the checks with the stamp the Administrator told her to use and bring back the deposit receipt. Everything was done at [local bank], and the money would go into a facility account.During an interview on 05/06/2026 at 1:55 PM, the Administrator revealed the arrangement made to pay back Resident #5 was a verbal agreement. The Administrator provided a copy of an undated document, signed by the Administrator, stating that the facility owed Resident #5 for a check that was mistakenly deposited into a facility account. The Administrator stated Resident #5 did not sign the agreement and there was no way to confirm Resident #5 agreed to the repayment. The Administrator stated mail was received addressed to Resident #5, a resident with a BIMS of 15. The Administrator stated staff should not open a resident's mail unless permission was given. Residents #8, #9, and #10During a concurrent observation and interview on 05/04/206 at 3:37 PM, the Activities Director stated she had been in the Activities Director position since March of 2025. The process for bingo payouts was tracked by keeping a list in a binder and on Thursdays or Fridays I put the bingo money in the envelopes. Bingo was played every day at 10:30 AM. Other money in the envelope may include money family brought in for a resident. The lockbox also held wallets and jewelry for some residents. The lock box was kept in the medication room and to access the box, The nurses can give me a key or let me in to the medication room to get the box. The nurse will enter the medication room with me or stand at the door. The Activities Director stated she would audit the lock box at least every other month. The Activities Director described the accounting process of tracking the resident funds that included all transactions of adding, removing money, and totals were documented on the outside of the resident's envelope. Receipts for purchases are placed into the envelope and subtracted out of the total on the outside of the envelope. Transactions were confirmed with the nurse with date and initial when money was added or removed from the envelope. Observation during the interview revealed envelopes for Residents #8, #9, and #10 had a total indicated, and a lower updated total, with no entries of fund removal. Resident #8's envelope had a total written as $355.82, an entry of $5.00 [April holiday] below the total, and a line under the total with Updated $47.57 + $25 GC. The Activities Director stated the notation of $25 GC was a $25.00 [corporate store] gift card. Resident #9's envelope had a total written as $128.40, with Updated $105.45 and $3.50. Resident #10's envelope had a total written as $112.75, and a line under the total with $92.00 - updated, and $0.25.The Activities Director was asked to count the money in each of the residents' envelopes and confirmed the amount in Resident #8's envelope was $47.57 and contained a [corporate store] gift card; Resident #9's envelope contained $108.90; Resident #10's envelope contained $93.00. The Activities Director had no knowledge of where the residents' missing money was.During an interview on 05/06/2026 at 6:20 AM, LPN #1 stated Resident #13 passed away and a relative was told, when picking up belongings, to ask for Resident #13's envelope containing $40.00 the resident received monthly, and bingo money for a total of $54.00. The family member picked the envelope up two months later and called the facility and told an unknown nurse there was only $14.00 in the envelope. LPN #1 and an unknown nurse went thru the envelopes and found money missing in about half of the envelopes. LPN #1 stated the total and updated was written on the outside of the envelope. LPN #1 revealed nursing had keys to the medication room and metal lockbox.During an interview on 05/05/2026 at 12:25 PM, the Administrator stated she took $47.00 from an envelope that was in the lockbox after the death of Resident #13. Nurses notified the family of the money and I didn't think they wanted it because they left a refrigerator, television and a bible. The money was returned after Resident #13's family came and picked up the envelope and when they opened it there was only $12.00 in it. The family called and asked where the money was, and I returned it to them. The Administrator stated she was a mandated reporter, and all staff were mandated reporters and incidents that should be reported included abuse, physical, mental, sexual and of course misappropriation of funds, any type of abuse.During an interview on 05/06/2026 at 11:09 AM, Staff #16 stated she put money into resident envelopes for bingo before the Activities Director took over. Staff #16 would count out money at the end of the week. Residents would go to the nurse's desk and request money. The nurse would obtain the lockbox and take money out of the envelope and provide funds to the resident. Money removed from the envelope would be written on the envelope and subtracted out of the total, and a new total written down. Once a week residents would provide a list of items they wanted from the store and an employee would go to the store to get what a resident may want. An example was given, the employee would take $10 out of the resident's envelope, it would be signed out on the envelope; to go to the store and the cost for items would be $2 and the employee would return with $8 change and that $8 would be put back in the envelope and added back in to the total on the envelope. Around the holidays or if a resident wanted to go shopping, residents would be taken to a store across the street from the facility that had booths inside, they had their money and could shop. Staff #16 indicated not being aware of anything that does not belong to residents being in the lock box, all money in the lockbox was resident money.During an interview on 05/06/2026 at 1:43 PM, the Administrator stated anyone with a medication room key had access to the lockbox and resident funds. Review of a facility policy titled, Resident Trust Fund Policy and Procedure, with an effective date of 2017, indicated, the policy applied to all employees involved in the handling, processing, or oversight of the trust funds. The purpose of the policy was To ensure proper management, documentation, and safeguarding of residents' personal funds held in trust by the facility, in accordance with applicable laws and regulations. The policy statement indicated the facility would maintain resident trust accounts for resident personal funds, acting as the fiduciary, and shall manage the funds responsibly, ethically, and in compliance with all relevant legal and regulatory requirements. Resident Trust Fund was defined as a non-interest-bearing or interest-bearing account held by the facility on behalf of a resident for personal use. The fiduciary responsibility was defined as legal obligation to manager funds in the best interest of the resident. The procedures indicated an individual ledger/electronic record must be maintained for each resident's funds, monthly statements would be provided, and all deposits, withdrawals, balanced and transparency would be ensured by the facility. Monthly auditing would be conducted by the finance department or designee, and annual audits would be performed by independent party or internal auditor. Security and safeguards included all funds to be stored in a secure, locked location or managed via secure financial software, and handled and accessed by authorized personnel. Oversight compliance and auditing were the responsibility of the Administrator, day-to-day management of fund operations was the responsibility of the business office manager, and staff were to ensure proper documentation and safeguarding of resident funds. Review of the facility's undated policy titled, Resident Rights, indicated each resident in the facility had the right to be informed of all services and costs included the basic per diem rate; manage their personal affairs, or if this is delegated, receive an accounting every 3 months upon request; be free of verbal, mental, sexual, corporal punishment, involuntary seclusion, and physical abuse; and receive private mail. Review of a facility policy titled, Abuse Prevention and Investigation Guidelines, revised 09/12/2018, included screening, training, prevention, identification, investigation, protection and reporting/response to eliminate the likelihood of abuse. Training included, All employees are required to report any suspected misappropriation of resident property to the Administrator, DON. Prevention included providing information to residents, families, and employees on how to report, evaluation of resident and staff member reports of personality conflicts. Identification included, any staff member who has a reasonable cause to suspect that a resident has been subjected to conditions or circumstances which have or could have resulted I abuse or neglect is required to immediately notify the facility Administrator or DON. The facility would ensure all suspected incidents or allegations were thoroughly investigated, at the time allegation is reported. The Administrator or DON will notify the Office of Long-Term Care of any alleged, suspected, or witnessed occurrences of misappropriation of resident property, or exploitation of a resident. Review of a facility document titled, Administrator, with a date of hire of 04/01/2006, indicated the administrative functions of the Administrator included, Delegate a responsible staff member to act in your behalf when you are absent from the facility.

Based on observations, interviews, and record review, the facility administration failed to effectively and efficiently manage its resources to ensure all residents who resided in the facility attained and maintained their highest practicable mental and psychosocial well-being. The findings include: Review of a facility document titled, Application for Employment, dated 09/25/2000, indicated the Administrator had experience that included office manager in a nursing facility in Arkansas, was a certified nursing assistant (CNA) in an at home nursing agency, had experience billing Medicaid, filing Medicaid paperwork, handling accounts payable, and doing timecards. The Applicant's Statement certified the responses were true and complete and was signed by the Administrator. Review of a facility document titled Administrator Job Description, with a date of hire 04/01/2006, indicated the purpose of the Administrator was to direct the day-today functions of the facility in accordance with current federal, state, and local standards, guidelines ad regulations that govern nursing facilities to assure that the highest degree of quality are can be provided to our residents. The delegation of authority advised the Administrator had the authority, responsibility, and accountability necessary for carrying out their assigned duties. Duties and Responsibilities, Administrative functions included development and maintenance of written policies and procedures and professional standards of practice governing the operation of the facility; ensuring all employees, residents, and others follow the established policies and procedures; assume administrative authority, responsibility and accountability of directing the activities and programs of the facility. Budget and Planning Functions included assisting in the establishment and maintenance of an adequate accounting system; reporting suspected or known incidents of fraud relative to filing of false cost reports, receipt/payment of kickbacks, etc., to appropriate agencies. Resident Rights included, Ensure that resident funds maintained by the facility are managed in accordance with current federal and state regulations and that appropriate accounting records are maintained. Review of an Arkansas Secretary of State Corporations document titled Corporation Details, dated 04/20/2010 indicated the Administrator was the registered agent and President of the for-profit corporation [facility name]. Review of a document titled, Health Insurance Benefit Agreement, dated 07/29/2010, indicated the Administrator was the Owner/Administrator. Review of a document titled, Arkansas Department of Human Services Nursing Home Administrator License, revealed the Administrator was issued an administrator's license numbered [license number], on July 31, 2012. Review of a letter issued by Centers for Medicare & Medicaid Services (CMS), dated 09/05/2012, issued a CMS Certification Number (CCN) of [CCN number] and indicated CMS was notified your organization became the new owner of the skilled nursing facility, with an effective date of 08/01/2012. Review of a facility document titled, Facility Assessment Tool, updated 06/11/2025, indicated the Administrator was also the Governing Body Representative. Review of a facility document titled [Facility Name] Cumulative General Ledger, dated 09/01/2025 to 02/28/2026, revealed transfer of money from A/R Officer line item to Administrator's personal banking account. Line-item payments also included payments to the Administrators personal credit card account. Administrator hand wrote Monies paid to [NAME] from prepaid items bought by her. Beginning balance was $449,040.53 and ending balance was $86,913.84. Review of the line item Private, with a handwritten note indicating Private Deposits Pays from Residents, included deposit transfers from Administrators personal account. Beginning balance was (-$568,373.96) and ending balance was (-$1,182,315.08.) Review of line item Therapy Supplies, with a handwritten note indicated Therapy for Residents Loan to pay bank on facility, revealed payment to [Bank Name] in the amount of $1,601.54. Beginning balance was $0.00 and ending balance was $3,601.54. Review of line item Beauty & Barber Exp Allowable, with a handwritten note Paid from her debit card on personal account revealed a transfer to the Administrator's personal account and cash withdrawals totaling $1,940.00. There were no other transactions on this line item. Review of the Bank Service Chgs, revealed wire transfer charges $30.00; Dormant Fees of $18.00; Overdraft and Returned item fees in the amount of $8,832.00. Review of a bank statement for the Resident Fund Account, dated 03/31/2026 revealed a transfer of funds out of the account, in the amount of $500.00, to an account number identified by the Administrator as Adm. Personal acct. During an interview on 05/05/2026 at 12:10 PM, the Administrator stated the facility manages funds for two residents and the money was deposited into the Resident Fund account which was an interest-bearing account, and the facility did not have a trust account. When resident funds were received, the facility paid the residents their $40.00, and there was a total of seven or eight residents whose funds were sent directly to the facility and did not go into the resident fund account. The Administrator stated she wrote checks for $40.00, put the checks at the nurses' desk, and their families came in and get the $40.00, and buy what the resident wants. The Administrator stated there was no documentation of families signing for the checks or providing receipts for purchases using resident funds. The Administrator stated the check was the facility's documentation that the $40.00 resident funds were provided to the residents. The Administrator did not have ledgers or other documentation that funds were provided to the families. The Administrator stated she would have to locate the information for which residents the facility managed funds for stating I am the only one that handles the resident trust funds. The Administrator stated any monies over $5.00 must be placed in the resident account. Review of a facility document titled, Participant Ledger Account Cash Journal, with a date range of 05/03/2025 to 05/01/2026, indicated Resident #8 received SSA $1.339.00, (-$40.00) leaving balance of $1,536.79 on 05/03/2025. No beginning balance was noted. An entry on 06/03/2025 indicated SSA $1339.00, (-$40.00) leaving a balance of $1,576.79. The next line item indicated Interest =.08 with a balance of .08. No other debits were noted in the journal. Review of a facility document titled, Participant Ledger Account Cash Journal, with a date range of 05/03/2025 to 05/01/2026, indicated Resident #14 had balance of $1,324.45, $40.00 leaving a balance of $1,364.45 on 05/03/2026. An entry on 06/03/2025 indicated SSA $40.00 leaving a balance of $1,404.45. The next line item was interest .07 with a balance of $1,404.52. An entry on 05/01/2026 indicated personal care needs, $500.00 which was deducted leaving a balance of $1,344.77. The check for $500.00 was made out to Resident #14's daughter. No receipts were attached. Review of facility documents titled, Participant Ledger Account, for Resident #2, Resident #15, Resident #16, and Resident #17, indicated monies came into the accounts and resident allowance in the amount of $40.00 came out of the accounts. The DON stated these were the ledgers of the residents whose families received $40.00 from the facility to purchase resident requested items. No information was attached that indicated who picked up the checks, and no receipts indicating what was purchased with resident funds was presented. During an interview on 05/05/2026 at 12:25 PM, the Administrator acknowledged Resident #5's settlement check was deposited into a facility account on 07/30/2025; and that the funds were utilized for facility business. The facility did not have the funds to return Resident #5's money and continued to use the funds for the benefit of the facility. The Administrator stated it was misappropriation of Resident #5's money. The Administrator stated she told Resident #5 she could not just come up with fifty-six thousand dollars, and started paying $1,000.00 a week. I did not get the letter from disability; the letter did not have our address on it. It was not clear that the check was for disability. The Administrator did not know how long Resident #5 was waiting on the check but stated Resident #5 asked about mail. We all knew Resident #5 was waiting for a check and thought it would be a huge lump sum. The way the check was presented I thought it was back pay that Resident #5 owed me. Review of a facility policy and procedure titled Resident Trust Fund. with an effective date of 2017, indicated the policy applied to all employees involved in the handling, processing, or oversight of the trust funds. The purpose of the policy was To ensure proper management, documentation, and safeguarding of residents' personal funds held in trust by the facility, in accordance with applicable laws and regulations. The policy statement indicated the facility would maintain resident trust accounts for resident personal funds, acting as the fiduciary, and shall manage the funds responsibly, ethically, and in compliance with all relevant legal and regulatory requirements. Balances and Limits Interest bearing accounts will be used for residents with balances above [Insert Threshold], and interest will be credited to their accounts accordingly. Resident Trust Fund was defined as a non-interest-bearing or interest-bearing account held by the facility on behalf of a resident for personal use. The fiduciary responsibility was defined as legal obligation to manager funds in the best interest of the resident. The procedures indicated an individual ledger/electronic record must be maintained for each resident's funds, monthly statements would be provided, and all deposits, withdrawals, balanced and transparency would be ensured by the facility. Monthly auditing would be conducted by the finance department or a designee, and annual audits would be performed by independent party or internal auditor. Security and safeguards will include all funds to be stored in a secure, locked location or managed via secure financial software, and only authorized personnel may access and handle resident funds. Oversight compliance and auditing was the responsibility of the Administrator. Day-to-day management of fund operations was the responsibility of the Business Office Manager (BOM); and staff were to ensure proper documentation and safeguarding of resident funds. A review of the facility's undated policy titled, Resident Rights, indicated each resident in the facility had the right to be informed of all services and costs included the basic per diem rate; manage their personal affairs, or if this is delegated, receive an accounting every 3 months upon request; be free of verbal, mental, sexual, corporal punishment, involuntary seclusion, and physical abuse; and receive private mail. A review of a facility policy titled, Abuse Prevention and Investigation Guidelines, revised 09/12/2018, included screening, training, prevention, identification, investigation, protection and reporting/response to eliminate the likelihood of abuse. Training included, All employees are required to report any suspected misappropriation of resident property to the Administrator, DON. Prevention included providing information to residents, families, and employees on how to report, evaluation of resident and staff member reports of personality conflicts. Identification included, any staff member who has a reasonable cause to suspect that a resident has been subjected to conditions or circumstances which have or could have resulted I abuse or neglect is required to immediately notify the facility Administrator or DON. The facility would ensure all suspected incidents or allegations were thoroughly investigated, at the time allegation is reported. The Administrator or DON will notify the Office of Long-Term Care of any alleged, suspected, or witnessed occurrences of misappropriation of resident property, or exploitation of a resident. Review of a facility document titled, Key Personnel, undated revealed there was no business office manager position. Review of Arkansas Title 4, Business and Commercial Law, Subchapter 8 – Directors – Officers – Meetings – Standards of Conduct Section 4-27-842 – Standards of conduct for officers, revealed, (a) An officer with discretionary authority shall discharge his duties under that authority: (1) in good faith; (2) with the care an ordinarily prudent person in a like position would exercise under similar circumstances; and (3) in a manner he reasonably believes to be in the best interests of the corporation.

Based on interviews, record review, and facility document review, it was determined that the facility failed to have a governing body in place for oversite of the Administrator and operations of the facility, affecting all residents residing within. The findings include: Review of a document titled, Assignment of contract to participate in the Arkansas Medical Assistance Program Administered by the Division of Medical Services Title XIX (Medicaid), dated 08/01/2010, indicated the buyer was [the facility] and was signed by the Administrator, whose titled was listed as, Owner/Administrator. Review of a document titled, Contract to Participate in the Arkansas Nursing Home Program, with a signed date of 07/13/2010, indicated, To comply with all state and/or Federal regulations pertaining to resident personal funds. Review of a document titled, Health Insurance Benefit Agreement, dated 07/29/2010, indicated [the facility] agreed to conform to the provisions of section 1866 of the Social Security Act and applicable provisions in 42 CFR. The document was signed by the Administrator as Owner/Administrator. During an interview on 05/15/2026, the Administrator was asked to provide a list of Governing Body members with their contact information. The Administrator provided a written statement. Review of the undated written statement provided by the Administrator, indicated the Administrator was the sole governing body of [the facility] and was signed by the Administrator. During an interview on 04/29/2026 at 1:11 PM, the Director of Nursing (DON) stated the Administrator handled all banking and, everything. During an interview on 05/01/2026 at 1:21 PM, Registered Nurse (RN) #2 stated the Administrator handles all monies and was the owner and Administrator.

Based on observation, record review, and interview, the facility failed to act as a fiduciary (Person or organization legally obligated to manage someone else's property or money) of resident funds by safeguarding and managing Medicaid resident funds for five (Resident #5, #8, #9, #10, and #13) of five residents reviewed. The findings include: A review of Clinical Resident Profile, indicated the facility admitted Resident #5 to the facility on [DATE] with diagnoses that included narrowing of the lumbar spinal canal with pain, weakness in the legs, incomplete spinal cord injury at the 7th cervical vertebrae, and adjustment disorder. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. A review of Resident #5's Care Plan Report, initiated on [DATE], revealed the resident was independent for meeting emotional, intellectual, physician and social needs. Interventions included notifying resident of preferred activities, converse with resident to degree of intellectual functioning, and invite the resident to participate in all activities. Potential for adverse reaction to psychotropic medication. History of adjustment disorder with depressed mood. Monitor and document side effects including depression, hopelessness, negative statements, changes in appetite, and emotional distress. Notify MD of resident withdrawal from social interaction. A review of an attorney hearing reminder letter dated [DATE], located in Resident #5's electronic health record, indicated Resident #5 had a Social Security Hearing scheduled for [DATE] at 2:00 PM. A review of the front and back of the United States Treasury check, received by the facility, was dated [DATE], payable to Resident #5 in care of the facility, in the amount of $56,481.00 dollars, had a notation in the bottom left that indicated SOC SEC FOR INS. The back of the check included an endorsement Pay to the Order of [name of bank with account number] For Deposit Only [facility name and account number]. During an interview on [DATE] at 12:44 PM, Resident #5 stated that a social security disability check belonging to them in the amount of $56,481.00 was mistakenly deposited into a facility owned bank account in July of 2025. The MDS Coordinator was aware the check was received by the facility when Resident #5 showed the MDS Coordinator a copy of the check provided by Resident #5's attorney. Resident #5 stated the Administrator explained this was a mistake and would pay Resident #5 $1,000.00 a week over 56 weeks or until the funds were repaid. This created a loan without interest for the facility. Resident #5 expressed feelings of sadness and disappointment regarding how the incident was being handled. On [DATE] at 9:30 AM, the Administrator was requested to provide a general ledger showing charges for Resident #5, including bed charges. During an interview on [DATE] at 10:46 AM, the Administrator provided a Ledger Account Cash Journal from [DATE]-[DATE]. The Administrator verbalized that Resident #5 owed the facility around $39,000.00. The Ledger did not show bed charges, or an outstanding balance of $39,000.00, and the Administrator stated there had not been a discussion with Resident #5 regarding any past due balance. The Administrator stated the electronic system used by the facility for accounting was never correct for the facility, so accounting was done on paper. During a second interview on [DATE] at 12: 15 PM, the Administrator stated only two residents had a Resident Trust Account, but there were others that have their check sent to the facility and the family comes and gets their $40.00 and buys what they need. The Administrator stated, Nobody signs when picking up a residents' checks. A review of a facility document titled, Care Plan Report, with a revision date of [DATE], revealed Resident #13 was admitted on [DATE] with diagnoses of hypertension, malignant melanoma of scalp and neck, diabetes, and chronic obstructive pulmonary disease. Resident #13's preferred activities included bingo. A review of Progress Notes, dated [DATE] at 02:40 AM, indicated Resident #13 was pronounced deceased by hospice at 10:19 PM. During a third interview on [DATE] at 1:15 PM, the Administrator said bingo and game winnings as well as receipts and change from resident purchases are placed in resident envelopes. The Administrator revealed Resident #13 passed away and had $47.00 in $1.00 bills. Resident #13's family had left a lot of things behind, and a long time had gone by, and the Administrator stated she took the $47.00 and instructed the Activity Director to put Resident #13's money into the bingo fund. Then, days later a relative came and picked up an envelope belonging to Resident #13 that had $12.00, so resident must have had more than one envelope. A review of a facility document titled, Care Plan Report, with a revision date of [DATE] indicated Resident #8 was admitted to the facility on [DATE]. A review of a facility document titled, Medical Diagnosis, undated revealed Resident #8 had diagnoses that included cerebral palsy, diabetes, and mild intellectual disability. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident had moderate cognitive impairment. Resident #8 required substantial/maximal assistance with upper body dressing and was dependent upon staff for all other care. A review of a facility document titled, Care Plan Report, with a revision date of [DATE] indicated Resident #9 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Resident #9 required set-up assistance with eating, and oral hygiene, was independent with upper body dressing, personal hygiene and toileting; required partial to moderate assistance with lower body dressing. Diagnoses included anxiety disorder and dementia, A review of a facility document titled, Care Plan Report, with a revision date of [DATE] indicated Resident #10 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated Resident #10 had moderate cognitive impairment. Resident #10 required partial to moderate assistance with oral hygiene, bathing, upper body dressing and personal hygiene; was dependent on staff for toileting and lower body dressing; and required set-up assistance for eating. Diagnoses included depression and dementia. During a concurrent observation and interview on [DATE] at 3:37 PM, revealed envelopes for Residents #8, #9, and #10 had a total indicated on the outside of the envelope, and a lower updated total written below, with no entries of fund removal. Resident #8's envelope had a total written as $355.82, an entry of 5.00 Easter below the total, and a line under the total with Updated $47.57 + 25 GC. Activities stated the notation of 25 GC was a $25.00 Walmart gift card. Resident #9's envelope had a total written of $128.40, with Updated $105.45 and $3.50. Resident #10's envelope had a total written of $112.75, and a line under the total with $92.00 – updated, and .25. Activities was asked to count the money in each of the residents' envelopes and confirmed the amount in Resident #8's envelope was 47.57 and contained a Walmart gift card; Resident #9's envelope contained $108.90; Resident #10's envelope contained $93.00. Activities had no knowledge of where the residents' missing money was. During an interview on [DATE] at 6:20 AM, LPN #1 stated that envelopes containing resident funds were locked in a metal box in the medication room and, contained the $40.00 given to residents monthly, and bingo winnings. LPN #1 revealed a total was documented on the outside of the envelope documenting money being deposited or removed from a resident's envelope. LPN #1 said, if family or staff took money out to purchase items for residents, they were to return the receipts with change and nursing staff would add the change back on the outside of the residents' envelope. LPN #1 revealed that several envelopes found in the box, did not have an accurate accounting of said funds. Surveyors later determined the envelopes belonged to Resident #8, Resident #9, and Resident #10. Review of a facility policy titled, Resident Trust Fund Policy and Procedure, with an effective date of 2017, indicated, the policy applied to all employees involved in the handling, processing, or oversight of the trust funds. The purpose of the policy was To ensure proper management, documentation, and safeguarding of residents' personal funds held in trust by the facility, in accordance with applicable laws and regulations. The policy statement indicated the facility would maintain resident trust accounts for resident personal funds, acting as the fiduciary, and shall manage the funds responsibly, ethically, and in compliance with all relevant legal and regulatory requirements. Resident Trust Fund was defined as a non-interest-bearing or interest-bearing account held by the facility on behalf of a resident for personal use. The fiduciary responsibility was defined as legal obligation to manager funds in the best interest of the resident. The procedures indicated an individual ledger/electronic record must be maintained for each resident's funds, monthly statements would be provided, and all deposits, withdrawals, balanced and transparency would be ensured by the facility. Monthly auditing would be conducted by the finance department or designee, and annual audits would be performed by independent party or internal auditor. Security and safeguards included all funds to be stored in a secure, locked location or managed via secure financial software, and handled and accessed by authorized personnel. Oversight compliance and auditing were the responsibility of the Administrator, day-to-day management of fund operations was the responsibility of the business office manager, and staff were to ensure proper documentation and safeguarding of resident funds. Review of the facility's undated policy titled, Resident Rights, indicated each resident in the facility had the right to be informed of all services and costs included the basic per diem rate; manage their personal affairs, or if this is delegated, receive an accounting every 3 months upon request; be free of verbal, mental, sexual, corporal punishment, involuntary seclusion, and physical abuse; and receive private mail.

Based on record review and interviews the facility failed to ensure a system was in place to provide a complete and separate accounting of each resident's personal funds according to accounting principles, to ensure there was no comingling of resident funds with facility funds or that of other residents, affecting 4 (Resident #5, #8, #9, and #10) of 13 residents reviewed for misappropriation of property. The findings include: During an interview on 05/05/2026 at 3:15 PM, Licensed Practical Nurse [LPN] #3 revealed there was a lock box in the medication room containing envelopes of resident owned bingo money and money families can leave with nursing staff for their resident. During an interview on 05/06/2026 at 6:20 AM, LPN #1 stated that envelopes containing resident funds were locked in a metal box in the medication room and contained the $40.00 given to residents monthly, and bingo winnings. LPN #1 revealed a total was documented on the outside of the envelope documenting money being deposited or removed from a resident's envelope. LPN #1 said, if family or staff took money out to purchase items for residents, they were to return the receipts with change and nursing staff would add the change back on the outside of the residents' envelope. LPN #1 revealed that several envelopes did not have an accurate accounting of said funds. Review of envelopes for Resident #8, #9, and #10 showed accounting errors and incorrect balances. The envelopes reviewed contained the following funds and accounting of said funds: Resident #10's envelope contained $92.00 in cash, and $1.00 in change. Review of Resident #10's envelope accounting indicated on 03/20/2026 the beginning handwritten total was $97.50, following the total $1.25 was added for a total of $98.75; an entry titled holiday with $14.00 added to total $112.75. A total of $92 was counted in the envelope. An entry of Updated $92.00, $.25 with an addition of $20.00 dated 5/6/26, and a total of $112.75. No expenditure listed. Total missing was $20.50. No receipts were present in the envelope, per Activity Director. Review of the envelope for Resident #8 indicated a date of 04/10/2025 with a beginning balance of 306.82 cash and $25.00 [Named] Gift Card, on 04/10/2025. Entries did not have dates and included 1.75, 1.00, 2.00, (-20.00), 14.00, .75, 2.00, 2.00, .25, 1.25, 1.75, and 1.50 for a total of $316.82 on 07/11/2025. Additional entries without dates included 2.75, 1.00, 3.25, 3.75, 10.50, 5.00, 3.25, 6.50, 3.00, with a balance of $355.82, entry of 5.00 [holiday] and a line under the holiday entry, with Updated $47.57 + 25 GC. Activities stated the notation of 25 GC was a $25.00 [Named] gift card. Resident #9's envelope had a total written as $128.40, with Updated $105.45 and $3.50 written. Resident #9's envelope contained $104.00 in cash, and $4.90 in change, for a total of $108.90. No final total or expenditures were listed. Total missing was $19.50. No receipts were available, per the Activity Director. During an interview on 05/06/2026 at 8:46 AM, the Minimum Data Set [MDS] Coordinator revealed when the Administrator was on vacation the MDS would call the Administrator when a check came in and she would stamp the check and deposit the money in whichever account the Administrator indicated. The MDS revealed that Resident #5 received a Social Security Disability (SSD) check dated 07/20/2026, and the MDS was asked to deposit the resident's money in a facility checking account. During an interview on 05/06/2021 at 1:25 PM, the Administrator revealed that Medicaid dollars are deposited into an account ending in 43, and Social Security checks were deposited into account ending in 21. The Administrator responded, yes, when asked if Medicaid dollars had been comingled with business funds, and could not account for checks written because, errors were made. The Administrator stated, You can't tell, when asked where money in each facility account originated from. Review of the Administrator job description, signed 04/01/2026, revealed the Administrator would ensure resident fund management provided by the facility would be done according to state and federal guidelines, and using appropriate accounting practices.

Based on observation, record review, and interviews, it was determined that the facility failed to immediately and thoroughly investigate allegations of misappropriation of resident property for 2 (Resident #5 and Resident #6) of 13 residents reviewed for exploitation and misappropriation. The findings include: Review of facility job descriptions for the Administrator, signed 04/01/2026 and the DON, unsigned, indicated that both jobs required reporting and investigating of all allegations of abuse and misappropriation. Resident #5 Review of Resident #5's, Medical Diagnosis Report, included diagnoses of spinal stenosis, insomnia, and depression. Review of the annual Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 6/13/2025 revealed a Brief Interview for Mental Status [BIMS] score of 15 which indicated no cognitive impairment. During an interview on 05/01/2026 at 11:55 AM, Licensed Practical Nurse [LPN] #3 reported that Resident #5 had disclosed waiting nearly a year for a Social Security Disability [SSD] payment and learned approximately six to eight weeks earlier that the Administrator had deposited the resident's SSD check into a facility account. Resident #5 stated the Administrator had repaid Resident #5 $1,000 per week for four weeks and expressed sadness and disappointment that the Administrator had taken their money. During an interview on 05/01/2026 at 12:44 PM, Resident #5 reported an SSD check totaling $56,481.00, dated July 25, 2025, had been endorsed for deposit into a facility account. Resident #5 stated the Administrator informed the resident that the deposit was a mistake and confirmed the resident had received four, $1,000 payments. Resident #5 reported no interview had been completed as part of any investigation and was unaware if any investigation had occurred. Resident #5 revealed some staff, including LPN #1, and other residents had been told about the incident. During an interview on 05/06/2026 at 6:20 AM, LPN #1 stated Resident #5 had been sad, depressed, self-isolating, and sleeping excessively two to three months earlier. She stated she reported the issue to Registered Nurse [RN] #2 but was unaware of any investigation taking place. During an interview on 05/01/2026 at 1:21 PM, RN #2 stated financial abuse or suspected abuse should be reported to the Administrator and Ombudsman and stated that a reportable should be completed. During an interview on 05/01/2026 at 3:32 PM, the Administrator confirmed that four, $1,000 payments had been made and that the SSD check had been mistakenly deposited into a facility account in July 2025. The Administrator provided a copy of what was described as a repayment agreement. Record review revealed no evidence of an immediate investigation, no witness statements, no interviews with involved staff, no review of financial records, and no required 24 hour or 5 day reports. Resident #6 Review of Resident #6's Medical Diagnosis Report included diagnoses of bipolar disorder, diabetes II, and CHF. Review of Resident #6's quarterly MDS with an annual review date (ARD) of 02/12/2026 revealed a BIMS score of 15, which indicated no cognitive impairment. During an interview on 05/04/2026, at 2:55 PM, the Director of Nursing [DON] and MDS consultant reported that Resident #6 had provided debit card information to Resident #7's family member to purchase a bed for $50.00 but later reported unauthorized purchases. Resident #7's family member had been banned from the facility. The DON provided a file showing the incident had been reported but acknowledged there were no witness statements or investigation documentation. During an interview on 05/04/2026, at 4:30 PM, Registered Nurse [RN] #2 stated Resident #7's family member used Resident #6's debit card for unauthorized purchases and confirmed no witness statements, interviews, or investigations were completed because the individuals did not stay at the facility long. During an interview on 05/05/2026, at 8:42 AM, Resident #7 confirmed that Resident #6 had given the debit card to a family member and that unauthorized purchases occurred. Resident #7 stated the family member lived in a children's home and could not make good decisions. During an interview on 05/05/2026, at 12:30 PM, the Administrator stated all staff were mandated reporters and confirmed Resident #6 reported unauthorized charges of $700.00 to $900.00 from a personal bank account. The Administrator stated the facility had 24 hours to report and 5 days to investigate allegations. The Administrator acknowledged that interviews with other residents and staff should have been conducted. The Administrator was unable to provide requested bank statements of fraudulent charges, witness statements, or investigation notes. An OLTC [Office of Long-Term Care] Incident and Accident Report, dated 03/16/2026 indicated unauthorized charges had been made and cancellation of the debit card, but no evidence of a thorough investigation was provided. The facility failed to conduct a complete investigation, failed to interview witnesses, failed to gather financial documentation, and failed to meet CMS investigative and reporting requirements. Review of an in-service titled Abuse, dated 02/17/2026 given by RN #2. LPN #9 signed the in-service training, but the administrator's signature was not noted. Seven types of abuse including financial were included into the training. The in-service indicated, financial abuse occurs when someone steals or manipulates an older person to get money from then. This includes misuse of the POA, stealing resident cash, credit cards, or valuables. Keeping someone from accessing their bank account. Financial abuse can be just as damaging as other types of abuse and can cause anxiety and can prevent residents from having the money they need to pay for long term care.

Based on record review and interview, the facility failed to ensure residents were not subjected to abuse or misappropriation of their property and failed to ensure the right for privacy for 1 (Resident #5) of 13 residents reviewed for misappropriation. Specifically, Resident #5's mail was opened, and a check for $56,481.00 was deposited into a facility checking account without the resident's knowledge or consent. The findings include: Resident #5 Review of Resident #5's Medical Diagnosis Report, revealed medical diagnoses which included spinal stenosis (narrowing of that causes nerve pain, numbness and weakness of the legs and buttocks), insomnia, and depression. Review of Resident #5's quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] 03/18/2026 suggested a Brief Interview for Mental Status [BIMS] score of 15, which indicated the resident was cognitively intact. During an interview on 05/01/2026 at 11:55 AM, Licensed Practical Nurse [LPN] #3 reported that the Administrator had taken $56,000.00 from Resident #5 and had paid back $1000.00. Resident #5 was reported as having told LPN #3 the resident was sad and disappointed that the Administrator took the money. During an interview on 05/01/2026 at 12:44 PM, Resident #5 revealed a check from Social Security Disability [SSD] was mistakenly deposited into a facility bank account in July of 2025, and Resident #5 was being paid $1000.00 per week by the Administrator. Resident #5 revealed not having anything in writing regarding the missing money. Resident #5 showed this surveyor a picture of the front and back of a cancelled check made payable to Resident #5 in care of the facility. The back of the check was stamped Pay to the order of [named] bank, and stated, For Deposit Only [named] facility. The check was deposited into account ending in 43, identified by Administrator as the facility's Medicaid account. Resident #5 reported having begun asking questions regarding the missing money at the end of March 2026, and a copy of the cancelled check was sent to Resident #5. During an interview on 05/01/2026 at 3:32 PM, the Administrator stated an SSD check was mistakenly deposited into a facility bank account, and Resident #5 was being paid back $1000.00 per week. We got a check and I thought it was ours for insurance. The Administrator provided a letter stating $56,481.00 was mistakenly deposited into a facility account and the facility would pay $1000.00 a week until paid in full. The document stated Resident #5 owed the facility $39,261.44 but the facility was unable to produce an accounting of that total. During an interview on 05/06/2026 at 8:46 AM, the MDS Coordinator revealed that when the Administrator was on vacation the MDS Coordinator provided coverage at the facility. The MDS Coordinator revealed they had opened Resident #5's mail without the resident's knowledge or permission, then called the Administrator and was told to stamp a check included in the resident's mail made out to Resident #5 and deposit the check into a facility checking account. The MDS Coordinator stated the check for $56,481.00 was made out to the facility for Resident #5 and looked like an insurance check. The MDS Coordinator was shown a copy of the front and back of the cashed check and revealed the check was made out to Resident #5 in care of the facility, and confirmed this was the check the MDS Coordinator sent to the bank for deposit into a facility account. The MDS Coordinator stated Resident #5 had been asking for an unknown amount of time if the resident had gotten anything in the mail, and confirmed that Resident #5 was not told that a SSD check for $56,481.00 had been received in the mail. During an interview on 05/06/2026 at 1:25 PM, the Administrator stated that a resident with a BIMS of 15 was entitled to know an SSD check made out to them had been received by mail at the facility. The Administrator stated the facility should only open resident mail if the family had given permission and revealed that some residents lack capacity and family would like cards and stuff to be opened and read to them. Review of the Administrator Job Description, signed 4/01/2006, revealed the Administrator was to create a warm, calm environment in the facility, report known or suspected fraud related to false billing, receipt/payment of kickbacks, ensure resident rights to fair treatment, privacy, property and self-determination, and ensure resident funds are managed according to state and federal regulations and guidelines. Review of Resident Rights, dated 2017, revealed residents have the right to be informed of all services available and all cost including charges covered by Medicaid, Medicare and the daily per diem basic rate, to be free of physical, verbal, mental, sexual, involuntary seclusion, and corporal punishment, and to receive private mail. Review of an in-service titled Abuse, dated 02/17/2026 and given by Registered Nurse [RN] #2, revealed financial abuse occurs when someone steals or manipulates an older person to get money from them. This includes stealing resident cash, credit cards or valuables and can be just as damaging as other types of abuse, can cause anxiety and can prevent residents from having the money they need to pay for long term care.

Based on observation, record review, and interviews, the facility failed to immediately report allegations of misappropriation of resident property for 1 (Resident #5) of 13 residents reviewed for misappropriation. Specifically, the facility did not initiate a reportable for exploitation and misappropriation resulting in noncompliance. The findings include: Resident #5 Review of Resident #5's, Medical Diagnosis Report included diagnoses of spinal stenosis (narrowing that causes nerve pain, numbness and weakness of the legs and buttocks), insomnia, and depression. Review of Resident #5's quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] 3/18/2026 revealed a Brief Interview for Mental Status [BIMS] score of 15, indicating no cognitive impairment. Review of Resident #5's Care Plan Report, initiated on 06/13/2025 , revealed the resident was independent for meeting their own emotional, intellectual, physician, and social needs. Interventions included notifying resident of preferred activities, conversing with the resident to degree of intellectual functioning, and inviting the resident to participate in all activities. Potential for adverse reaction to psychotropic medication. History of adjustment disorder with depressed mood. Monitor and document side effects including depression, hopelessness, negative statements, changes in appetite, and emotional distress. Notify MD (medical doctor) of resident withdrawal from social interaction. During an interview on 05/01/2026 at 11:55 AM, Licensed Practical Nurse [LPN] #3 reported that Resident #5 disclosed waiting nearly a year for a Social Security Disability (SSD) payment and learned approximately six to eight weeks earlier that the Administrator had deposited the resident's SSD check into a facility account. Resident #5 told LPN #3 the Administrator had stolen close to $60,000.00 and repaid Resident #5 $1,000. Resident #5 expressed sadness and disappointment that the Administrator had taken the money. During an interview on 05/01/2026 at 12:44 PM, Resident #5 reported the SSD check totaled $56,481.00, was dated July 25, 2025, and had been endorsed for deposit into a facility account. Resident #5 stated the Administrator told the resident the deposit was a mistake and revealed the Administrator had made four $1,000 payments. Resident #5 reported not being interviewed as part of any investigation and was unaware if there had been a report or investigation into how the SSD check was deposited into the facility account. Resident #5 stated resident had informed staff, including LPN #1, and other residents about the incident. During an interview on 05/01/2026 at 1:21 PM, RN #2 stated that financial abuse or suspected abuse should be reported to the Administrator and Ombudsman and that a reportable should be completed immediately. During an interview on 05/01/2026 at 3:32 PM, the Administrator confirmed that four $1,000 payments had been made to Resident #5, and the Administrator stated the SSD check had been mistakenly deposited into a facility account in July 2025. The Administrator provided a copy of what was described as a repayment agreement. Record review revealed no reportable was submitted to the Office of Long-Term Care [OLTC], no immediate investigation, no witness statements, no interviews with involved staff, no review of financial records, and no required 24 hour or 5 day reports. During an interview on 05/05/2026 at 12:30 PM, the Administrator stated all staff were mandated reporters and the facility had 24 hours to report and 5 days to investigate allegations of misappropriation and acknowledged that interviews with other residents and staff should have been conducted. The Administrator stated she did not report depositing Resident #5's check into the facilities bank account because she made arrangements with Resident #5 to pay back the $56,481.00. I can see that I should have reported the mistaken deposit During an interview on 05/06/2026 at 6:20 AM, LPN #1 stated that Resident #5 had been sad, depressed, isolating, and sleeping excessively two to three months earlier. LPN #1 stated the issue was reported to RN #2 but was stated she was unaware of any report or investigation. During a second interview on 05/06/2026 at 1:55 PM, the Administrator revealed that the agreement to pay Resident #5 back $56,481.00 was a verbal agreement, and Resident #5 had nothing in writing. The Administrator agreed that there was nothing in writing showing that Resident #5 agreed with a plan to receive $1000.00 a week for 56 weeks. Review of facility job descriptions for the Administrator, signed 04/01/2006 and the DON, unsigned, indicated both were required reporting and investigating all allegations of abuse and misappropriation. An in-service dated 02/17/2026, given by RN #2, defined financial abuse and emphasized its emotional impact. The Administrator, LPN #1, and LPN #3's signature were not on the in-service.

Based on record review, interviews and facility document review, it was determined the facility failed to ensure written notification was provided to the resident and/or the resident's representative of transfer/discharge to the hospital and included all the required information for five (Resident #2, #5, #28, #32, and #36) of five residents reviewed for hospitalizations.The findings include:Resident #2Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/03/2025, indicated Resident #2 had diagnoses which included non-Alzheimer's dementia (cognitive decline unrelated to Alzheimer's disease), urinary tract infection and diabetes mellitus. The MDS also revealed a Brief Interview for Mental Status (BIMS) score of 4, which indicated Resident #2 had severe cognitive impairment.Review of a Hospital Record dated 10/02/2025, indicated Resident #2 was admitted to the hospital from [DATE] to 10/05/2025 with diagnosis of urinary tract infection.Review of a Hospital Discharge Summary dated 10/25/25, indicated Resident #2 was admitted to the hospital from [DATE] to 10/25/2025 with diagnosis of urinary tract infection and acute encephalopathy.Review of Resident #2's medical records on 01/07/2025 at 10:00 AM, indicated there was not a notice of transfer for when the resident transferred to the hospital on [DATE] or 10/16/2025.Resident #5Review of a quarterly MDS with an ARD of 12/04/2025, indicated Resident #5 had diagnoses which included end stage renal (kidney) disease, diabetes mellitus and other fractures. The MDS also revealed a Brief Interview for Mental Status (BIMS) score of 5 which indicated Resident #5 had severe cognitive impairment.Review of a Hospital Record dated 11/28/2026 indicated Resident #5 was admitted to the hospital on [DATE] after a fall with a fracture of the surgical neck of left humerus (long bone) and fracture of the pelvis.Review of Resident #5's medical records on 01/07/2025 at 10:05 AM, indicated there was not a notice of transfer for when the resident transferred to the hospital on [DATE].Resident #28Review of a quarterly MDS with ARD of 10/30/2025, indicated Resident # 28 had diagnoses which included cerebral palsy (neurological disorder caused by damage to a developing brain), paraplegia (loss of movement and sensation to the lower half of the body), and abnormality of albumin (protein level). The MDS also revealed a Staff Assessment for mental Status (SAMS) score of 3 which indicated Resident #28 had severe cognitive impairment.Review of Resident # 28's Progress Note, dated 12/21/2025 revealed the resident was hospitalized on [DATE] due to dislodgement of their Percutaneous Endoscopic Gastrostomy (PEG) -tube and for surgical replacement. Review of Resident #28's medical records on 01/07/2025 at 10:05 AM, indicated there was not a notice of transfer for when the resident transferred to the hospital 12/21/2025.Resident #36Review of a quarterly MDS with ARD of 10/24/2025, indicated Resident #36 had diagnoses which included cerebral palsy (neurological disorder caused by damage to a developing brain), paraplegia (loss of movement and sensation to the lower half of the body), and diabetes mellitus. The MDS also revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated Resident #36 was cognitively intact.Review of Resident #36's Progress Note dated 11/22/2025, revealed the resident was hospitalized on [DATE] due to being woke up and being nonverbal and not being able to move their arms or head normally. Review of Resident #36's Progress Note dated 12/05/2025, revealed the resident was hospitalized on [DATE] due to possible aspiration (accidental inhalation of foreign material into the lungs). Review of Resident #36's medical records on 01/07/2025 at 10:05 AM, indicated there was not a notice of transfer for when the resident transferred to the hospital on [DATE] and 12/05/2025.Resident #32 Review of a quarterly MDS with an ARD of 12/12/2025, indicated Resident #32 had diagnoses which included diabetes mellitus, chronic obstructive pulmonary disease, Bipolar Disorder, Anxiety Disorder. The MDS also revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #32 was cognitively intact.Review of Resident #32's Progress Note dated 11/20/2025, revealed the resident was hospitalized on [DATE] due to vomiting yellow tinged liquid. Review of Resident #32's medical records on 01/07/2025 at 10:10 AM, indicated there was not a notice of transfer for when the resident transferred to the hospital on [DATE]. Interviews During an interview on 01/08/2026 at 11:41 AM, the MDS Coordinator confirmed that Resident #2, #5, #28, #32, and #36 had been transferred to the hospital on the dates listed above and that she was responsible for completing the notification of transfer when residents were discharged or transferred to the hospital. After reviewing the Facility Letters that were sent to Resident #2, #5, #28, #32 and #36's representatives with the notification of transfer to the hospital, the MDS Coordinator confirmed that the letters did not contain information on the resident's appeal rights and process or how to contact the Office of State Long-Term Care Ombudsman as required. The MDS Coordinator indicated she was not aware of any other written notification being given to the resident or resident representative at the time of the transfers. During an interview on 01/08/2026 at 12:40 PM, the Administrator confirmed the MDS Coordinator was responsible for completing the notifications of transfer when residents are discharged or transferred to the hospital and the notices completed by the MDS Coordinator were the only notices that were sent to residents and/or their representatives regarding transfers. After reviewing the letters of transfer for Resident #2 for 10/02/2025 and 10/16/2025, Resident #5 for 11/25/2025, Resident #28 for 12/21/2025, Resident #32 for 11/20/2025, and Resident #36 for 11/22/2025 and 12/05/2025, the Administrator confirmed the letters did not contain information about the appeal process or how to contact the Office of Long-Term Care Ombudsman. The Administrator was asked for a copy of the policy on transfers to the hospital.PolicyReview of a facility policy titled, Notification of Family when Resident is sent Out to Hospital/ER (undated), it was determined that the facility policy did not address the notice containing information on the appeal process or how to contact the State office of the Long-Term Care Ombudsman.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to act in good faith as a fiduciary of the resident funds for two (Resident #2 and Resident #6) of six residents reviewed for resident trust fund interest payments. The findings include: A review of a facility policy titled, Resident Trust Fund, effective 2017 indicated, The facility will maintain resident trust accounts for residents who request the facility to manage their personal funds. The facility will act as a fiduciary and shall manage the funds responsibly, ethically, and in compliance with all relevant legal and regulatory requirements. Interest bearing accounts will be used for residents and interest will be credited to their accounts accordingly. The Administrator was to oversee compliance. A review of the resident funds bank statement from 06/01/2024 to 08/3/2025 indicated the interest rate for the resident trust fund pooled account was 0.02%, paid monthly on the account balance. Resident #2 A review of Resident #2's, Medical Diagnosis Page, indicated the facility admitted Resident #2 with diagnoses that included Dementia and Cognitive Communication Deficit. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/15/2025, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. A review of Resident #2's admission Packet's Authorizations Personal Funds, dated on 08/03/2020, revealed Resident #2's Power of Attorney (POA) initialed consent for the facility to handle personal funds. The document indicated authorization was granted for the facility to hold and disburse funds as required. A review of the Resident ledger pages for Resident #2 indicated an undated interest payment of $0.07 apparently on the 06/03/2025 balance of $1,404.45. No interest payments were made on the 07/2025 or the 08/2025 balances. Resident #6 A review of Resident #6's, Medical Diagnosis Page , indicated the facility admitted Resident #6 with diagnoses that included cerebral palsy and mild intellectual disability. The MDS, with an ARD of 07/25/2025, revealed Resident #2 had a BIMS score of 15 which indicated the resident was cognitively intact. A review of Resident #6's admission Packet's Authorizations Personal Funds, dated on 11/26/2018, revealed Resident #6's POA initialed consent for the facility to handle personal funds. The document indicated authorization was granted for the facility to hold and disburse funds as required. A review of the Resident ledger pages for Resident #6 indicated an undated interest payment of $0.08 apparently on the 06/03/2025 balance of $1,576.79. No interest payments were made on the 07/2025 or the 08/2025 balances. During an interview on 09/26/2025 at 10:53 AM, the Director of Nursing (DON) stated she had no role with the resident funds ledgers and did not have access to any of the bank accounts. During an interview on 09/26/2025 at 10:54 AM, the Assistant Director of Nursing (ADON) stated she had no role with the resident funds ledgers and did not have access to any of the bank accounts. During an interview on 09/26/2025 at 1:32 PM, the Administrator who was also acting as the Business Office Manager (BOM) stated, she did not know the interest on the resident trust fund bank account. It was her practice to add 0.0005 to the balances because her accountant stated that was the interest for [county name] and how it was done there. The Administrator stated she was not familiar with the federal regulations.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to utilize a generally acceptable accounting system for the resident trust fund to ensure no commingling of the residents' trust fund money with the facility's operational and payroll accounts, and to issue quarterly statements for six (Resident #2, #5, #6, #7, #8, and #9) of six residents reviewed for resident trust fund accounting practices. The findings include: A review of a facility policy titled, Resident Trust Fund, effective 2017 indicated, The facility will maintain resident trust accounts for residents who request the facility to manage their personal funds. The facility will act as a fiduciary and shall manage the funds responsibly, ethically, and in compliance with all relevant legal and regulatory requirements. Monthly statements will be provided and the facility shall ensure accurate tracking of all deposits, withdrawals, and balances. The Administrator was to oversee compliance. Resident #2 A review of Resident #2's, Medical Diagnosis Page, indicated the facility admitted Resident #2 with diagnoses that included dementia and cognitive communication deficit. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/15/2025, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident had severe cognitive impairment. A review of Resident #2's admission Packet's Authorizations Personal Funds, dated on 08/03/2020, revealed Resident #2's Power of Attorney (POA) initialed consent for the facility to handle personal funds. The document indicated authorization was granted for the facility to hold and disburse funds as required. A review of Resident #2's ledger page showed an available balance on 09/03/2025 of $1,524.60 with no withdrawals noted. During an interview on 09/26/2025 at 10:30 AM, Resident #2's POA stated she did not receive any type of financial statement regarding Resident #2's trust fund account from the facility. When the resident required a spin down of money or non-covered items the Administrator wrote a check. A couple of months ago the POA received a $500 check from the administrator. No receipts were returned to the facility to account for the used money and the POA stated they still had part of it they never spent. Resident #5 A review of Resident #5's, Medical Diagnosis Page, indicated the facility admitted Resident #5 with diagnoses that included Cerebral Palsy, Autism, and Epilepsy. The quarterly MDS, with an ARD of 08/05/2025, revealed Resident #5 had a Staff Interview for Mental Status (SAMS) score of 3, which indicated the resident had severe cognitive impairment. A review of Resident #5's admission Packet's revealed the resident's file did not contain a signed, Authorizations to handle Personal Funds document. A review of the Resident Trust Fund bank account statement revealed six residents had a Social Security check deposited. The Administrator indicated Resident #5's was the check for $933. There was no ledger page kept for Resident #5 to track the deposits and disposition of funds. Attempts to reach Resident #5's responsible party on 09/26/2025 at 12:50 PM were unsuccessful related to disconnected phone numbers. Resident #6 A review of Resident #6's, Medical Diagnosis Page, indicated the facility admitted Resident #6 with diagnoses that included cerebral palsy and mild intellectual disability. The annual MDS, with an ARD of 07/25/2025, revealed Resident #6 had a BIMS score of 15 which indicated the resident was cognitively intact. A review of Resident #6's admission Packet's Authorizations to handle Personal Funds, dated on 11/26/2018, revealed Resident #6's POA initialed consent for the facility to handle personal funds. The document indicated authorization was granted for the facility to hold and disburse funds as required. A review of Resident #6's ledger page showed an available balance on 09/03/2025 of $1,656.95. Application of general accounting principles revealed an error of the interest paid line to the 06/03/2025 balance resulting in the resident's 07/03/2025 $40 allowance not being credited to Resident $6's available balance. During an interview on 09/25/2025 at 10:09 AM, Resident #6 reported they did not receive any paper statements regarding their resident trust fund account. Resident #6 believed there was over $300 in their resident trust fund account and stated they give it to me when describing the process for accessing funds. Resident #7 A review of Resident #7's, Medical Diagnosis Page, indicated the facility admitted Resident #7 with diagnoses that included cerebrovascular disorder, depressive episodes, and heart disease. The quarterly MDS with an ARD of 09/11/2025, revealed Resident #7 had a BIMS of 5 which indicated the resident had severe cognitive impairment. A review of Resident #7's admission Packet revealed no Authorizations to handle Personal Funds. During an interview on 09/26/2025 at 12:55 PM, Resident #7's POA stated the Administrator wrote them a check every month and they managed the funds in their own personal account. A review of the Resident Trust Fund bank account statement revealed six residents had a Social Security check deposited. The Administrator indicated Resident #7's was the check for $1,551. There was no ledger page kept for Resident #7 to track the deposits and disposition of funds to the POA. Resident #8 A review of Resident #8's, Medical Diagnosis Page, indicated the facility admitted Resident #8 with diagnoses that included frontotemporal neurocognitive disorder, dementia, and cognitive communication deficit. The quarterly MDS with an ARD of 08/22/2025, revealed Resident #8 had a BIMS of 8 which indicated the resident had moderate cognitive impairment. A review of Resident #8's admission Packet's revealed Resident #8's responsible party initial Authorization to manage Personal Funds for Resident #8's personal funds. Attempt to reach Resident #8's responsible party on 09/26/2025 at 1:02 PM was unsuccessful related to disconnected phone number. A review of the Resident Trust Fund bank account statement revealed six residents had a Social Security check deposited. The Administrator indicated Resident #8's was the check for $927. There was no ledger page kept for Resident #8 to track the deposits and disposition of funds. Resident #9 A review of Resident #9's, Medical Diagnosis Page, indicated the facility admitted Resident #9 with diagnoses that included frontotemporal schizoaffective disorder and bipolar disorder. The quarterly MDS with an ARD of 08/21/2025, revealed Resident #9 had a BIMS of 12, which indicated the resident had moderate cognitive impairment. A review of Resident #9's admission Packet's revealed Resident #9's responsible party initialed Authorizations to manage Personal Funds for Resident #9's personal funds. A review of the Resident Trust Fund bank account statement revealed six residents had a Social Security check deposited. The Administrator indicated Resident #9's was the check for $933. There was no ledger page kept for Resident #9 to track the deposits and disposition of funds. During an interview on 09/26/2025 at 10:53 AM, the Director of Nursing (DON) stated she had no role with the resident ledgers and no access to the bank accounts. During an interview on 09/26/2025 at 10:54 AM, the Assistant Director of Nursing (ADON) stated she had no role with the resident ledgers and no access to the bank accounts. A review of the resident trust fund bank statements showed a beginning balance for the 06/02/2025 to 06/30/2025 of $59.00, the combined total for resident trust funds was $2,981.24. The resident account was missing $2,922.24. The beginning balance for the 07/01/2025 to 07/31/2025 was $517.05, the combined total for resident funds was $2,981.37. The resident account was missing $2,464.32. The beginning balance for the 08/01/2025 to 09/01/2025 was $25.06, the combined total for resident funds was $3,281.22. The resident account was missing $3,256.16. During an interview on 09/26/2025 at 8:43 AM, the Administrator stated the account ending in 3243 was a facility operational account and the account ending in 3294 was the payroll account. A review of resident liability provided by the Administrator showed as: -06/2025 Resident #2 $1,081, Resident #5 $893, Resident #6 $1,299, Resident #7 $1,511, Resident #8 $887, Resident #9 $1,157. The total liability to the resident account was $6,828. $6,600 was transferred into the facility's operational account ending in 3294. -07/2025 Resident #2 $1,081, Resident #5 $893, Resident #6 $1,299, Resident #7 $1,511, Resident #8 $887, Resident #9 $1,157. The total liability to the resident account was $6,828. $7,000 was transferred into the facility's operational account ending in 3294 and $200 was transferred into the facility's payroll account ending in 3294. -08/2025 Resident #2 $1,081, Resident #5 $893, Resident #6 $1,299, Resident #7 $1,511, Resident #8 $887, Resident #9 $1,157. The total liability to the resident account was $6,828. $6050 was transferred into the facility's operational account. $3,000 was transferred into the facility payroll account and $2,000 was transferred back into the resident trust fund account. At no time was the documented trust fund balance equal to the residents' personal ledger balance. During an interview on 09/26/2025 at 1:32 PM, the Administrator stated the facility kept resident ledgers for two residents: Resident #2 and Resident #6. The Administrator was transferring the resident funds out of the trust fund account into the facility's operational and payroll account monthly. When needed she wrote checks to Residents #2 and #6's representatives out of the facility's operational account. The Administrator stated she wrote a check to Resident #5, #7, #8, and #9's representatives for their $40 allowance out of the facility's operational account, but she did not keep a resident ledger page to show disposition of resident funds to the responsible party. The Administrator stated she transferred the resident funds balance into that account at the end of every month, I guess you would say they should be in [the resident trust fund account]. I do it so I can write a check. I do not have checks for the resident trust fund account. The Administrator stated she did not have written consent to co-mingle operational accounts with trust fund money from the residents. The Administrator stated the facility did not issue any quarterly statements to the resident or representatives for the resident trust fund accounts. The Administrator stated she was not familiar with the federal regulations in this case.

Based on observations, interviews, and record review, the facility failed to ensure 2 (Residents #5 and #14) residents and/or resident representatives was notified at least quarterly of the account activities and/or balance. The finding include: 1. According to an admission Record, Resident #5 was a Medicaid recipient. a. A review of a Participant Ledger Account Cash Journal Resident #5 had a balance of $2,176.51. b. According to an Annual Minimum Data Set (MDS) with an Assessment Reference Date 7/25/2024 Resident #5 scored 03 on the Brief Interview of Mental Status (BIMS) indication severe cognitive impairment. 2. According to an admission Record, Resident #14 was a Medicaid recipient. a. A review of Participant Ledger Account Cash Journal Resident #14 had a balance of $2,004.20. b. According to Quarterly Minimum Data Set (MDS) with the Assessment Reference Date 8/16/2024 Resident #5 scored 03 on the Brief Interview of Mental Status (BIMS) indication severe cognitive impairment. On 08/22/24 at 12:00 PM, the Administrator stated statements are not provided to residents or residents representatives unless they are requested.

Based on observations, interviews, and record review, the facility failed to ensure the residents and/or resident's representative were notified when 2 (Resident #5 and #14) sampled resident's account were within $200.00 of the maximum amount a Medicaid recipient can have in cash assets. The finding include: 1. According to an admission Record, Resident #5 was a Medicaid recipient. a. A review of a Participant Ledger Account Cash Journal Resident #5 had a balance of $2,176.51. b. According to an Annual Minimum Data Set (MDS) with an Assessment Reference Date of 7/25/2024, Resident #5 scored 03 on the Brief Interview of Mental Status (BIMS) indication severe cognitive impairment. 2. According to admission Record Resident #14 was a Medicaid recipient. a. A review of Participant Ledger Account Cash Journal Resident #14 had a balance of 2,004.20. b. According to Quarterly Minimum Data Set (MDS) with the Assessment Reference Date 8/16/2024 Resident #5 scored 03 on the Brief Interview of Mental Status (BIMS) indication severe cognitive impairment. On 08/22/24 at 12:00 PM, the Administrator stated neither the resident nor the resident representative was notified when the resident's account was within $200.00 of the allowed amount of cash assets of a Medicaid recipient. The Administrator confirmed the residents could have Medicaid payments rejected for being over the allowed amount.

Based on record review, observation, and interview, the facility failed to complete Minimum Data Set (MDS) assessments accurately for 2 (Resident #3 and #16) sampled residents. The findings are: 1. Review of an Order Summary Report revealed Resident #3 had diagnoses of heart failure, diabetes mellitus, and transient ischemic attacks (mini strokes). a. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/17/2024 indicated that the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS) and received an anticoagulant medication. b. A physician's order dated 10/3/23 indicated, .Clopidogrel Bisulfate Oral Tablet 75 MG (milligram) Give 1 tablet by mouth one time a day related to personal history of transient ischemic attack (TIA) . c. On 08/20/24 at 11:45 AM, a review of Resident #3's Order Summary Report from 07/01/2024 through 8/20/2024 did not show the resident had an order for an anticoagulant medication. d. On 08/20/24 at 11:50 AM, a review of Resident #3's Medication Administrator Record (MAR) for July 2024 did not show that the resident received an anticoagulant medication. e. On 08/20/2024 at 1:51 PM, during an interview the MDS Coordinator stated that she had incorrectly coded the antiplatelet medication Clopidogrel as an anticoagulant on Resident #3's quarterly MDS assessment dated [DATE]. The MDS Coordinator stated it was important to code the MDS correctly because the information entered into the MDS was linked to the resident's care plan and the care that the resident receives. f. On 08/21/2024 at 11:00 AM, the Administrator was asked if the facility had a policy on accuracy of MDS assessments. g. On 08/21/24 at 11:30 AM, the policy titled, Accuracy of care plan/MDS indicated, .It is crucial that the Minimum Data Set (MDS) assessment is accurate and comprehensive to ensure proper care and treatment of residents . 2. A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/20/2024 revealed Resident #16 had a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident was cognitively intact, and that Resident#16 had diagnoses of bipolar disorder and schizophrenia. a. A Care Plan for Resident #16, revision on 2/21/2024, revealed the resident was taking psychotropic medications related to bipolar schizoaffective disorder. b. Review of the State Designated Professional Associates letter dated July 23rd, 2018, provided by the facility showed Resident #16 did not require specialized services for the mental illness, intellectual disability, and/or developmental disability beyond the capabilities of a nursing facility. c. On 08/20/24 at 10:55 AM, the Minimum Data Set (MDS) Coordinator stated Resident #16 was considered by the state level II Preadmission Screening and Resident Review (PASRR) process to have serious mental illness and/or intellectual disability, or a related condition and that information should have been reflected on the comprehensive assessment. d. On 08/22/24 at 11:15 AM, the Director of Nursing (DON) confirmed Resident #16 was considered by the state PASRR level II process to have serious mental illness and/or intellectual disability and that information should have been reflected on the comprehensive assessment. The DON stated if the assessment was not accurately completed the resident's care could have been affected.

Based on record review, observation, interview and policy review, the facility failed to ensure staff washed hands, changed gloves and followed infection control precautions appropriately during medication administration, wound care for 1(Resident #17) sampled resident, and enteral feedings for 1(Resident #9) sampled residents. The findings are: 1. On 08/20/24 at 11:30 AM, the Survey observed Licensed Practical Nurse (LPN) #1 administer medication to 5 residents without using proper hand hygiene before or after medication administration. The Surveyor observed LPN #1 wipe sweat from her face and wipe her nose with her hands without using hand hygiene afterwards or prior to an encounter with a resident. The Surveyor observed LPN #1 handling cups by placing her finger inside the cup used to provide water for medication administration. The Surveyor observed LPN #1 touch computer, medication cart, keys, and mouse with gloves used check blood glucose. 2. A review of Physician's orders indicated Resident #9 had an order to receive enteral feed every 4 hours 250 milliliters (ML) and flush with 100 cubic centimeters (cc) of water (H2O) before and after meals and medication administration via Percutaneous Endoscopic Gastrostomy (PEG). a. According to Quarterly Minimum Data Set with the Assessment Reference Date of 8/1/2024 indicated that Resident #9 scored 03 on the Staff Assessment for Mental Status indicating the resident was severely impaired. Resident #9 had diagnoses of cerebral palsy, autistic disorder, and dysphagia (difficulty swallowing). Resident #9 had a feeding tube while a resident. b. A Care Plan for Resident #9, revision on 5/02/2024, revealed Resident #9 required tube feeding related to dysphagia and had nutritional problem or potential nutritional problem related to PEG tube used for feeing Resident #9 was on Enhance Barrier Precautions which required staff to wear gowns and gloves when providing high contact resident care. c. On 08/20/24 at 1:05 PM, the Surveyor observed LPN #1 cough toward the open nutritional supplement held in her right gloved hand then poured more of the supplement into the PEG tube. The Surveyor observed LPN #1 remove left gloved from holding the PEG, wipe sweat from her forehead with left gloved hand, and place left gloved hand back on the PEG tube. The Surveyor observed LPN #1 cough a second time toward to the open nutritional supplement held in her right gloved right gloved hand prior to pouring the remaining amount in the PEG tube. The Surveyor observed LPN #1 cap the lumen on the PEG tube using both left and right gloved hands. d. On 08/20/24 at 1:47 PM, LPN #1 confirmed she did not wash or sanitize hands between administrating medications to 5 residents. LPN #1 confirmed she potentially contaminated the supplement when she coughed in the direction of the open nutritional supplement held in the right hand. e. On 08/22/24 at 11:15 AM, the Director of Nursing (DON) stated the nurse should have used hand hygiene between each resident and after hands encounter bodily fluids. The DON stated hand hygiene was important to maintain a clean environment and not spread germs from resident to resident or from staff to resident. f. A policy titled Handwashing noted Wash hands: after using restroom, between handling of individual patients, after blowing or wiping nose, leaving an isolation area. 3. Review of an Order Summary Report showed Resident #17 had diagnoses of Diabetes Mellitus with diabetic neuropathy, history of transient ischemic attack, non-pressure chronic ulcer to left foot, carrier or suspected carrier of methicillin resistant staphylococcus aureus. a. The quarterly Minimum Data Sheet (MDS) with a date of 8/8/24 indicated a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact). b. A physicians order dated 8/14/24 showed .Order Summary: Cleanse wound to top left foot with NS (Normal Saline) and pat dry. Apply calcium alginate with silver to wound bed. Apply calmoseptine to skin around wound bed. Cover with abdominal pad and wrap with gauze and secure with tape. every day shift for diabetic ulcer PRN (as needed) or if visibly soiled . c. A care plan with an initiated date of 08/08/2024 indicated the resident had stage 2 pressure ulcer left foot and potential for further pressure ulcer with potential for further skin problems due to diabetes and immobility. Goal: The resident will not have further skin issues or skin deterioration. d. On 8/20/2024 at 1:43 PM, LPN # 2 prepared wound care supplies, then applied gloves after using hand sanitizer. Resident # was on enhanced barrier precautions, LPN #2 put on a gown, and gloves, entered the resident's room, removed dressing to left foot, did not remove gloves, touched floor, performed wound care as ordered, did not remove gloves or cleanse hands during wound care and placed dressing on bare floor without a barrier device. f. On 8/20/2024 at 2:00 PM, the Surveyor conducted an interview with LPN # 2. The surveyor asked LPN #2 when gloves should be changed and hands washed during wound care and should bandage/wound care supplies be placed on the bare floor. LPN #2 stated they had only been a nurse since last June and we were never trained on wound care. g. On 8/22/2024 at 11:00 AM, the Surveyor interviewed the DON regarding Inservice training on hand washing or wound care. No Inservice/training was provided. h. On 8/22/2024 at 11:45 AM, the Surveyor asked the DON when a nurse providing wound care should wash hands and change gloves. The DON responded wash hands and change gloves before providing wound care and before applying new dressing. h. The facility provided a policy titled Infection Control, Standard Precautions that indicated, change gloves between tasks and procedures on the same resident after contact with material that may contain microorganisms.

Based on observations, interviews, and facility policy review, the facility failed to ensure 1 (Resident #16) sampled resident's personal and health information was properly protected. The findings include: A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/20/24 revealed Resident #16 had a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. On 08/20/24 at 11:45 AM, the Surveyor observed Licensed Practical Nurse (LPN) #1 leaving a laptop unattended while Resident #16's personal and medical information was visible on the screen. On 08/21/24 at 11:47 AM, LPN #1 confirmed the laptop was left open and stated the computer should have been pushed down. On 08/22/24 at 11:15 AM, the Director of Nursing (DON) stated the nurse should have put the laptop computer screen down prior to walking away to make sure patient information was hidden. The DON stated it was a risk to the resident's privacy and a violation of the Health Insurance Portability and Accountability Act (HIPAA) if the unattended laptop screen was left up and displayed a resident's personal and health information. A policy titled Privacy Policy for Electronic Health Records (EHRs) 5.3 Confidentiality - Confidentiality: All electronic health records will be kept confidential. All staff must maintain this practice while away from the nurses station. Screens on electronic devices must be hidden.

Based on observations, interviews, and facility policy review, the facility failed to ensure medications were stored securely in an unattended medication cart. The findings include: On 08/20/24 at 12:00 PM, the Surveyor observed Licensed Practical Nurse (LPN) #1 leave a medication cart unlocked, unattended, and out of view while in a resident's room. On 08/20/24 at 1:46 PM, LPN #1 stated the medication cart should be locked prior to leaving it unattended. LPN #1 stated if the medication cart is left unlocked when unattended someone could get in it and get something. On 08/22/24 at 11:15 AM, the Director of Nursing (DON) stated the nurses should make sure the medication cart is locked and the screen is hidden prior to walking away. The DON stated if the medication cart was left unlocked a resident could have gotten inside the medication cart and gotten something that could have harmed them. A policy Medication Storage noted 3. Security Locking Mechanism: Use the locking feature of the cart to restrict access to authorized personnel only.

Based on observation and interview, the facility failed to ensure leftover food items were used to maintain food quality; 1 ice machine was maintained in clean and sanitary condition; food stored in the dry storage area refrigerator, and freezer were covered, or sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from I of I kitchen; failed to ensure foods were dated the day received to assure first in, first out usage to prevent potential for food bone illness; floor tiles were free of chipped, stains, air vent was free of rust; wall baseboard was free of stains, secured and were maintained in clean sanitary conditions; dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 28 residents who received meals from the kitchen, (total census:30) as documented on a list provided by the Dietary Supervisor on 09/11 /2023 at PM The findings are: 1. On 09/10/23 at 09:51 AM a pan of leftover pureed eggs, pan of pureed oatmeal and a pan of ground sausage were on a shelf in the up-right refrigerator. The surveyor asked Dietary Employee (DE) #1 what do you use the leftover pureed eggs, pureed oatmeal, and ground sausage for? She stated, We use it for the pureed diet the next morning. 2. On 09/10/23 at 09:56 AM, the following observations were made in the kitchen area. a. The floor between the hand washing sink, deep fryer and upright refrigerator had accumulation of grease on it. b. The wall above the deep fryer and the stove had grease stains. c. The floor tiles under and in front of the deep fryer and under a cart where boxes of oil were kept were missing. The areas that were missing had black caked on greasy residue in it. d. There was a gap under the stove. The area that was exposed had debris. e. The floor leading to the Janitor's closet, between a rack and the counter by the milk refrigerator were chipped exposing the cement. 3. On 09/10/23 at 10:06 AM the ice machine panel in the kitchen had wet black residue on it. The surveyor asked DE #1 to wipe the panel. The wet residue easily transferred to the tissue. She stated, They were black stains. The Surveyor asked DE #1, who uses the ice from the ice machine, and how often do you clean it? She stated, That's the ice the CNAs [Certified Nursing Assistants] use for the water pitchers in the residents' rooms and the residents' beverages at the mealtimes. We clean it once a month. 4. On 09/10/23 at 10:08 AM three containers of potato salad were on a shelf in the refrigerator. There was no received date on them. 5. On 09/10/23 at 10:13 AM an opened box of cookies was on a shelf in the freezer. The box was not covered or sealed. 6. On 09/10/23 at 10:27 AM there were 2 bags of hot dog buns on a shelf in the freezer. The bags had an expiration date of 6/17/2023. 7. On 09/10/23 at 10:32 AM the floor leading to the storage room, dining room, and in front of the freezer and refrigerator were chipped. The areas that were chipped had an accumulation of dirt and debris. 8. On 09/10/23 at 11:11 AM the baseboard on the wall above the metal around the dish washing machine was loose. The areas that were exposed had accumulation of back residue on it. 9. On 09/10/23 at 11:15 AM DE #2 took a carton of milk in the kitchen after passing a 10:00 AM snack. When she was ready to put it in the milk refrigerator, the Surveyor asked DE #2 to check the temperature of the milk. She did and stated, it was 47 degrees Fahrenheit. The Surveyor asked DE #2 what temperatures should the cold foods be? The Assistant Supervisor stated 41% Fahrenheit. 10. On 09/10/23 at 03:30 PM DE #2 opened the cabinet and removed a box of zip lock bags and placed the bag on the counter. Without washing her hands, she placed gloves on her hands, then used her contaminated gloved hand to place cookies in the zip lock bags to be served to the residents for supper meal. 11. On 09/11/23 at 10:46 AM DE #2 removed a box of nectar thickened lemon-flavored water, 4 boxes of supplemental shake, balanced nutritional drink, 2 boxes of boost control, muscle health energy rich chocolate, a pitcher of sweetened tea, a pitcher of unsweetened tea and placed them on the counter. Without washing her hands, she picked glasses by their rims and placed them on the counter. She then poured beverages in the glasses to be served to the residents for lunch. The surveyor asked DE #2 what should be done after touching dirty objects and before handing clean equipment? She stated, Washed my hands. 12. On 09/11/23 at 10:56 AM DE# 4 wore gloves on her hands when she turned on the food preparation sink faucet and rinsed tomatoes. She then turned off the faucet with the same gloves. With the same gloves DE #4 placed tomatoes on the cutting board and sliced them to be served to the residents for supper. At 10:59 AM DE #5 placed sliced tomatoes into a pan. The surveyor asked DE #5 what should you have done after touching dirty objects and before handing clean equipment. She stated, I didn't think about it. I should have washed my hands. 13. On 09/11/23 at 11:25 AM DE #3 walked into the kitchen from outside. Without washing her hands, she picked up 2 pans and placed them on the steam table with her fingers touching inside the pans. She picked a pot of peas from the stove to empty it into the pan to be served to the residents for lunch. The Surveyor asked DE #3 what should have done after touching dirty objects and before handing clean equipment? She stated, I should have washed my hands. 14. On 09/11/23 at 11:37 AM DE #3 scratched her head. Without washing her hands, she picked up a clean blade and attached it to the base of the blender. When she was ready to place food items in the blender the surveyor asked DE#3 what should you have done after touching dirty objects and before handing clean equipment? She stated, I should have washed my hands. 15. On 09/11/23 at 11:58 AM DE #5 removed a pan of pineapple and placed it on a pan of ice on the counter by the steam table. Without washing her hands, she picked a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the resident on a puree diet. The surveyor asked DE #5 what should you have done after touching dirty objects and before handing clean equipment? She stated, I should have washed my hands. 16. The facility policy titled, hand washing policy for dietary staff provided by the Administrator on 9/11/2023 at 2:00 PM showed, All staff members must wash their hands before starting work or entering the dietary area. After touching their face, hair, or any other body parts and after any other activity that may contaminate their hands. On 9/12/23 at 8:05 AM a policy was received from the Director of Nurses titled, Food Quality. It showed, .Pureed food shall be prepared fresh as needed, ensuring that it meets the nutritional requirements and preferences of each resident .

Based on observation, record review, and interview the facility failed to ensure indwelling urinary catheter tubing was not in plain sight to provide dignity for 1 (Resident #1). The findings are: On 9/11/2023 at 2:45 PM observed Resident #1 in a chair in the lobby/common area with 8 other residents present. A urinary catheter tube was observed protruding through the front opening area of the resident's pants and hung down into a privacy bag attached to chair. The urinary catheter tube was visible to all other residents and staff in the lobby area. On 9/11/23 at 3:00 PM observed Resident #1 in the Resident Council meeting with 4 other residents, the urinary catheter tube was protruding through the front opening of the resident's pants and was visible to all in the meeting. During an interview on 9/11/2023 at 4:00 PM, CNA #1 confirmed the urinary catheter tube should be covered and stated, it's a dignity thing. During an interview on 9/11/2023 at 4:10 PM Licensed Practical Nurse (LPN) #1 confirmed the catheter tubing protruding from the resident's pants should be covered. On 09/11/2023 at 4:15 PM the Director of Nurses (DON) confirmed the catheter tubing should be covered. Review of document titled, Foley Cath/peg tube dignity, undated, showed .foley tubing must be covered or discretely placed beside person .

Based on observation and interview, the facility failed to ensure the residents had knowledge of the State Inspection Book, and to make it accessible to them if they chose to read it. The findings are: a. On 9/11/23 at 3:10 pm, during a Resident Council Meeting, the Surveyor asked the residents if they were familiar with the State Inspections Book and where it was located in the facility. All 5 Residents stated they were not aware of the State Inspections Book, or where it was located. b. On 9/11/23 at 3:13 pm, observed the State Inspection Book in the front of the facility in the walkway by the front door. There was a locked door in the dayroom which led into the walkway where the book was located. c. On 9/11/23 at 3:15 pm, the Surveyor asked the Administrator if the residents want to read the State Inspection Book how will they be able to read it since the door leading to it was locked. The Administrator stated, if the residents want to read the book they ask, and we let them read it. The Surveyor asked the Administrator, should the residents have to ask to read the book? The Administrator stated, they should not have to ask for it. d. On 9/12/23 at 2:33 pm, the Surveyor asked the Director of Nursing (DON), who is responsible for letting the residents know about the State Inspections Book? The DON stated, the Activities Director or Social Services. The Surveyor asked, should the State Inspections Book be accessible to the residents at all times? The DON stated, yes.