Every finding on record at Silver Cross Health & Rehab

Based on observation, interview, and policy review, the facility failed to maintain a safe, functional, and homelike environment for residents in a common area, Specifically, the facility failed to repair missing floor tiles in the dining room, a high-traffic area for four (4) out of 4 days of survey.Findings include:A review of the facility's Resident Rights policy revealed, The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.On 12/08/2025 at 12:10 PM, chipped and partially missing floor tiles were observed in the front right section of the dining room.On 12/09/2025 at 12:05 PM, during the lunch dining period, the chipped and missing tiles remained unrepaired.On 12/10/2025 at 2:11 PM, chipped and missing tiles were again observed in the dining room common area for the third consecutive day of the recertification survey.On 12/10/2025 at 12:24 PM, in an interview with the Maintenance Director, he stated that chipped tiles could cause a tripping hazard and that he attempts to glue tiles down as needed when he notices they become loose or missing. He acknowledged that he was unaware of the currently missing tiles in the dining room and stated that no work order had been submitted.On 12/10/2025 at 4:15 PM, during an interview with the Director of Nursing (DON), he stated that the area with missing tiles could pose a tripping hazard. He acknowledged that Certified Nursing Assistants and nurses are routinely present in the dining room during meals and could have submitted a work order. He stated that the area with missing tiles was typically covered by a long table, and the issue may have only been recently visible due to the placement of a Christmas tree.On 12/11/2025 at 11:25 AM, chipped tiles continued to be observed in the same area for the fourth consecutive day of survey.On 12/11/2025 at 1:03 PM, in an interview with the Nursing Home Administrator (NHA), he stated that the Maintenance Supervisor provides new staff with orientation on submitting work orders for environmental concerns. However, he confirmed there was no formal policy in place to address environmental safety hazards such as chipped or missing flooring.

Based on observation, interview, and facility policy review, the facility failed to ensure food items were stored under sanitary conditions by not removing expired food from the dry storage area for one (1) of three (3) observation days. This failure had the potential to result in foodborne illness for residents consuming food from the kitchen. Findings Include:A record review of the facility's First IN First Out (FIFO) policy undated revealed a product rotation is important for both quality and safety reasons. FIFO means that the first batch product prepared in storage should be used first. Identify the food items use by or expiration date. Throw out food that has passed its manufacturers use or expiration date.On 12/8/25 at 10:20 AM an initial tour of the kitchen revealed the following items were expired and found in the dry storage room: Honey grade A five (5) ounces opened 12/9/24 expiration 10/10/25. There were 5 bottles of lemon juice that expired on 4/5/25. There were two gallons of Monarch Italian dressing expiration 10/2/25.On 12/8/25 at 11:08 AM in an interview with the Dietary Manager (DM) stated the cook is responsible for pulling expired food. She stated the staff should rotate items when putting up stock. She stated it is her responsibility to make sure staff do their job. She stated expired foods could make residents sick.On 12/11/25 at 3:14 PM in an interview with the Nursing Home Administrator (NHA) stated he expects staff to monitor daily and staff to pull all foods expired.

Based on observation, interview, facility policy review, and record review, the facility failed to implement the care plan interventions related to hearing needs and activity of daily living (ADL) needs for one (1) of 17 sampled residents (Resident #10). Specifically, the facility failed to follow up on a June 2025 audiology appointment that documented the need for further evaluation, failed to ensure the resident had functional hearing aids per her preferences and needs, and failed to coordinate care in accordance with the resident's care plan and physician orders.Findings Include:A record review of the facility's policy, Comprehensive Plan of Care with a revision date of 2/17/25, revealed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident consistent with residents rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing.needs and all services that are identified in the residents comprehensive assessment and professional standards of quality.A record review of Resident #10 Comprehensive care plan revealed interventions to refer to audiology for hearing consult and assist with all ADL's and personal hygiene needs every shift and as needed.Observation and interview on 12/08/2025 at 2:11 PM Resident #10 has a moderate amount of grey hair under her chin and upper lip. She confirmed that she does not like the hair on her face. She stated that if she is lucky, they will shave her twice a week. She stated she was shaved early last week. She wants to be shaved every other day. An interview with Certified Nursing Assissant #1(CNA) on 12/10/2025 at 10:49 AM confirmed that Resident #10 had a moderate amount of facial hair and had not been shaved in days. She stated the resident has expressed to her that she does not like the facial hair on her face and wants it shaved.An interview with the Director of Nursing (DON) on 12/10/2025 at 3:32 PM stated that Resident #10 should be shaved when it is needed. He expects staff to do Activities of Daily Living (ADL) care daily. In an interview on 12/08/2025 at 2:00 PM Resident #10 stated she needs her new hearing aids. She stated she went to a doctor five months ago and still does not have new hearing aids. She stated they took her to a Miracle Ear Physician in a nearby city.An interview with Social Worker (SW) on 12/10/25 at 4:13 PM confirmed that Resident #10 was sent out to a nearby city for hearing evaluation in June. She stated she does not have the visits summary and will have to call to get it faxed over.On 12/11/25 at 11:15 AM an interview with DON stated Resident #10 was sent to Miracle Ear at her request. He stated if the physician office sends a summary, it would be bought back CNA #2 Transportation Aid. He stated sometimes the physician will fax summaries. He stated a CNA or nurse could get the summary if it does not come back with transportation. He confirmed that no one had followed up with getting the physician summary.A record review of Resident #10 Appointment Summary dated 6/3/25 from her hearing aid supplier revealed Outcome results: Needs further evaluation. Outcome Notes: impacted. The patient brought aids in they were stopped up. Cleaned and changed domes. Patient hearing better. Will get ears cleaned out and come back when she can.On 12/11/25 at 12:29 PM in an interview with CNA #2 /transportation stated she took resident to her Miracle Ear appointment. She stated she goes back with resident for appointment to make sure nothing is missed. She stated when the summary is given to her, she gives it to the Unit Manager. She stated she was informed by physician that Resident #10 ear and hearing aid was packed with wax. She was not given the summary to bring back. She stated she makes follow up appointments and if knew she would have made appointment for evaluation.On 12/11/25 at 2:04 PM in an interview with Registered Nurse #2/Care Plan Nurse stated the care plan is used by all staff for providing care. The care plan lets staff know preferences. She stated that if ADL is not done the care plan was not followed. She further stated the care plans also revealed need further evaluation by the Audiologist and if it was not done after the Audiologist visit in June, then care plan was not followed. On 12/11/2025 at 2:09 PM in an interview with the DON stated the physician at Miracle Ear should have followed up with the facility. He stated if he had known what the summary revealed he would have called the physician for clarity. A record review of Resident #10 admission Record revealed an admission date of 10/16/24 with diagnosis of Encounter for Prophylactic Measures, Unspecified and Vitamin D Deficiency Unspecified. A record review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/9/25 revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicates cognitively intact.

Based on interview and record review, the facility failed to ensure accurate and complete documentation of advance directive status for one (1) of seventeen (17) sampled residents, Resident #5. Findings include: A record review of the admission Record revealed the facility admitted Resident #5 on 3/25/25 and she had diagnoses including Type 2 Diabetes Mellitus. A record review of the Acknowledgement of Advance Directives Decisions, Rights, and Information, signed by the resident representative (RR) and dated 3/25/25, indicated, I have formulated the following advance directives before admission to this facility. There was no indication as to what type of advance directive was formulated and there was also an x indicating I decline to formulate an Advance Directive at this time. On 12/09/2025 at 10:42 AM, in an interview with the Admissions Coordinator/Staff Scheduler, she stated she had searched for to see if any type of Advance Directive was provided to the facility. She was unable to find a copy and stated that she believed the RR initialed the form indicating an Advance Directive was formulated was done in error. On 12/10/2025 at 11:06 AM, in an interview with the Director of Nursing (DON), she stated the Acknowledgement of Advance Directives Decisions, Rights, and Information had been corrected on 12/9/25 and Resident #10 did not have an Advance Directive. On 12/11/2025 at 1:30 PM, in a joint interview with the Administrator and the Admissions Coordinator/Staff Scheduler, the Administrator stated that they were in the process of changing the Advance Directive form to make it more user friendly and less confusing.

Based on observation, interview, facility policy review and record review, the facility failed to ensure that one (1) of three (3) residents (Resident #8) assessed as moderately cognitively impaired was properly evaluated for the safe self-administration of medication. Findings Include:A record review of the facility's policy, Self-Administration of Medication and Bedside Medication with a revised date of 3/10/25 revealed this facility's policy is that residents may self-administer their medications given the approval of the interdisciplinary or care planning team. A resident may administer his/her own medications if the disciplinary team determines that this practice is safe. A Self-Administration evaluation should be completed in the Electronic Health Record. (EHR)On 12/08/2025 at 4:13 PM an observation and interview revealed Resident #8 with a 3.5-ounce jar of Vapor Rub on his bedside table . Resident #8 stated he uses it as he needs it and he brought it from home. He stated he rubs it under his nose. He stated staff do not know when he uses it but he was using it at home.On 12/09/2025 at 2:50 PM in an interview and observation of Resident #8 with the Director of Nursing (DON) the Vapor Rub remains on the bedside table. Resident #8 stated I use that on my nose when I have a cough or cold. On 12/09/2025 at 3:18 PM in an interview with the DON he stated Resident #8 should not have Vapor Rub at bedside. He stated that for a resident to self-administer medications there are multiple assessments that should be completed. He stated he can have inhalation issues by using it on his own and breathing it in his nares. He confirmed Resident #8 has not had any self-administration of medication assessments done.A record review of Resident #8's admission Record revealed an admission date of 10/23/25 with diagnoses including Vascular Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance and Anxiety, and Primary open-angle Glaucoma, right eye, moderate stage.A record review of Resident #8's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/29/25 revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicates moderately impaired cognition.A record review of Resident #8's Physician Orders revealed there was no order for Vapor Rub.

Based on resident and staff interviews, facility policy review, and record review, the facility failed to ensure one (1) of four (4) sampled residents (Resident #25) was treated with dignity and respect by staff during care and communication. Findings Include:A record review of the facility Resident's Rights policy revealed the resident has a right to be treated with respect and dignity.On 12/10/25 at 4:30 PM, in an interview with Licensed Practical Nurse (LPN) # 4, she stated there had been concerns raised regarding a nurse, LPN #3, who was reported for interactions with multiple residents, including Resident #25 and Resident #11, and who often works the A hall. LPN 4 described the issue as related to tone and arguing with residents.On 12/11/25 at 9:01 AM, in an interview with Resident #25, he stated that LPN # 3, who works the night shift, talks to him in a loud and gruff tone, which he compared to a police officer. He reported she does not threaten residents but does not speak to them in a respectful or dignified manner.On 12/11/25 at 9:15 AM, in an interview with the Director of Nursing (DON), he confirmed that a recent complaint had been investigated regarding LPN #3 although it was unsubstantiated. He stated that while her tone is structured, there had been no formal complaints related to her communication style.On 12/11/25 at 9:30 AM, in an interview with Resident #11 she described LPN # 3 as someone who often argues with Resident # 25 and raises her voice, stating that she likes to be loud and get smart with him, especially when the resident calls the nurse baby and she argues with him loudly and tells him not to call her that.On 12/11/25 at 11:10 AM, in an interview with LPN # 3, she stated she had never received formal complaints but acknowledged that she had been in-serviced recently regarding tone due to residents not being able to hear her, leading her to raise her voice at times. She admitted redirecting residents like Resident #25 who call her pet names such as sugar by asking them to use her name instead.A record review revealed Resident #11 admission Record revealed was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis.Record review of Resident #11's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/27/25 revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating cognitive intactness.A record reviewed of Resident #25 admission Record revealed he was admitted on [DATE] with a diagnosis of Chronic Diastolic Congestive Heart Failure.Record review of Resident #25's MDS with an ARD of 11/17/25 revealed a BIMS score of 15 indicating no cognitive impairment.

Based on observation, interview, facility policy review, and record review, the facility failed to maintain appropriate infection prevention and control practices during enteral medication administration for one (1) of three (3) residents reviewed for infection control concerns (Residents #27). Findings Include: A record review of the facility's policy Infection Prevention and Control Program with a revision date of 2/17/25 revealed this facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines .11. Equipment Protocol: a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment. Resident #27: On 12/10/25 at 1:04 PM, Licensed Practical Nurse (LPN) #5 was observed administering Percutaneous Endoscopic Gastrostomy (PEG) tube meds to Resident # 27, at this time, the nurse took the syringe apart to drain meds into the stomach by gravity with the peg tube and placed the syringe plunger onto the bedside table next to other household items without laying it on clean barrier or disinfecting the table. After the task was completed, the nurse rinsed the syringe with water and placed it back into the resident's zip lock bag on the bedside pole and exited the room. In an interview on 12/10/25 at 1:07 PM LPN #5 was asked if a barrier should have been used to place the syringe on, she stated yes, to prevent from spreading infections to the resident. She stated she rinsed it so it should have been okay. When asked if she used soap and water, she said no but she patted it dry. LPN #5 was asked if she thought this was sufficient to clean the bacteria off from the bedside table before another nurse uses it for a feeding and she said no, I'll get a new syringe for the resident. On 12/10/25 at 2:52 PM in an interview with the Infection Preventionist LPN #2, she stated that the plunger of the PEG tube syringe should not have been placed on a surface such as the bedside table without a barrier due to it being a contaminated surface and not knowing what is on that surface. It could spread infection and cause possible infection to the resident since the syringe directly goes into the stomach, she stated the nurse should have replaced the syringe and not placed it back on the pole for someone else to come by and use later. At 10:05 AM on 12/11/25 in an interview with the Director of Nursing (DON), he stated that a barrier should have been laid down between the syringe plunger and the table and it should have been properly cleaned or disposed of and a replacement obtained in this situation since it was contaminated. A record review of the admission Record revealed Resident #27 was admitted on [DATE] with a diagnosis of Parkinson's Disease. A record review of the most recent Minumum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/10/25 revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated a mild cognitive impairment.

Based on observation, interview, and record review, the facility failed to ensure that professional nursing standards were followed during percutaneous endoscopic gastrostomy (PEG) tube care for one (1) of one (1) resident (Resident #44) reviewed for enteral nutrition. Findings Include:On 12/10/2025 at 10:00 AM in an observation of Registered Nurse #1 (RN)/Wound care provide peg tube care to Resident #44, she cleaned the PEG site with a gauzed soaked in wound cleaner. She cleaned the site using the same gauze in a circular motion four times without discarding and replacing it with a new gauze for each wipe, as per infection control standards. On 12/10/2025 at 10:12 AM in an interview with RN #1 stated she should have discarded the gauze and got another one while cleaning the site. She stated it could cause Resident #44 to get an infection. If infection is at the site, it could have spread the infection.On 12/10/2025 at 3:35 PM in an interview with the Director of Nursing (DON) stated that RN#1 should have wiped once and discarded gauze with each wipe. She should not have continuously wiped in circular motion that could cause infection around the PEG site, skin irritation, and discomfort to the resident.A record review of Resident #44 admission Record revealed an admit date of 1/5/24 with diagnosis of Hemiplegia and Hemiparesis following other Nontraumatic Intracranial Hemorrhage affecting Right Dominant side and Dysphagia following other Non-traumatic Intracranial Hemorrhage.A record review of Resident #44 Physician orders revealed cleanse PEG tube site with wound cleanser and pat dry, apply sure prep topically under and around peg tube, cover with drain sponge, and secure with paper tape and as needed.A record review of Resident #44 Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/29/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicates cognitively intact.A record review of RN #1 Licensed Nurse Competency revealed she was checked off on PEG tube management by lecture and direct observation on 6/25/25.

Based on observation, interview, and record review, the facility failed to ensure that a resident received care consistent with professional standards of practice and physician orders for the treatment of a pressure ulcer for one (1) of three (3) residents reviewed for pressure ulcers (Resident #38). Findings Include:Record review of Resident #38's physician orders revealed an order dated 12/10/25 to cleanse the Stage 3 pressure ulcer to the coccyx with normal saline, pat dry, apply Medi-Honey to the wound bed, place calcium alginate over the honey, and cover with border foam dressing daily.On 12/10/2025 at 10:58 AM, wound care was observed being administered to Resident #38 by Registered Nurse (RN) #1 with the assistance of Licensed Practical Nurse (LPN) #1. During the procedure, RN #1 applied Zinc Oxide ointment around the edges of the wound after completing the ordered wound care.On 12/10/2025 at 11:15 AM, during an interview RN #1 verified that Zinc Oxide was not listed as an active order for Resident #38 on the Medication Administration Record (MAR).On 12/10/2025 at 12:40 PM, during an interview with the Director of Nursing (DON), he confirmed that medical orders must be followed as written and that the addition of Zinc Oxide without a physician's order did not align with the established wound care plan.Record review of admission Record revealed that Resident #38 was admitted on [DATE] with diagnoses that included cerebral infarction, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the left dominant side, and a Stage 3 pressure ulcer of the sacral region. Record review of Resident #38's Minimum Data Set (MDS) with an Assessment Reference date of 10/16/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident is cognitively intact.

Based on observation, interview, facility policy review, and record review, the facility failed to ensure timely follow-up and coordination of care related to hearing needs for one (1) of three (3) residents reviewed for sensory impairment (Resident #10). Specifically, the facility failed to ensure the resident's hearing aids were functional, to act on evaluation results that indicated further follow-up was needed, and to implement or revise care plan interventions related to hearing loss. These failures resulted in the resident experiencing prolonged difficulty hearing and unmet sensory needs.Findings Include:A record review of the facility's Physician Order Review policy dated 1/9/15 revealed, Purpose: To ensure safety and comply with standards of care. To verify the necessity to initiate, continue or change appropriate treatments as ordered. To maintain appropriate continuity in resident care.On 12/08/2025 at 2:00 PM Resident #10 stated she needs her new hearing aids. She stated she went to a doctor five months ago and still does not have new hearing aids. She stated they took her to a Miracle Ear Physician in a nearby city.On 12/10/25 at 4:13 PM an interview with Social Worker (SW) confirmed that Resident #10 was sent out to a nearby city for hearing evaluation in June. She stated she does not have the visits summary and will have to call to get it faxed over.On 12/11/25 at 8:45 AM the Director of Nursing (DON) confirmed that they did not have appointment summary yet. He stated the Miracle Ear is requesting consent to fax summary.On 12/11/25 at 9:10 AM an interview with SW confirmed she had to get it faxed to the facility. She stated usually CNA aid brings the summary back when a resident goes out to an appointment.On 12/11/25 at 11:01 AM in an interview with SW stated Resident #10 went to a local hearing aid supplier. She stated she was sent out to them by resident request. She stated she was aware of resident hearing issues upon admission. She stated Certified Nursing Assistant #2 (CNA) is the Transportation Aide. She stated that usually transportation aid brings back the summary. The Unit Manager or Medical records request summaries if they are not brought back to the facility.On 12/11/25 at 11:15 AM an interview with the DON he stated Resident #10 was sent to the hearing aid supplier at her request. He stated if the physician office sends a summary, it would be bought back by CNA #2 Transportation Aide. He stated sometimes the physician will fax summaries. He stated a CNA or nurse could get the summary if it does not come back with transportation. He confirmed that no one had followed up with getting the physician summary. There is no specific person that gets the summary from physician offices and follows up.On 12/11/25 at 12:29 PM in an interview with CNA #2 /Transportation stated she took Resident #10 to her hearing aid appointment. She stated she goes back with resident for appointment to make sure nothing is missed. She stated when the summary is given to her, she gives it to the Unit Manager. She stated she was informed by physician that Resident #10 ear and hearing aid was packed with wax. She was not given the summary to bring back. She never was given the summary or made aware of the follow-up appointment. She stated if she knew she would have made appointment for evaluation.On 12/11/2025 at 2:09 PM in an interview with the DON stated the physician at the hearing aid supplier should have followed up with the facility. He stated if he had known what the summary revealed he would have called the physician for clarity.A record review of Resident #10 admission Record revealed an admission date of 10/16/24 with diagnosis of Encounter for Prophylactic Measures, Unspecified and Vitamin D Deficiency Unspecified.A record review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/9/25 revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicates cognitively intact.A record review of Resident #10 Appointment Summary dated 6/3/25 from her hearing aid supplier revealed Outcome results: Needs further evaluation. Outcome Notes: impacted. The patient brought aids in they were stopped up. Cleaned and changed domes. Patient hearing better. Will get ears cleaned out and come back when she can.

Based on observation, interview, facility policy review, and record review, the facility failed to ensure grooming needs were met in accordance with the resident's preferences and needs for one (1) of three (3) residents reviewed for activities of daily living (Resident #10). Specifically, the facility failed to provide facial shaving per resident request and failed to document refusal of care when shaving was not provided, resulting in unaddressed personal hygiene needs and potential negative impact on resident dignity. Findings Include:A record review of the facility's policy, Activities of Daily Living revised 9/16/22 revealed, .Care and services will be provided for the following activities of daily living: bathing, dressing, grooming, and oral care.3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral care.On 12/08/2025 at 2:11 PM observation and interview of Resident #10 revealed a moderate amount of grey hair under her chin and upper lip. She confirmed that she does not like the hair on her face. She stated that if she is lucky, they will shave her twice a week. She stated she was shaved early last week. She revealed her preference is to be shaved every other day. On 12/10/2025 at 10:49 AM, an interview with Certified Nursing Assistant (CNA) #1 confirmed Resident #10 had a moderate amount of facial hair and had not been shaved in several days. CNA #1 stated the resident had expressed dissatisfaction with the facial hair and had requested to be shaved.On 12/10/2025 at 3:32 PM, an interview with the Director of Nursing stated Resident #10 should be shaved as needed. The Director of Nursing stated he expects staff to provide activities of daily living care on a daily basis.A record review of Resident #10's admission Record revealed an admission date of 10/16/2024 with diagnoses that included Depression Unspecified and Primary Osteoarthritis of the right shoulder.A record review of Resident #10 Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/9/25 revealed a Brief Interview of Mental Status (BIMS) score of 14, which indicates cognitively intact.

Based on observation, interviews, and record review, the facility failed to ensure treatment of pressure ulcers was provided in a manner to prevent cross contamination and promote healing, as evidenced by failure to change gloves and perform proper hand hygiene during wound care for one (1) of two (2) residents reviewed for pressure ulcers. Resident #36 Findings include: On 5/15/24 at 11:03 AM, an observation of wound care for Resident #36 revealed Licensed Practical Nurse (LPN) #1 did not removed her soiled gloves, perform hand hygiene, and apply clean gloves prior to applying alginate to the wound bed and covering with a border dressing. On 05/15/24 at 11:10 AM, in an interview with LPN #1, she confirmed she forgot to remove her soiled gloves after cleaning the resident's wound. She stated she should have removed her gloves, performed hand hygiene, and applied clean gloves before applying the clean dressing. LPN #1 stated her action could lead to contamination of the wound and was considered an infection control issue. On 05/16/24 at 10:32 AM, in an interview with the Director of Nurses (DON), she confirmed LPN #1 should have changed her gloves after cleaning the wound. She stated LPN #1 should have performed hand hygiene after cleaning the wound and should have donned new gloves before applying the clean dressing. She stated this was an infection control issue and could delay wound healing. Review of the Admission Record revealed the facility admitted the resident on 5/8/23. Diagnoses included Pressure Ulcer of Sacral Region, Stage 4 and Disorder of the Skin and Subcutaneous Tissue, Unspecified.

Based on staff and resident interviews, record reviews, and facility policy review, the facility failed to ensure dependent residents received the necessary services to maintain oral hygiene for one (1) or 15 sampled residents. Resident #44. Findings include: Review of the facility's policy, Activities of Daily Living (ADL), revised 9/15/22, revealed, Based on the resident's comprehensive assessment and consistent with the resident's needs and choices, the facility will ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care; . Policy Explanation and Compliance Guidelines: .3.A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene . In an interview 05/13/24 at 11:59 AM, Resident #44 stated that she wants her teeth brushed. The resident stated that the staff give her a bed bath daily and fix her hair, but they do not help her brush her teeth. She revealed that she has mentioned to the staff that she would like to brush her teeth, but does not recall the last time she mentioned it to them. In an interview on 05/14/24 at 4:55 PM, Resident #44, she revealed that she did not get to brush her teeth again today and the staff never mentioned oral care. The resident stated that in the past, she would brush her teeth twice a day, but at this point, she would be happy if she could just brush them once a day. In an interview on 05/15/24 at 11:14 AM, in an interview with Certified Nursing Assistant (CNA) #3, she revealed that brushing a resident's teeth is part of ADL care. The CNA confirmed she did not assist Resident #44 to brush her teeth today or yesterday, but would do so now. She confirmed oral care should be done in the AM, before breakfast, as cleaning the mouth helps to make food taste better. In an interview on 05/16/24 at 10:26 AM, the Director of Nurses (DON), revealed that oral care if part of ADL care, and she expects staff to provide oral care every shift. She stated good oral hygiene decreases the risk of a resident developing an oral infection. Record review of the Admission Record of Resident #44 revealed the facility admitted the resident on 5/25/23. Diagnoses included Muscle Weakness (Generalized), and Unspecified Lack of Coordination. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/14/24, revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Section GG revealed the resident requires supervision or touching assistance with oral hygiene. Record review of the Task List Report, for Resident #44, revealed the task of Personal Hygiene was initiated on 9/5/23. The task was to be performed by a CNA every shift and prn (as needed).

Based on observation, interviews, record reviews and facility policy review, the facility failed to revise comprehensive care plan interventions for falls for one (1) of two (2) residents reviewed for accidents. (Resident #9) Findings include: A review of the facility's policy, Comprehensive Plan of Care, revised 10/10/2022, revealed, .It is the policy of this facility to develop and implement a comprehensive care plan for each resident .Policy Explanation and Compliance Guidelines .5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set) assessment . A record review of the of the comprehensive care plan for Resident #9 revealed Focus (Proper Name) is at risk for falls r/t (related to) history of frequent/recurrent/repeated falls .Interventions 1/1/21-Colored tape to wheelchair for identification of chair .12/1/20-Cup holder attached to 1/4 side rail while in bed .3/23/21-Resident to have TV remote attached to bedside table .3/25/24-Anti-rollbacks to wheelchair .4/25/22-Reacher secured to wheelchair .6/23/22-Mirror mounted to wall near bed .7/10/22-Resident may have raised toilet seat for use as needed .9/25/20 Dycem (slip resistant material) on top of and underneath wheelchair cushion . On 5/14/24 at 2:45 PM, in an observation, Resident #9 was not in her room. There was no cupholder observed attached to the bed rail, the TV remote was not attached to the bedside table, and there was no mirror mounted to the wall near her bed. On 5/14/24 at 2:50 PM, in an interview and observation, Registered Nurse (RN) #1 explained she was the care plan and MDS nurse for the facility. RN #1 reported that she did not resolve care plan interventions related to falls if they were still active. She reviewed and acknowledged Resident #9 had care plan interventions for falls that were from 2020. In an observation of Resident #9's room, RN #1 confirmed there was no cup holder attached to the side rail, the TV remote was not attached to the bedside table, and there was no mirror mounted to wall near the bed. Resident #9 was not in her room at the time of the observation. RN #1 explained she did not reconcile the interventions or conduct visual inspections to ensure the interventions that are listed on the care plan are being provided to the resident. On 5/14/24 at 3:16 PM, in an observation and interview with Certified Nurse Aide (CNA) #1, she explained that she was assigned to care for Resident #9 at times. CNA #1 used the Point of Care (POC) kiosk to review the Kardex for Resident #9 which included fall interventions. In an observation of the resident's room, CNA #1 confirmed there was no cup holder attached to the side rail and she believed the resident had not had one for a long time because she assists her to bed sometimes. She also confirmed there was no mirror mounted to the wall near the bed and the TV remote was not attached to the bedside table. CNA #1 said she thought the TV remote used to have Velcro to attach it to the bedside table, but she believed Resident #9 had gotten a new table since then. Resident #9 was not in her room at the time of the observation. On 5/14/24 at 03:40 PM, in an interview and observation with Resident #9, she was sitting in her room in her wheelchair. The wheelchair did not have an anti-rollback device attached to her chair, there was no colored tape on her wheelchair, there was no reacher secured to her wheelchair, and there was no dycem on or underneath her wheelchair cushion. Resident #9 remarked that she does not think there has ever been a mirror mounted on the wall near her bed or a cup holder on bed rail, and acknowledged there was no anti rollback device applied to her chair, no colored tape on her chair, there was no dycem material on her chair cushion, and there was no reacher mounted to the wheelchair she was sitting in. She stated she was not sure if she ever had those things on her wheelchair. Review of the resident's toilet revealed there was an over commode chair in place. On 5/15/24 at 8:47 AM, in an interview with the Director of Nursing, she stated that previously, the staff completed random care plan audits to ensure the care plan interventions were revised to accurately reflect the current interventions the resident required. The DON stated she had been made aware there were numerous care plan interventions related to falls for Resident #9 that were old and the care plan should have been revised to reflect the resident's current needs. There was also an intervention for Resident may have raised toilet seat for use as needed that should have been revised on 12/16/23 when Resident #9 had a fall in which the intervention was for therapy to evaluate for over commode chair and remove raised toilet seat. She stated when the care plan nurse advised her of the issue with Resident #9's fall care plan yesterday, the facility immediately reviewed and revised the interventions. The DON commented that although there were many interventions for falls that were being implemented for Resident #9, there were several interventions that should have been resolved because they were old. A record review of the Admission Record revealed the facility initially admitted Resident #9 on 6/26/20 and she had current diagnoses including Unspecified lack of coordination. A record review of the Quarterly MDS with an Assessment Reference Date (ARD) of 2/28/24 revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact.

Based on interviews, record reviews, and facility policy review the facility failed to ensure the comprehensive care plan interventions was implemented for a resident who was dependent for Activities of Daily Living (ADL) care for one (1) of 15 sampled residents. Resident #44. Findings include: Review of the facility's policy titled, Comprehensive Plan of Care, revised 10/10/22 revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Policy Explanation and Compliance Guidelines: . 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . f. Resident specific interventions that reflect the resident's needs and preferences . Record review of the Comprehensive Care Plan for Resident #44, undated, revealed, (Proper Name of Resident #44) has an ADL self-care performance deficit .Interventions .Personal hygiene/oral care: The resident is totally dependent on 1-2 staff for personal hygiene and oral care. During an interview on 5/13/24 at 11:59 AM, Resident #44 revealed she wanted to brush her teeth. She revealed that in the past, she had mentioned brushing her teeth to the staff, but did not remember the last time that she had mentioned it. During an interview on 5/14/24 at 4:55 PM, Resident #44 confirmed that she had not brushed her teeth again today. During an interview on 05/15/24 at 11:14 AM, Certified Nursing Assistant (CNA) #3, confirmed that she had not assisted Resident #44 with oral care yesterday and had not yet assisted the resident with oral care today. She revealed that oral care should be done daily, before breakfast, as it helps the food to taste better. During an interview on 05/16/24 at 10:10 AM, in an interview with Registered Nurse (RN) #1/Care Plan Nurse, she revealed the Comprehensive Care Plan is done to drive the care of the resident, as it lets the staff know what the resident needs, and guides personalized care. The nurse stated oral care is part of ADL care. Review of the Admission Record, for Resident #44 revealed that the facility admitted the resident on 5/25/23. Current diagnoses included Unspecified Lack of Coordination, Muscle Weakness (Generalized), and Hemiplegia and Hemiparesis Following Cerebral Infarction affecting Left Non-Dominant Side.

Based on observations, staff interviews, record reviews, and facility policy review, the facility failed to remove expired Pneumovax-23 (pneumococcal vaccine polyvalent) vials from the medication storage refrigerator for one (1) of one (1) medication rooms observed. Findings include: Review of the facility's policy, Safe Medication Practices with a revision date of 7/31/15, revealed, .Ensure expiration date is within defined limits . On 11/20/22 at 3:45 PM, an observation of the medication storage room with Licensed Practical Nurse (LPN) #2 revealed seven (7) Pneumovax-23 vials in the medication storage refrigerator with an expiration date of 10/12/22. On 11/20/22 at 4:00 PM, in an interview with LPN #2, she confirmed it is the responsibility of the nursing staff to remove expired medications from the medication storage refrigerator. She stated expired vaccines should not be given to a resident, as they could be less effective. On 11/20/22 at 4:08 PM, in an interview with LPN #3/Charge Nurse, she explained the nurses on the night shift are responsible for checking expiration dates of medications in the storage room and removing them. She stated if a resident is given expired medication, depending on the medication, the medication could be less effective, or the resident could have an adverse reaction. She confirmed that there were seven (7) vials of Pneumovax-23, with an expiration date of 10/12/22, that should have been removed. On 11/22/22 at 2:45 PM, in an interview with the Director of Nursing (DON), he revealed checking for expired medications are part of the assigned duties to the nursing staff working at night. The DON confirmed that expired Pnemovax-23 can be less effective, and the resident could still develop pneumonia.

Based on observation, interviews, facility policy review, and record review, the facility failed to maintain a medication error rate below 5 percent (%) for two (2) of 25 medication opportunities, resulting in an 8% medication error rate. Findings include: Review of the facility's policy, Medication Administration, with a revision date of 11/12/21, revealed, . Medication Administration Record (M.A.R.) shall be compared with physician orders prior to preparation of any medications. The individual administering the medication shall verify the medication and be aware of the following information concerning each medication route and frequency of administration: .Route and frequency of administration . On 11/21/22 at 9:45 AM, observed Licensed Practical Nurse #1 (LPN) administer a Baclofen 5 milligram (MG) tablet and 20 milliliters (ML) of Tegretol suspension to Resident #2 per percutaneous endoscopic gastrostomy (PEG) tube. Record review of the active orders for Resident #2 on the Physician Orders List, revealed orders for Baclofen 5 MG tablet: Give one tablet PO (by mouth) TID (three times a day) and Tegretol 100 MG/5ML suspension: Give 20 ML to equal 400 MG PO TID. Record review of the Face Sheet of Resident #2 revealed an admitted [DATE]. The resident's diagnoses include Dysphagia unspecified and Cerebral Palsy. Record review of the Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 9/5/22 for Resident #2 revealed a Brief Interview of Mental Status (BIMS) score of 03, which indicated severe cognitive impairment. On 11/21/22 at 3:05 PM, in an interview with LPN #1 she confirmed she made a mistake and should have given Resident #2 his medication by mouth as ordered. She explained that administering the medications by the wrong route, could cause adverse effects. On 11/21/22 at 3:40 PM, in an interview with the Director of Nursing (DON), he stated that LPN #1 should have followed physician orders. The DON revealed that administering the medication through the PEG tube could cause an absorption problem for the resident. The DON stated he expects the nurses to follow Physician orders.

Based on observation, interview, record review, and facility policy review, the kitchen was found to be unsanitary due to one (1) out of four (4) dietary aides not wearing a hairnet to prevent hair from falling into the food while preparing resident meals. This has the potential to affect all residents receiving meals from the kitchen. Findings Include: Record review of the facility provided policy titled Nutritional Services dated 11/28/17 stated .Scientific methods of food preparation shall be used to ensure safe, sanitary and efficient preparation of all meals and nourishments . On 9/15/22 at 10:45 AM, a telephone interview with the complainant revealed he was the son of Resident #1. He voiced concern that his father had reported to him that he had found hair in his food on a couple of occasions. On 9/15/22 at 11:30 AM, observation in the kitchen revealed that one of four dietary aides preparing food in the kitchen were not wearing hair covering. Dietary Aide #1 was standing at the steam table removing clear plastic wrap from pans of cooked foods without a hairnet or any hair covering to prevent hair from falling into the food. Dietary Aide was observed to walk to the side of the kitchen opposite the windows and put on a hair net approximately two minutes after the observation began. On 9/15/22 at 11:35 AM, in an interview with Dietary Aide #1, she revealed she had received training on safe food handling and was aware that a hair covering to prevent hair falling from into food was required. On 9/15/22 at 11:50 AM, in an interview with Resident #1, he confirmed that he had hair in the food served to him at the facility once or twice. On 9/15/12 at 1:15 PM, an interview with the Administrator revealed he expected anyone who entered the kitchen to wear hair protection to prevent hair from falling into the food. He stated he was positive all dietary staff had been provided in-service training to wear hair protection while in the kitchen. The Administrator said, They know they are supposed to wear something to cover their hair in there (the kitchen). Record review of the Face Sheet for Resident #1 revealed Resident #1 was originally admitted by the facility on 4/12/18 with current admitted listed as 5/04/20. He had diagnoses of Diabetes, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] and Peripheral Vascular Disease. Record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/04/22, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to store foods in a manner to prevent possible contamination and failed to remove expired food and milk from the refrigerator and milk cooler. Findings Include: A review of facility policy revealed that the first priority should be obtaining and documenting the temperatures for the freezer and refrigerator milk cooler when starting the morning shift. If temperatures are above the recommended 41 degrees Fahrenheit (F) for the refrigerator and milk cooler when starting the shift and/or above 0 degrees F for the freezer, contact maintenance immediately. All foods should be covered, labeled, and dated. Products should also be assessed to assure there is no spoilage (sour smell or taste, mold, etc.) and that expiration dates are reasonable, so that products can be used in a timely fashion. Expired milk will be separated. It will be labeled that milk is expired with signage and staff will be alerted. If a freezer does not have a thermometer, staff will immediately notify the Dietary Manager. The thermometer should be checked at least twice each day. Do not record temperatures if there is not a thermometer in the freezer. Inspect all canned foods upon on delivery. Remove any dented cans and place dented cans in the designated area labeled dented cans. On [DATE] at 10:10 AM, an initial tour of the kitchen revealed a freezer without a thermometer in it. It contain two (2) boxes of frozen biscuits and four (4) plastic bags of rolls. The temperature log sheet had recordings done for [DATE] AM and PM. While checking canned goods, observation revealed two (2) dented cans of vegetables that had not been moved to the dented area of the kitchen. A check of the refrigerator revealed a half plastic container of strawberries with mold and the container had no date. The milk cooler contained two (2) crates of out-dated milk, 32 cartons of 2 percent (%) dated [DATE], and three (3) cartons 2% milk dated [DATE]. There were seven (7) chocolate milk cartons dated [DATE], and four (4) fat free milk dated [DATE]. On [DATE] at 10:55 AM, an interview with the Dietary Manager (DM) revealed she removes spoiled food from the refrigerator on Monday and Thursday before the food truck comes. The DM stated expired milk is to be left in the milk cooler, in a separate crate, until the milkman comes to pick it up. On [DATE] at 11:10 AM, an interview with Dietary Aide #2 revealed he did not see a thermometer in the biscuit freezer. He stated, I was in a rush and I just wrote something down for the AM and PM temperature. On [DATE] at 1:08 PM, a tour of the kitchen revealed the half plastic carton of molded strawberries remained in the refrigerator, with no date. On [DATE] at 10:50 AM, an interview with the DM revealed she estimated the thermometer had been missing since last Friday ([DATE]). She stated the staff have been trained to inform her of missing thermometers and not to document falsely on temperature logs. She stated that her dish washing staff are responsible for checking temperatures and documenting them. She confirmed she forgot to take out the molded strawberries and write a date on them when she opened them. She stated she did not see the dented cans, if she had she would have moved them to the dented can sections in the storage area. She stated she usually does an in-service monthly. She also stated expired milk can cause the residents to be served sour milk. She stated that she should have removed the expired milk from the milk cooler. On [DATE] at 11:08 AM, an interview with Dietary Aide #2 revealed he has had in-services on monitoring temperatures in the freezer and refrigerator. He also stated it was a long morning and he was in a rush to get things done. He stated that he can not recall the last time they had in-services. He confirmed that he should have contacted the Dietary Manager about the missing thermometer. On [DATE] at 10:53 AM, an interview with the Administrator revealed the expired milk should have been removed from the milk cooler and the dented cans should have been removed from the can storage area; that the refrigerator items should be checked and removed daily. The Administrator stated falsifying temperature logs can effect the residents well being. He stated that the food not stored properly can potentially effect the well being of the residents. He also stated oversight issues has a potential to cause harm to the residents.

Based on observation, staff interviews, record reviews, and facility policy review, the facility failed to provide wound care in a manner to prevent possible infection for two (2) of three (3) resident wound care observations, Resident #37 and Resident #28. And, failed to provide catheter care in a manner to prevent the possible spread of infection for one (1) of two (2) catheter care observations, Resident #45. This affected three (3) of five (5) resident care observations. Findings include: Review of the facility's Standard Precautions policy, Section: Infection Prevention and Control,revealed: It is the policy of the facility to provide patient care services that reflect the Standard Precautions infection control practices when interacting with residents. Standard Precaution components include, but are not limited to, the following: Hand Hygiene-Personal Protective Equipment (gloves, masks, gowns, etc.) Review of the Facility Policy and Procedure, Treatment Observation Checkoff, revealed: Wash hands and put on clean gloves, loosen tape and remove the existing dressing, discard into appropriate receptacle. Wash hands and put on gloves. Cleanse wound as ordered, dress wound as ordered, discard disposables and gloves, then wash hands. Universal Precautions Observed. Review of the facility's policy Hand Hygiene in Healthcare Settings, revealed: Protect yourself and your patients from potentially deadly germs by cleaning your hands. Be sure you clean your hands the right way at the right times. A review of the facility's policy titled Infection Prevention Program, dated (YEAR), revealed all facility staff shall participate and support the program through compliance with infection prevention practices, policies and procedures, reporting infection prevention concerns, and cooperation with the Infection Prevention Officer/Infection Prevention Committee as needed and required. Resident #28: On 10/08/19 at 2:45 PM, observation of catheter care for Resident #28 revealed Certified Nursing Assistant (CNA) #2 and CNA #1 washed their hands, applied clean gloves, and began care. When CNA #1 unfastened Resident #28's brief the resident did not have a securing device in place to either of his thighs. As Resident #28's trash can became full of soiled supplies, with her gloved hands CNA #1 pushed the overfilled trash slightly down in the trash can. CNA #2 placed the plastic bag that had the soiled pad in it and the resident's soiled pants on Resident #28's floor bedside his bed. After CNA #1 cleaned Resident #28, she placed the soiled pants in the plastic with the soiled pad and sat the plastic bag on the floor. Record review of the physician orders, dated 9/27/19, indicated an order for [REDACTED]. On 10/09/19 at 9:05 AM, an interview with CNA #1 revealed when she pushed the trash down in Resident #28's trash can, that caused cross contamination and when she sat the plastic bag on the resident's floor, that was an infection control problem. On 10/09/19 at 9:10 AM, an interview with CNA #2 revealed when she sat the plastic bag on Resident #28's floor, that was an infection control issue. On 10/09/19 at 9:36 AM, an interview with the Director of Nursing (DON) revealed when CNA #1 sat the plastic bag on Resident 28's floor and pushed the trash down in the trash can, that is an infection control issue. She also stated when CNA #2 sat the plastic bag on the resident's floor that is an infection control issue. On 10/09/19 at 9:54 AM, an interview with Registered Nurse (RN) #2 revealed CNA #1 and CNA #2 putting the plastic bag on the floor was an infection control issue. On 10/09/19 at 10:05 AM, an interview with RN #1 revealed when CNA #1 and CNA #2 sat the plastic bag on the resident's floor, that causes cross contamination and is an infection control issue. Resident #45 On 10/07/19 at 2:43 PM, an observation revealed Registered Nurse (RN) #3 washed her hands and applied clean gloves, then she opened a catheter kit, removed her glasses from her top left uniform pocket, put her glasses on, opened the catheter tubing, and opened the sterile gloves. After RN #3 inserted the suprapubic catheter, she washed her hands, applied clean gloves, opened the leg bag, and laid it on the resident's over-bed table, without a barrier. She then left Resident #45's room to get some scissors, returned to the resident's room, washed her hands and applied clean gloves. RN #3 cut some of the catheter drainage tubing off, then connected the drainage tubing the catheter tubing, removed her gloves, opened the securing device and applied the securing device to the drainage bag. On 10/9/19 at 10:05 AM, an interview with RN #1 revealed when RN #3 removed her glasses from her uniform pocket with her gloved hands and continued to set up her supplies, that was an infection control issue. She also stated when RN #3 sat the drainage bag on the resident's over-bed table without a barrier, that was an infection control issue. On 10/10/19 at 12:05 PM, an interview with RN #5 revealed she would expect the nurse to use aseptic technique when providing care. On 10/10/19 at 12:16 PM an interview with RN #3 revealed, when she removed her eyeglasses from her left uniform pocket, that was cross contamination and when she sat the urinary drainage bag on the resident's over-bed table without a barrier, that was cross contamination. Resident #37 Review of the 9/16/2019 Physician Orders for Resident #37, revealed: Cleanse Stage three (3) Pressure Ulcer to Sacrum with Normal Saline, Pat Dry, Apply Collagen (lightly dampen with Normal Saline) cover with Opti foam every Monday, Wednesday, and Friday until healed. Observation on 10/08/19 at 2:54 PM, revealed Registered Nurse (RN) #3, performed wound care on Resident #37 per physician orders. RN #3 placed a barrier, prepared supplies, washed hands and donned gloves. RN #3 removed the dirty dressing, cleaned wound with Normal Saline, applied Collagen and covered the wound per orders. RN #3 removed gloves, and washed hands at the end of the procedure. On 10/09/19 at 10:32 AM, an interview was conducted with RN #3 on speaker phone, with the Director of Nursing (DON) present. RN #3 confirmed she only washed her hands at the beginning of the procedure, but did not wash her hands or don gloves from dirty to clean. RN #3 revealed not washing her hands from dirty to clean could cause both infection control issues and cross contamination. The DON confirmed by RN #3 not washing her hands and keeping the same gloves on during the entire procedure, could cause both infection control issues and cross contamination. On 10/09/19 at 2:52 PM, an interview with RN #2, Infectious Control Registered Nurse, revealed by RN #3 not washing her hands from clean to dirty of dressing change, and not changing gloves after removing dirty dressing, may cause cross contamination and infection control issues. On 10/09/19 at 3:00 PM, an interview with the Staff Development Coordinator, revealed the procedure of wound care performed on Resident #37, by RN #3, revealed not washing hands or changing dirty gloves after dirty dressing removal, may cause cross contamination and infection control issues.

Based on observation, record review, staff interview and facility policy review the facility failed to ensure resident safety when using a transfer device for one (1) of 16 residents reviewed, Resident #15. Certified Nursing Assistant #8 transferred Resident #15 without assistance of another CNA as required per assessment and care plan, which resulted in injury with treatment at the local Emergency Department. Findings include: Review of the facility policy entitled Safe Lifting Program, with a revision date of 08/10/17, revealed, residents of the facility who are unable to transfer themselves independently shall be transferred safely with the Hoyer Lift. At Least two (2) nursing staff are needed to transfer a resident when using a Hoyer Lift. Staff (including new hires) shall be provided sufficient training on lift usage so that they can properly operate equipment. Interview and observation of Resident #15 on 8/23/17 at 11:30 AM, revealed she was wearing a splint on the third finger of the right hand and the laceration (over the left eye) had healed. Resident #15 did not respond when spoken to. Review of the facility's documentation of an investigation, dated 08/07/17, revealed on 08/05/17 Resident #15 was noted to be on the floor under the total lift. Certified Nursing Assistant (CNA) # 8 reported that she and CNA #5 were lifting the resident and the lift got caught on the roommate's fall mat and began tilting over, resulting in the resident falling to the floor. On 08/06/17, the facility was made aware of discrepancies regarding the statements made by CNA #8. Further investigation by the facility revealed CNA #8 had used the lift without the assistance of another person and that she had forged a statement indicating CNA #5 had assisted her. CNA #8 was terminated for not following protocol with using two (2) people with a lift transfer. The investigation revealed that the fall resulted in a dime-sized laceration over the top of the resident's left eye, measuring 2.5 centimeters (cm) wide. The resident was transferred to the local Emergency Department (ED) where treatment included six (6) sutures above her left eye. The investigation revealed that Resident #15 returned to the ED on 8/6/17, with complaint of finger and leg pain, and she received a splint to the middle finger on her right hand due to a [DIAGNOSES REDACTED]. Review of the facility's Departmental Notes, dated 8/5/17 at 7:33 AM, revealed Resident #15 was noted on the floor under the mechanical lift. She had sustained a laceration above the left eye, measuring approximately 2.5 centimeters (cm), with active bleeding noted. Resident #15 was transferred to the emergency room for evaluation and treatment of [REDACTED]. Departmental Notes dated 8/5/17 at 12:59 PM, revealed Resident #15 received six (6) stitches over the left eye for a laceration. Resident also noted to have edema and purple discoloration to the middle finger on her right hand. Departmental Notes dated 8/6/17 at 10:19 PM, revealed Resident #15 returned from the ED at 8:25 PM, with [DIAGNOSES REDACTED]. Treatment included a splint to the finger and an ACE wrap to the right ankle. Review of an X-ray report, dated 8/6/17, revealed Resident #15 had a fracture involving the distal aspect of the middle phalanx of the middle finger. In an interview with CNA #8 on 08/24/17 at 3:50 PM, the CNA admitted that the incident occurred when she was using the mechanical lift to transfer Resident #15 without assistance of another staff. She stated that the lift tilted and Resident #15 fell to the floor. She stated that she had not received any training and had not been shown how to use the Hoyer lift. Review of CNA #8's training records revealed CNA #8 had received in-service training regarding transfers on 03/10/15, with the In-service Coordinator, CNA #2. Review of a statement by CNA #2 revealed she trained CNA #8 on how to properly use a lift on 03/03/17. Review of the facility Daily Staffing Record for 03/03/17, revealed CNA #8 was working and was paired with CNA #2 for training. Interview with four (4) CNA's on 08/24/17, between 4:30 PM and 4:40 PM, (CNAs #7, #9, #10 and #11) revealed that use of the lift required two (2) people. CNA #7 stated that she had been taught that if another CNA was not available to get the nurses to help with lifting a resident with the Hoyer. Interview with the Director of Nursing (DON) and the Administrator on 8/24/17 at 10:00 AM, revealed CNA #8 not only transferred Resident #15 by herself but lied about it to start with, by initially stating there were two (2) CNAs in the room. The DON stated the incident could have been avoided and policy was for two (2) person assistance with lift transfers. A review of the facility's face sheet revealed the facility admitted Resident #15 on 01/06/05. The resident's [DIAGNOSES REDACTED]. Review of the residents most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/15/17, revealed staff assessed the resident with severe cognitive impairment. Further review of the MDS revealed the resident is totally dependent on staff and requires assistance of two (2) or more staff for transfers.

Based on staff interview, record review and facility policy review, the facility failed to follow the comprehensive plan of care for three (3) of 18 care plans reviewed, Resident #7 and #13 for catheter care, and Resident #15 for assistance with transfer with the lift. Findings include: A review of the facility's policy entitled, Comprehensive Plan of Care with an effective date of 10/27/14, reads; Plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident related to clinical [DIAGNOSES REDACTED]. Resident #7: Record review of Resident #7's care plan, initiated 7/27/17, revealed approaches of catheter care as ordered and check for leg strap. Observation on 8/23/17 at 3:20 PM, revealed CNA #3 and CNA #4 turned Resident #7 onto her left side while leaving the catheter hanging on the opposite side of the bed and having no securing device/strap to the resident's leg. Interview on 8/23/17 at 3:30 PM, with CNA #3 revealed her stating, The catheter is supposed to be put on the side the she (referring to Resident #3) is turned to and we needed a strap on it. CNA #3 acknowledged the care plan wasn't followed by not having the strap to secure the tubing. Interview with Registered Nurse (RN) #1 on 8/23/17 at 3:50 PM, revealed the catheter tubing should be over the thigh and the leg strap should be in place to prevent pulling out the catheter (per care plan). A review of the facility's Face Sheet revealed Resident #7 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident #7's Admission Minimum Data (MDS) assessment with an Assessment Reference Date (ARD) of 8/9/17, revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Resident #13: Record review of Resident #13's care plan with a problem onset date of 8/15/17, revealed the resident had a Foley catheter with approaches for catheter care every shift and a leg strap in place every shift. Observation on 8/24/17 at 11:00 AM, revealed CNA #1 and #2 turned Resident #13 onto her right side while leaving the catheter on the opposite side of the bed. No leg strap was observed. Interview on 8/24/17 at 11:45 AM, revealed the DON to state, Well you don't want it (referring to the catheter), to pull, it always need to go to the side they are turned to drain properly and it decreases trauma. Interview on 8/24/17 at 11:50 AM, with RN #1 revealed her stating They should always have a leg strap in place. The catheter tubing should be over the leg not under the leg. Of course, make sure there is no tension on it. RN #1 acknowledged the care plan was not followed for the leg strap. A review of the facility's Face Sheet revealed Resident #13 was admitted on [DATE], with diagnose of Urinary Tract Infection and [MEDICAL CONDITION]. A review of Resident #13's Admission Five Day MDS assessment with an ARD of 8/22/17, revealed a BIMS score of 9, which indicated a moderately impaired cognitive status. Review of the Care Plan for Resident #15, with an onset date of 05/30/17, revealed the resident required extensive to total assistance with activities of daily living (ADL's) with an approach to use the lift for all transfers. The resident was also at risk for falls, with an approach that stated the lift required two (2) individuals at all times. Review of the facility's Departmental Notes and documentation of the investigation for Resident #15's fall on 8/5/17, revealed the resident sustained [REDACTED].#8, which constituted noncompliance with policy and procedure. The CNA was terminated. Resident #15 received a 2.5 centimeter (cm) laceration over the left eye, which required six (6) sutures. Resident #15 also received a [MEDICAL CONDITION] finger on her right hand due to the fall and both required outside medical attention from the Emergency Department. Interview with CNA #8 on 08/24/17 at 3:50 PM, revealed she admitted that the incident occurred with Resident #15's fall from the lift when she transferred the resident by herself instead of having assistance (per care plan). CNA #8 stated she had not been trained on the lifts. Interview with RN #2 on 8/24/17 at 10:00 AM, revealed the care plan was not followed when CNA #8 transferred Resident #15 with the lift without the assistance of another person. Review of an in-service, dated 3/10/15, revealed CNA signed the training which included the following statement: Its important for the safety of the resident that they are being transferred properly. If a resident is care planned to be transferred using a lift, make sure to use the correct lift with the correct sling. At no time you should manually transfer a resident that requires a lift. It should also fire on Kiosk related to transfers and lifts to use. Disciplinary action will be followed, including termination, if this is not followed. Remember, safety is the number one priority. Thanks. A review of Resident #15's face sheet revealed the facility admitted the resident on 01/06/05. Resident #15's [DIAGNOSES REDACTED]. Review of Resident #15's most recent MDS with an ARD of 08/15/17, revealed staff assessed the resident with severe cognitive impairment.

Based on observation, record review, staff interview, and facility policy review the facility failed to ensure residents were not neglected as evidenced by staff's failure to follow the care plan and transfer the resident with the appropriate amount of assistance to help prevent injury for one (1) of 16 residents reviewed, Resident #15. The Certified Nursing Assistant (CNA) transferred Resident #15 with the mechanical lift without the required assistance of another staff, resulting in a fall and injury to the resident. The resident sustained [REDACTED]. Findings include: Review of the facility's policy, Abuse and Neglect: Recognizing and Reporting, dated 10/17/14, revealed the facility shall protect residents from real or perceived abuse, negligence or exploitation from anyone. Neglectful Supervision: Placing in, or failing to remove, the resident from a situation requiring judgment beyond his/her physical condition or mental abilities that results in bodily injury or substantial risk of immediate harm to the person. Review of the facility policy entitled Safe Lifting Program, with a revision date of 08/10/15, revealed residents of the facility who are unable to transfer themselves independently shall be transferred safely with the Hoyer Lift. At Least two (2) nursing staff are needed to transfer a resident when using a Hoyer Lift. Staff (including new hires) shall be provided sufficient training on lift usage so that they can properly operate equipment. Interview and observation of Resident #15 on 8/23/17 at 11:30 AM, revealed she was wearing a splint on the third finger of the right hand and the laceration (over the left eye) had healed. Resident #15 did not speak when addressed. Review of the facility's documentation of their investigation, with a date of 08/07/17, for Resident #15, revealed on 08/05/17 the resident was noted to be on the floor under the total lift. Certified Nursing Assistant (CNA) #8 reported that she and CNA #5 were lifting the resident and the lift got caught on the roommate's fall mat and began tilting over, resulting in the resident falling to the floor. Resident #15 was transported to the Emergency Department (ED) with a dime-sized laceration measuring 2.5 centimeters (cm) over her left eye. On 08/06/17, the facility was made aware of discrepancies regarding the statements made by CNA #8. Further investigation by the facility revealed CNA #8 had used the lift without the assistance of another person and that she had forged a statement indicating CNA #5 was assisting her. The investigation revealed that Resident #15 was again transferred, on 8/6/17, to the ED with a [DIAGNOSES REDACTED]. The investigation revealed that CNA #8 was terminated for disregarding facility lift policy causing minor injury to a resident, which could have been avoided. Review of the facility's Departmental Notes, dated 8/5/17 at 7:33 AM, revealed Resident #15 was noted on the floor under the mechanical lift. She had sustained a laceration above the left eye, measuring approximately 2.5 centimeters (cm), with active bleeding noted. Resident #15 was transferred to the emergency room for evaluation and treatment of [REDACTED]. Departmental Notes dated 8/5/17 at 12:59 PM, revealed Resident #15 received six (6) stitches over the left eye for a laceration. Resident also noted to have [MEDICAL CONDITION] and purple discoloration to the middle finger on her right hand. Departmental Notes dated 8/6/17 at 10:19 PM, revealed Resident #15 returned from the ED at 8:25 PM, with [DIAGNOSES REDACTED]. Treatment included a splint to the finger and an ACE wrap to the right ankle. Review of an X-ray report, dated 8/6/17, revealed Resident #15 had a [MEDICAL CONDITION] right finger, related to a fall with hand injury. Review of the Patient Visit information dated 8/6/17, revealed an ankle sprain and fractured right finger. X-ray of the right ankle was unremarkable.The right knee X-ray revealed a small effusion. Resident #15 was sent back to the facility with a splint on her finger. In an interview with CNA #8 on 08/24/17 at 3:50 PM, the CNA admitted that the incident with Resident #15 occurred when she was using the lift alone. She admitted to lying about another CNA assisting with the transfer and falsifying a witness statement. She stated that she had not received any training and had not been shown how to use the Hoyer lift. She stated during the transfer the resident fell from the lift when it tilted. Review of a written statement, documented by CNA #5, undated, revealed CNA #8 asked her to come to Resident #15's room. CNA #5 documented that Resident #15 was in the floor and her head was bleeding. CNA #5 documented that CNA #8 said if she could have gotten Resident #15 back in the bed she was going to say the resident scratched herself. CNA #5 stated that CNA #8 wanted her to say they were in there together, but she did not assist with the transfer. Interview with the Director of Nursing, on 8/24/17 at 10:00 AM, revealed that CNA #8's actions of transferring Resident #15 by herself could be considered negligence. She stated, not only was it wrong, but she lied about it. Interview with the Administrator on 8/24/17 at 11:30 AM, revealed CNA #8 admitted transferring Resident #15 alone when the resident fell from the lift and sustained injury. The Administrator stated they did not report the CNA to the registry because they terminated her and the family was okay with what happened and resident had not sustained serious injury. Review of CNA #8's training records revealed CNA #8 had received in-service training regarding transfers on 03/10/15, with the In-service Coordinator and following the care plan. Review of a statement by CNA #2 revealed she trained CNA #8 on how to properly use a lift on 03/03/17. Review of the facility Daily Staffing Record for 03/03/17, revealed CNA #8 was working and was paired with CNA #2 for training. Interview with four (4) CNA's on 08/24/17, between 4:30 PM and 4:40 PM, (CNAs #7, #9, #10 and #11) revealed statements that they all had received training on use of the Hoyer Lift. All four (4) stated that use of the lift required two (2) people. CNA #7 stated that she had been taught that if another CNA was not available to get the nurses to help with lifting a resident with the Hoyer. Review of the Care Plan for Resident #15 revealed a problem with an onset date of 05/30/14, which stated the resident required extensive to total assistance with activities of daily living (ADL's) with an approach to use the mechanical lift for all transfers. Another problem listed the resident was at risk for falls with an approach that stated the lift required two (2) individuals at all times. A review of the facility's face sheet revealed the facility admitted Resident #15 on 01/06/05. The resident's [DIAGNOSES REDACTED]. Review of the residents most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/15/17, revealed staff assessed Resident #15 with severe cognitive impairment. Further review of the MDS revealed the resident is totally dependent on staff and requires assistance of two (2) or more staff for transfers.

CI MS # Based on observation, interview, record review, facility policy and contract review, the facility failed to obtain the appropriate services for a resident who was exhibiting psychological adjustment difficulties for one (1) of eight (8) residents (Resident #2) in the total sample of 8 residents reviewed resulting in increased resident agitation and aggressive behaviors. Findings include: Resident #2 Review of the facility "Agreement for Behavioral Health Services", dated 1/15/2012, defined services to be performed through licensed mental health associates and the facility. Services included: "Psychological evaluations to determine [DIAGNOSES REDACTED]." Resident #2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #2's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/12/13, reflected an inability for Resident #2 to complete the Brief Interview for Mental Status (BIMS) test due to the resident's severely impaired cognition. The MDS also reflected behavior as combative toward staff and residents at times, with a note that she "grabbed other resident by (L) left arm/elbow causing redness/bruising". Resident #2 began exhibiting an inability to control her behavior shortly after admission, with aggressive behavior directed at staff and confusion involving other residents and their belongings. Record review revealed Resident #2 was moved to three (3) different rooms in a three (3) month period of time due to increased behaviors. As early as 8/25/13 (20 days after admission) a nurse's note reflected that Resident #2 was trying to take another resident into her room and Resident #2 began hitting and slapping a nurse who was safely removing the other resident (Resident #5) from the room. There was no evidence of prompt action to determine if this behavior was unavoidable or to seek prompt mental health interventions, despite staff having knowledge of a behavioral health service contract, and despite staff having been trained on abuse and neglect and having watched Hand in Hand Modules 1 and 2. Record review revealed a physician order [REDACTED]. The Psychiatric Nurse Practitioner's report reflected the first psychiatric visit occurred on 9/10/13, fourteen (14) days later. This report revealed once resident was evaluated the Psychiatric Nurse Practitioner recommended medications which included: Trazadone 25 mg every 2 p.m., [MEDICATION NAME] 0.25 mg twice a day, as needed, [MEDICATION NAME] 13.3 mg/24 hour patch every a.m. and [MEDICATION NAME] 25 mg every a.m. and 50 mg every night. She recommended a test for a urinary tract infection to rule out medical cause for mood changes and to provide low stimulating activities. No urine test results were noted. Behavior continued to worsen as exhibited by nurse's note on 8/31/13 in which Resident #2 had to be removed from Resident #1's bed, nurse's note on 9/5/13 in which Resident #2 was going through another resident's closet "looking for her baby", cursing and threatening staff, then got into Unsampled Resident A's empty bed. Another nurse's note on 9/17/13 at 5:15 a.m. revealed Resident #2 threatened to hit staff with a glass vase and threw a nebulizer machine at the nurse, hitting her on the back of her leg. Resident #2 was not transferred to a Senior Care psychiatric facility until 9/20/13. The Resident #2 was admitted to the medical hospital on [DATE] instead of the Senior Care Psychiatric hospital due to a low Hemoglobin and Hematocrit level. Resident #2 was seen by a psychiatrist while in the medical hospital and medications were reviewed and changed. On 9/27/13, the Resident #2's [DIAGNOSES REDACTED]. Resident #2 was returned to the facility on [DATE]. On 10/22/13 at 6:20 p.m., an interview with the facility's Administrator revealed he got recommendations after the 8/25/13 incident from the mental health professional "psych doctor" for the resident's medications to be changed and the mental health professional did not recommend transferring the resident to a psych unit. The facility's Psychologist revealed in an interview on 10/23/13 at 10:40 p.m. that she had never seen or evaluated Resident #2. The Psychiatric Nurse Consultant on 10/24/13 at 2:10 p.m., during a telephone interview, revealed that she did not know why the order for a consult ASAP was delayed for two (2) weeks. Record reviewed revealed the Resident #2 was not seen by the Psychiatric Nurse Practitioner until 9/10/13 for the "ASAP" order give on 8/27/13.

CI MS # Based on observation, interview, record review, facility policy and agreement review, the facility failed to obtain timely services of a qualified professional who could provide psychiatric recommendations to meet the resident needs and failed to implement a care plan for these services for one (1) of eight (8) residents in the sample (Resident #2) resulting in resident aggressive behavior toward staff and residents. Findings include: Resident #2 Facility staff did not include personnel with the expertise to address Resident #2's adjustment and behavior problems in the planning of care and did not address a comprehensive plan of care to deal with the aggression towards staff. Resident #2's care plan reflected: independence in transfer and ambulation, wanders looking for exit, and "rummages in her clothes closet". The care plan was updated on 10/6/13 with "potential to abuse others due to dementia". No specific psychiatric interventions or referrals were added to the care plan. Resident #2, age 78, was admitted to the facility on [DATE]. The Minimum Data Set (MDS), with a date of 8/12/13, reflected Resident #2 was unable to complete the Brief Interview for Mental Status (BIMS) due to her severely impaired cognitive ability. The MDS also reflected behavior as combative toward staff and residents at times. Interview with the facility's Administrator on 10/22/13 at 6:20 p.m. revealed that the 8/25/13 incident occurred on a Sunday and was fully investigated on Monday. The Administrator stated he got recommendations from the mental health professional for Resident #2's medications to be changed and did not recommend a psych unit. An interview on 10/23/13 at 10:40 p.m. with the facility's Psychologist revealed she had never seen or evaluated Resident #2. A telephone interview with the Psychiatric Nurse Consultant on 10/24/13 at 2:10 p.m. revealed that she did not know why the order for a consult ASAP was delayed two (2) weeks. Record reviewed revealed the Psychiatric Nurse Practitioner did not see the resident until 9/10/13 for the "ASAP" order give on 8/27/13. Resident #2 was sent to a Senior Care Facility on 9/20/13 where she was seen by a psychiatrist and medications were reviewed and changed. Resident #2 was readmitted to the facility on [DATE]. There had been no documented incidents since her return. Review of the facility's "Agreement for Behavioral Health Services", dated 1/15/2012, defined services to be performed through licensed mental health associates and the facility. Services included were: "Psychological evaluations to determine [DIAGNOSES REDACTED]."

CI MS # Based on observation, record review and staff interview, the facility failed to provide medically related social services for one (1) of eight (8) residents in the sample (Resident #2) regarding timely arrangement for a psychiatric consult to meet the resident's emotional needs and decrease or prevent aggressive behavior. Findings include: Resident #2 There were no noted interventions by Social Services to arrange for counseling services or to identify and seek interventions to meet Resident #2's emotional needs and prevent Resident #2's behavior as evidenced by continued escalation of confusion, baby seeking behaviors, and misplaced protection of residents leading to aggression against staff. Resident #2, date of birth 11/12/35, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/12/13, reflected an inability for Resident #2 to complete the BIMS test due to severely impaired cognitive ability. On 8/25/13 at 7 p.m., Resident #2 required staff intervention twice because she was forcing Resident #5 into another room, and had grabbed Resident #5 by the (L) arm causing redness/bruising. Further notes by nursing on 8/25/13 reflected that Resident #2's daughter was notified, and sat with Resident #2 until she fell asleep. Review of a nurse's note dated 9/5/13 at 10:30 p.m. revealed the nurse was called to another Resident's room where Resident #2 was going through the closet and dresser, convinced they were hiding her baby. At 10:45 p.m. on 9/25/13 Resident #2 shut herself in the conference room, cursing and threatening staff, and looking for her children. It took several attempts to get her to come out. Interview with LPN #3 on 10/23/13 at 3:45 p.m. revealed that she was not really afraid of Resident #2. LPN #3 said Resident #2 always wanted to protect "her children". LPN #3 related that at some point Resident #2's daughter told her that someone, maybe DHS, took her children away from her and maybe she (LPN #3) looked like that woman. Interview on 10/22/13 at 10:15 a.m. with Social Service Director (SSD) #1, who is a Licensed Practical Nurse, revealed the facility was in the process of changing Social Service Directors in mid-September. SSD #1 stated that the August admission was the second one for Resident #2. SSD #1 stated that there was no history of aggressive behavior and the only concern noted by her son with this 2nd admission was risk of elopement. SSD #1 stated that she resigned in mid-September and that a couple of weeks before, she had talked to Resident #2's son about sending Resident #2 to a Senior Care Unit. SSD #1 stated that at first he refused, but after meeting with her and the DON, he did consent. SSD #1 said they had discussed Resident #2's medications with her physician. Resident #2's record review revealed that Resident #2 was listed on the 8/27/13 twenty-four "24" hour report as having an unexplained altercation with her roommate. The care plan was updated and Resident #2 was moved to another room. Interview with the Director of Nursing (DON) at 3:15 p.m. on 10/22/13 did not determine what had occurred and she was unable to determine any details. There was a note on the care plan but no other notes to support. There was an indication on the 8/27/13 24 hour report that the physician had been contacted and gave an order for [REDACTED]. Resident #2 again had a room change. This was noted on the QA stand-up note. The DON indicated on 10/22/13 at 3:15 p.m. that they thought Resident #2 might be confused/fixated on Resident #5, thinking she was "her baby", and would be better off not being so close to her room. Interview with SSD #2 on 10/23/13 at 3:10 p.m. revealed that she had been the Activity Director before taking the SSD position and that she did not recall any combative behavior with Resident #2 prior to these recent episodes. SSD #2 stated that Resident #2 wanted to take care of other residents because she thinks they are "her babies". The first indication of a Psychiatric Nurse Practitioner consult was on 9/10/13, fourteen days after the physician's orders [REDACTED].

Based on observation, resident and staff interviews, record review, facility policy review and facility investigation review, the facility failed to protect two (2) of eight (8) residents out of a total sample of 8 residents reviewed (Residents #5 and #6) for abuse as evidenced by the failure to: (A) CI MS # Prevent Resident to Resident physical abuse for Resident #5. Resident #5 was led into a room by Resident #2, who grabbed her by the arm causing redness and bruising on 8/25/13. (B) CI MS # Prevent Staff on Resident physical and psychological abuse for Resident #6. CNA #4 handled Resident #6 roughly while bathing on 10/16/13 and disregarded Resident #6's wishes resulting in fearfulness on the part of Resident #6. Findings include: (A.) Resident to Resident Physical Abuse Review of the facility's policy entitled, "Abuse, Neglect, or Exploitation Policy" (no date) gave the definitions for verbal, sexual, physical and mental abuse and stated that "All residents have the right to be free from abuse.", "Residents are assessed for the potential to abuse others", and "Residents will be protected." Review of a "Report to the State" from the facility dated 8/26/13 revealed that on 8/25/13 at 7:00 p.m. Resident #5 was forced into another room by another resident (Resident #2), and (Resident #2) grabbed Resident #5 by the (L) arm causing redness/bruising. Record review revealed Resident #5 was forced into a room by Resident #2 and grabbed by the arm, causing redness and bruising on 8/25/13. Interview with Certified Nursing Assistant (CNA) #5 on 9/18/13 at 2:50 p.m. revealed that on 8/25/13, Resident #5 was "guided" into Resident #2's room by Resident #2, and laid on Resident #2's bed. CNA #5 stated that when staff intervened, Resident #2 got upset and went over to her roommate's bed (Resident #4) and "grabbed the siderails" but did not touch the resident. Interview with the Assistant Director of Nursing (ADON) on 9/18/13 at 11:45 a.m. revealed that Resident #2 had a room change on 8/25/13 to separate her from Resident #5's area. Interview with the Director of Nursing (DON) on 10/22/13 at 11:40 a.m. revealed the facility had discussed Resident #2 at the daily stand-up meetings after the incident with Resident #5 on 8/25/13, and discussed sending her to a geri-psych unit. The DON stated that following Resident #2's first aggressive activity, the facility initiated interventions to protect all residents by assessing all residents with aggressive behavior problems and placing all of these residents on fifteen minute to one hour visual checks as applicable, and to discuss interventions every day at stand-up meetings and at monthly Quality Assurance (QA) meetings. Review of the physician's orders [REDACTED]. Record review revealed every fifteen minute (15 min) monitoring was initiated on 8/31/13 for Resident #2 after having to be removed from another Resident's bed (Resident #1). Review of a nurse's note dated 9/5/13 at 10:30 p.m. revealed the nurse was called to a resident's room where Resident #2 was going through the closet and dresser convinced the facility was hiding her baby and that at 10:45 p.m. on that same date of 9/5/13, Resident #2 shut herself in the conference room, cursing and threatening staff. It took several attempts to get her to come out. According the nurses notes on 9/5/13 at 11 p.m., Resident #2 was in another resident's bed, (Unsampled Resident A) attempting to go to sleep. Psychiatric Nurse Consultant reports were on the record for a visit on 9/10/13. This report revealed recommendations for medications: [MEDICATION NAME] 25 mg every 2 p.m., [MEDICATION NAME] 0.25 mg twice a day, as needed, [MEDICATION NAME] 13.3 mg/24 hour patch every a.m. and [MEDICATION NAME] 25 mg. every a.m. and 50 mg. every night. The Psychiatric Nurse Consultant recommended a test for a urinary tract infection to rule out medical cause for mood changes. The Psychiatric Nurse Consultant also recommended low stimulating activities. Review of LPN #3's nurse's note for 9/17/13 at 5:15 am revealed that LPN #3 was called to Resident #2's room by a Certified Nursing Assistant (CNA) attempting to care for Resident #4 (Resident #2's roommate). Resident #2 threatened to hit staff with a glass vase and threw a nebulizer machine at LPN #3, hitting her on the back of her leg. The nurse recorded that when she bent down to pick up the machine, Resident #2 grabbed her (L) arm and twisted it behind her back. When she (LPN #3) called for help, and the CNA tried to enter the room, Resident #2 grabbed at the nurse's face. She recorded that they got extra help and were able to get the roommate (Resident #4) out of harm's way and removed any objects of threat. The nurse recorded that when she left the room, Resident #2 slammed the door. They placed a CNA outside the room to monitor, and objects were heard hitting the door and walls. LPN #3 recorded that at 6 a.m. when she opened the door to check on her, Resident #2 had foot pedals off a wheelchair in her hand, threatening to hit her, but they were successful in obtaining them and calming Resident #2 down. Record review reflected Resident #2 was transferred to a psychiatric hospital on [DATE], but due to renal problems, the Resident #2 required transfer to an acute care hospital. Resident #2 was seen by a psychiatrist while in the acute care hospital. Review of Resident #2's care plan reflected on 10/6/13, "potential to abuse others due to dementia" was added to the care plan. Interview with Resident #2's physician on 10/22/13 at 12:15 p.m. revealed that he had cared for Resident #2 for [AGE] years. Resident #2's physician said Advanced Dementia and Alzheimer's recently developed. Resident #2's physician stated that she started wandering and had some evidence of agitation, but no overt aggression when readmitted to the facility. Interview with the Social Service Director (SSD) #1 on 10/22/13 at 10:15 a.m. revealed that they were in the process of changing social service directors in mid-September. SSD #1 stated that the August admission was the second one for Resident #2. She stated that there was no history of aggressive behavior and the only concern noted by her son with this 2nd admission was risk of elopement. SSD #1 stated she resigned in mid-September and that a couple of weeks before that she had talked to Resident #2's son about sending Resident #2 to a Senior Care Unit. SSD #1 stated that at first he refused, but after meeting with her and the DON, he consented. SSD #1 said they had discussed her medications with her physician. (SSD #1 is a Licensed Practical Nurse). Interview with SSD #2 on 10/23/13 at 3:10 p.m. revealed that she had been the Activity Director before taking the SSD position and that she did not recall any combative behavior with Resident #2 prior to these recent episodes. SSD #2 stated that the resident has had an elopement wish. SSD #2 stated that Resident #2 wanders all over the facility with several of her "buddies". SSD #2 says she wanders with Resident #5, Resident #1, and Unsampled Resident A. SSD #2 stated that in activities and at mealtime they sit together. SSD #2 stated that they are all confused, but are "walking buddies" and would not hurt one another. SSD #2 stated that Resident #2 wanted to take care of them and thinks they are "her babies". Interview with LPN #3 on 10/23/13 at 3:45 p.m. revealed that she was not really afraid of Resident #2 and she did not feel the resident meant to hurt me. LPN #3 stated that Resident #2 gets sundowner syndrome and would be aggressive with anyone who she felt had threatened her, but once the resident had calmed down and slept, Resident #2 forgot it happened. LPN #3 said Resident #2 always wanted to protect "her children". LPN #3 related that at some point Resident #2's daughter told her that someone, maybe DHS, took her children away from her and maybe she (LPN #3) looked like that woman. LPN #3 related that she had been doing every 15 minute monitoring of Resident #2. Review of an October 10, 2013 report the Psychiatric Nurse Practitioner visit reflected a recent return from the hospital with medication changes and a favorable response. New medications were ordered, in addition to those ordered on readmission. The Psychiatric Nurse Practitioner suggested non-pharmacologic interventions for redirection using calm reassuring conversation when patient exhibits agitation and provide positive reinforcement for out of room behavior. Recommendations also included monitoring for side effects of medications. Psychoactive medications listed were: [MEDICATION NAME] 13.3 mg. patch applied every morning, [MEDICATION NAME] 25 mg at noon and 50 mg at HS (hour of sleep), and [MEDICATION NAME] 25 mg every 2 p.m. A telephone interview with the Psychiatric Nurse Practitioner on 10/24/13 at 2:10 p.m. revealed that she did not know why the order for a "psych nurse consult ASAP", was delayed two (2) weeks but that unless it was marked as "urgent" she would not visit except on her regular every two week schedule. The Psychiatric Nurse Practitioner stated she believed there was no likelihood of a risk of Resident #2 seriously harming other residents. The Psychiatric Nurse Practitioner stated that it is not unusual for an Alzheimer's patient to hold the arm of another patient and pull them along for company. Resident #2 was observed lying in bed in her room at 1:55 p.m. on 9/18/13 with her back to the door. When addressed by her name, Resident #2 denied that name and gave another one saying she'd only been there a few days and reflected total confusion. Interview with CNA #3 (Resident #2's assigned care giver) on 10/24/13 at 11:10 a.m. revealed Resident #2 had been very cooperative with her. CNA #3 stated that this morning Resident #2 had gotten up and put on three pairs of panties and two pairs of slacks. CNA #3 said there was no problem changing them and that she has never had a problem with her. CNA #3 said, "It's how you approach her". CNA #3 said the DON had told of ways to get difficult residents to cooperate. Observation on 10/24/13 at 11:05 a.m. revealed Resident #2 in her room up in a chair dressed in a sweat suit. CNA #3 stated that she was fine, just a little sleepy. Resident #2, date of birth 11/12/35, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/12/13, reflected an inability for Resident #2 to complete the Brief Interview for Mental Status (BIMS) test due to having severely impaired cognitive ability. The MDS also reflected behavior as combative toward staff and other residents at times, with a note which documented, "grabbed other resident by (L) left arm/elbow causing redness/bruising". Resident #5, date of birth 11/30/33, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/17/13, revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS) test due to severely impaired cognition. Observation of Resident #5 on 9/18/13 at 3:50 p.m. revealed the resident lying in bed with her eyes closed. Observation of Resident #5 on 10/22/13 at 1 p.m. revealed a pleasant lady lying on her back in bed, covered by an afghan. Resident #5 stated that she was fine and felt safe here. Resident #5 stated that staff treat her nice, and she is not afraid of any other residents. A 10/9/13 MDS reflected an inability to conduct a BIMS score interview due to dementia. The care plan continued to address wandering about the facility. (B.) Staff to Resident Physical and Psychological Abuse Review of the facility's sheet for a self reported incident on 10/17/13 which occurred on 10/16/13 involving Resident #6 and CNA #4 revealed the following: On October 16 at 6:00 a.m., Resident #6 put on a call light and asked to be taken to the potty. CNA #4 instructed Resident #6 that she would just give her a bath now, so she would not have to come back. Resident #6 stated that CNA #4 was rough with her and jerked her around pulling on Resident #6's clothes. Resident #6 stated, "It makes me want to leave here, the way she treated me." Resident #6 had been at the facility since 1/23/09. Review of the Director of Nursing's report indicated that the Director of Nursing (DON) was summoned to Resident #6's room about 8:15 on 10/16/13 when Resident #6 reported the incident to the DON. Resident #6 stated to the DON that she was scared to have CNA #4 back in her room because, "I am afraid she (CNA #4) is going to hurt me". CNA #4 was suspended on 10/16/13 following the incident, and terminated after an in-house investigation on 10/17/13. Record review revealed that Resident #6 entered the facility on 1/23/09 with [DIAGNOSES REDACTED]. Her most recent quarterly Minimum Data Set (MDS) had a Brief Interview for Mental Status(BIMS) scored at 15 which indicated that Resident #6 was cognitively intact. Observation and interview on 10/22/13 at 12:00 noon revealed that Resident #6 was pleasant and smiled and stated she enjoyed living in the facility, apart from the recent incident with CNA #4, which caused her concern and worry. Resident #6 stated, "When a person leaves your room, they shouldn't leave you with a worry. I worried after she (CNA #4) left. I was afraid of what she might do next." Interview with the DON on 10/22/13 at 3:30 p.m. revealed, "When I got to work about 8 a.m. on that day, (CNA #4) came to me to tell me that she had had a problem with Resident #6 while trying to give her a bath. I later found out it was the other way around. Resident #6 had a problem with CNA #4. She didn't want her bath till later, but CNA #4 insisted, and Resident #6 said she jerked her clothing and was rough with her and in a hurry. She told me that she was afraid the CNA was going to hurt her. I pulled CNA #4 off the floor around 8:25 a.m. and suspended her, pending investigation. The incident happened around 6 a.m. but Resident #6 was still upset two hours later. She was not physically hurt, but it upset her, and she was frightened. If there is ever any problem between staff and a cognitive resident, I will always side with the resident. That's just the way it has to be." An interview was attempted on 10/24/13 at 10:30 a.m., and again at 10:45 a.m., with CNA #4 by phone without success. A review of facility in-service given on 7/18/2013 entitled "Abuse, Neglect, Resident Rights, Accountability" was reviewed. CNA #4 had signed a sign in sheet that stated, "I have read and understand the in-service given 7/18/2013". Specific items discussed on that day included, "Talk to residents as you do care, make them feel like you want to (be) here, and like you enjoy your job. Do not make them feel like they are trouble to care for." "Provide them (residents) with the best care we can give and give no cause to even suspect any type of abuse to the resident. If you find yourself becoming angry and out of control - take a break." A review of the facility's log entitled "Grievance/Complaint/Concerns Log", dated 10/17/13, stated under Resident #6, "Staff frighten resident by verbally demanding her to do as she was told." A review of CNA #4's personnel file indicated that the incident on 10/16/13 marked the second suspension without pay for CNA #4.

CI MS # Based on observation, record review, staff interview, and policy review, the facility failed to ensure the proper management of resident trust funds for 11 of 11 residents reviewed for misappropriations of resident trust funds, failure to provide quarterly statements, and failure to pay a Medicare supplement policy premium for a Resident with a trust fund account (Residents #1, #7, #10, #11, #15, #17, #19, #20, #21, #22, and #23). Both a standard survey and complaint investigation were conducted from [DATE] to [DATE]; an extended survey was conducted from [DATE] to [DATE]. Please note that additional investigation occurred at the facility on [DATE] regarding conveyance of personal funds upon death. During the survey, the facility was found not to be in substantial compliance with Medicare and Medicaid requirements. An Immediate Jeopardy (IJ) and/or Substandard Quality of Care (SQC) was identified on [DATE] at 5:55 p.m.; the Business Office Manager and Nurse Consultant were subsequently notified of the IJ at 6:10 p.m. (as the facility Administrator was hospitalized at that time). The IJ was determined to begin on [DATE]. The facility submitted an Allegation of Compliance (AoC) on [DATE] at 11:57 a.m.; it was determined not to be acceptable. A second AoC was submitted on [DATE] at 3:23 p.m.; it was determined not to be acceptable. The IJ was not removed upon exit from the facility on [DATE], and is considered ongoing. Findings Include: Resident #1 (Complaint MS- ) Record review of Resident #1 revealed a date of birth of [DATE]. She was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed a cognitive status of severely impaired. Observation and interview on [DATE] at 11:05 a.m. revealed Resident #1 in a wheelchair with a waist restraint in place. During an interview on [DATE] at 3:30 p.m. with the Office Manager and Registered Nurse (RN) Consultant, it was revealed that the Administrator was in the hospital, and that the Office Manager and RN Consultant would answer questions regarding the missing money for Resident #1. The Office Manager stated, "During that time the RP (Responsible Party) was out of town. She started out behind in her (Resident #1's) account and the family started bringing in money. On [DATE] we received two (2) payments of $600 which made her account current. The family brought $600 cash and a $600 money order. I gave receipts, but when I got ready to close, the money didn't balance. There were Audits for September through February. We had a lot to do. We had a company that does bank reconciliations. (Terminated Resident Trust Fund Coordinator) was in charge of the trust funds when the money was taken. There are several Residents with funds missing. We are looking at between $25,000 and $37,000. We give receipts now; as opposed to cash, we take checks and money orders. We are still dealing with the problems. The Attorney General's Office is still resolving the issue." During a telephone interview on [DATE] at 3:38 p.m. with the Administrator more details of the Resident Trust Fund concerns were revealed. The Administrator stated, "She (terminated Resident Trust Fund Coordinator) admitted to taking the $1200.00, and that's all she admitted to. She would always say it (the records) is correct. She wouldn't let anybody touch it (the records). I never doubted it because the State came in to check and audit. We didn't do any internal audits. I thought my Office Manager was checking and (terminated Resident Trust Fund Coordinator) provided a spread sheet that made things look ok. I am sixty-nine (69) years old and I don't do computers. I'm really sorry that it happened." An interview was conducted on [DATE] at 10:30 am with Resident #1's Daughter. She stated, "I had requested receipts but they said I'd need to get mother's permission to get information on her account. She (terminated Resident Trust Fund Coordinator) wouldn't tell me about her account. It bothered me because my Mom's [AGE] years old and confused. How could she give me permission to know about her account? My sister is her Responsible Party but she lives in Alabama. I'm here in town; that's why I take care of things. We would bring money for her and they would never give a receipt." The terminated Resident Trust Fund Coordinator was contacted on [DATE]; she requested an in-person interview at a local hotel. She requested the interview to be held at 8:00 p.m.; however, she did not come to the interview. Phone contact with the terminated Resident Trust Fund Coordinator was attempted on [DATE] at 10:00 a.m., with a message left on her personal answering machine requesting a call back. There was no response from terminated Resident Trust Fund Coordinator. Resident #7 Record Review for Resident #7 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Trust Fund account for Resident #7 showed there were discrepancies noted by the accountant. In November of 2008, a check in the amount of $344.00 was deposited in the bank, but was not recorded on the trust fund account. In June of 2009, the resident's family paid $366.00 on the nursing home bill, but that same amount was posted on the trust fund account as being paid from the trust fund. There was no documentation of discrepancies for the current year. On [DATE] at 10:15 a.m., an interview with the Business Office Manager/Bookkeeper confirmed the trust fund account for Resident #7 had discrepancies. She stated the facility was in the process of correcting the discrepancies. She further confirmed the facility's system failed to prevent the misappropriation of resident funds. Resident #10 An observation of Resident #10 on [DATE] at 5:15 p.m. revealed that she was sitting in her room in a wheelchair, neatly dressed. Review of Resident #10's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed that she scored 15 of 15 on the Brief Interview for Mental Status (BIMS), which indicated that she was cognitively intact. An interview with Resident # 10, conducted on [DATE] at 5:15 p.m., confirmed that she had a Trust Fund Account. Review of a statement from (Name of Medicare Supplement), dated [DATE], revealed "Lapse Notice - Your Attention is Needed". It also revealed, "Your insurance coverage has terminated due to non-payment of your required premium". The amount due for policy period [DATE] to [DATE] was $293.00, which was due on [DATE]. Review of a copy of a check for Resident #10's Resident Trust Fund revealed a check, dated [DATE], for (Name of Medicare Supplement) for $293.00. It was written for "Two hundred ninety + No/100". This check was signed by the facility Administrator and the former Resident Trust Fund Coordinator. Resident #11 Record review of Resident #11 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Quarterly MDS, with an ARD of [DATE], revealed her cognitive status was moderately impaired, some confusion in new situations. Observation on [DATE] at 10:18 am revealed Resident #11 was transferring independently into a low wheelchair. She was noted to talk loudly. RN#1 acknowledged Resident #11 was hard of hearing, and indicated her white board and a marker. During an interview on [DATE] at 3:30 p.m., the Office Manager and the RN Consultant acknowledged all of the Residents with Trust Fund accounts were affected by the misappropriation because money was taken from the trust and used to pay for things for other Residents not in the Trust. An interview was conducted with Resident #11 on [DATE] at 2:40 p.m.; she revealed she wasn't aware of any problems with the Trust Fund money. Resident #15 Record review of Resident #15 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Significant Change MDS, with an ARD of [DATE], revealed her cognitive status as severely impaired with decisions never/rarely made. Interview on [DATE] at 3:30 pm with the Office Manager and RN Consultant acknowledged the family of Resident #15 questioned the Trust Fund Coordinator about a bill they had received. Contact with the Responsible Party for Resident #15 was attempted on [DATE] at 6:00 p.m.; contact was made on [DATE] at 3:28 p.m. He stated, "I did have problems with them. I would ask for receipts and they wouldn't give them. Then they would send a bill saying we owed $3,000. But her checks were going to the facility. I couldn't understand that. I'm a Certified Public Accountant and the numbers didn't add up. They didn't correct it until she passed away in February 2012. We paid the $800 then. I'm still sending money because the Beauty Shop Lady said Mother owed a couple hundred dollars. I have a spread sheet and my cancelled checks. I'll email them to you." Resident #17 Resident #17 was not observed, since this Resident had been discharged . Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #17's significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed that she had severely impaired decision-making skills. Review of the facility document, "Personal Fund Authorization", which was not dated, revealed "This is an authorization for Silver Cross Home to hold and dispense my personal funds as my needs require. You are to keep complete records of all deposits and disbursements of these funds, and to make this record available to me or my representative upon request." An interview, conducted on [DATE] at 4:40 p.m. with Resident # 17's family member, revealed the following statements: 1. "My mother had a trust fund, but she never got any trust fund statement." 2. "We would put in cash in the trust fund and (former Resident Trust Fund Coordinator) never gave us a receipt." 3. "When we asked for petty cash, she (terminated Resident Trust Fund Coordinator) would say she lost her keys." This family member was unaware of the actual account balance in the trust fund. Resident #19 Closed Record review of Resident #19 revealed she moved into the home on [DATE] with [DIAGNOSES REDACTED]. Review of her Death Certificate revealed [DATE] as her date of death . Record review of the Resident #19's significant change MDS, with an ARD of [DATE], revealed a cognitive status of severely impaired. An interview was conducted on [DATE] at 9:30 a.m. with the Business Office Manager; she acknowledged Resident #19 did participate in the facility Resident Trust. Interview on [DATE] at 11:50 a.m. with the Resident #19's Responsible Party revealed he did receive a check from the facility after his Mother passed but admitted he didn't follow her Resident Trust close enough to notice any discrepancies. Resident #20 Closed Record review of Resident #20 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #20's MDS Discharge Assessment, with an ARD of [DATE], revealed a cognitive status of independent consistent and reasonable. Interview with the Business Office Manager on [DATE] at 9:34 a.m. acknowledged Resident #20 participated in the facility Resident Trust fund. Interview on [DATE] at 12:19 p.m. with the Responsible Party for Resident #20 acknowledged concerns with the money deposited for Resident. She stated, "I sent money down there but it was spent. They never gave me any receipts for things. I sent $250 dollars total for two months. It went quick. I sent a check but never got a receipt. I never got anything after she passed." Resident #21 Closed Record review of Resident #21 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #21's MDS Discharge Assessment, with an ARD of [DATE], revealed a cognitive status of severely impaired. Interview on [DATE] at 9:35 a.m. with the Business Office manager acknowledged Resident #21 participated in the facility Resident Trust fund. Interview on [DATE] at 12:15 p.m. with the Responsible Party of Resident #21 acknowledged that there was not much money deposited; she believed she did get some receipts, but was not sure of the total number. She also acknowledged she got a notice in [DATE] that there was a $10 dollar refund. Her mother died in [DATE]. Resident #22 Closed Record review of Resident #22 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #22's Quarterly MDS, with an ARD of [DATE], revealed a cognitive status of moderately impaired. During an interview on [DATE] at 10:16 a.m. with the Business Office Manager, she acknowledged Resident #22 did participate in the Resident Trust fund. Contact with the Responsible Party for Resident #22 was attempted by telephone on [DATE] at 11:55 a.m. All of the telephone contact numbers were disconnected. Resident #23 Closed Record review of Resident #23 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #23's Admission MDS, with an ARD of [DATE], revealed a cognitive status of independent decision-making. During an interview on [DATE] at 9:40 a.m. with the Business Office Manager, she acknowledged Resident #23 did participate in the facility Resident Trust fund. Contact with the Responsible Party for Resident #23 was attempted by telephone on [DATE] at 12:04 p.m. There was no answer at either telephone number called, with no answering machines. Interview on [DATE] at 3:30 p.m. with the Business Office Manager and the Registered Nurse (RN) Consultant acknowledged all Residents who participated in the Resident Trust fund were affected by the misappropriation of funds. On [DATE] at 4:15 p.m., an interview was conducted with the facility Office Manager and the Accountant Consultant; during that interview, they provided details of Resident Trust Fund audits. The Office Manager stated, "We made the (Administrator) aware of the concern of her (terminated Resident Trust Fund Coordinator) records. (Administrator) told us not to worry about it. (Consultant Accountant) was aware (the Consultant Accountant nodded in agreement). The Accountant Consultant stated, "I offered to do an audit and she (Administrator) refused. That was over a year ago. My concern was that she was not keeping up with her records." A review of the facility policy titled "Resident Fund Policy", dated [DATE] was conducted. The policy states, "It is the policy of this facility that resident funds will be handled as follows: 1. With written request from the resident for the facility to handle the funds. 2. At no charge to the Resident. 3. Amounts less than $50.00 will be maintained in the facility. 4. Amounts over $50.00 will be deposited in an interest bearing account. 5. Requests for funds less than $50.00 will be honored within the same day. 6. Requests for funds more than $50.00 will be honored within 3 three days. 7. A monthly report of funds will be provided to the Resident and/or family. 8. The facility will maintain a full, complete and separate accounting of each Resident's fund. 9. The facility will notify each Medicaid recipient when the amount in the Resident's account reaches $200.00 less than the SSI (Social Security Income) resource limit for one person (That, if the amount is the account, in addition to the value of the Resident's other nonexempt resources, reaches the SSI resource limit for one person, the Resident may lose eligibility for Medicaid or SSI. In Event of Death: 1. Upon death of the resident with a personal fund with the facility, The facility will convey the Resident's fund within 30 days and a final accounting of those funds to the individual or probate jurisdiction administering the Resident's estate. Procedure for Check and Balance for Resident Funds: 1. The Secretary will receive the payment. 2. A numbered receipt will be given when payment is received. 3. The Bookkeeper will make a deposit, posts to the Resident's account and reconciles the trust fund. 4. The Administrator or designee will check the fund for accuracy. 5. A statement of each Resident's trust fund will be sent to the Resident and/or family monthly." No other policy related to Resident Trust was provided. The facility requested an interview on [DATE] at 1:00 p.m. with the Board of Director's President, Consultant Accountant, and Private Attorney for the Board of Directors; details on Resident Trust Fund concern were revealed during the interview. The Consultant Accountant stated, "2007 was when the money started going missing. Medicaid would come in yearly. I think the State didn't follow-up as clearly as they should. We had no documentation. We had to go to the bank and get deposit information. She (terminated Resident Trust Fund Coordinator) was very smart. She was constantly manipulating money to cover, robbing Peter to pay Paul." The Board President stated, "There were procedures and things that should have taken place that wasn't. She (Administrator) would tell us at the Board Meeting that (terminated Resident Trust Fund Coordinator) would not allow her stuff (records) to be done (internal audit). The statements that should have been mailed quarterly were not sent. We don't have verification of what (amount) was actually taken because receipts were destroyed. It was brought to the Board on [DATE] and again on [DATE]. The Board gave the Consultant Accountant permission to correct the problems. The majority was discharged and closed Residents. We are putting in place audits and monitoring by others that will keep things from happening again." Interview on [DATE] at 5:30 pm with the Board of Directors President, Consultant Accountant, DON, RN Consultant, Private Attorney for the Board of Directors, and the Business Office Manager revealed an attempt to resolve concerns. The Board President stated, "We have a system; it didn't work. We recognize we messed up. We have discussed how to prevent it from happening again."

Both a standard survey and complaint investigation were conducted from 7/31/12 to 8/10/12; an extended survey was conducted from 8/2/12 to 8/4/12. Please note that additional investigation occurred at the facility on 08/10/12 regarding conveyance of personal funds upon death. During the survey, the facility was found not to be in substantial compliance with Medicare and Medicaid requirements. An Immediate Jeopardy (IJ) and/or Substandard Quality of Care (SQC) was identified on 8/1/12 at 5:55 p.m.; the Business Office Manager and Nurse Consultant were subsequently notified of the IJ at 6:10 p.m. (as the facility Administrator was hospitalized at that time). The IJ was determined to begin on 8/1/12. The facility submitted an Allegation of Compliance (AoC) on 8/3/12 at 11:57 a.m.; it was determined not to be acceptable. A second AoC was submitted on 8/3/12 at 3:23 p.m.; it was determined not to be acceptable. The IJ was not removed upon exit from the facility on 8/10/12, and is considered ongoing. Based on record review, staff interview, and policy review, and the systematic failure to prevent misappropriation of the residents' trust funds/resident property and to convey personal funds after death, the facility was not administered in a manner to maintain the highest practicable mental and psychosocial well-being for 11 of 11 residents with regard to resident trust funds (Residents #1, #7, #10, #11, #15, #17, #19, #20, #21, #22, and #23) and to convey funds after death for six (6) of six (6) Residents (Residents #15, #19, #20, #21, #22, and #23). Findings include: Cross refer to F-159 for the facility's failure to ensure for the proper management of Resident Trust Funds for 11 of 11 Residents reviewed for Misappropriations of Resident Trust Funds, failure to provide quarterly receipts, and failure to pay a Medicare supplement policy for a Resident with a trust fund account. Cross refer to F-160 for the facility's failure to ensure resident trust fund accounts were dispersed upon death for six (6) of six (6) discharge records reviewed. Cross refer to F-224 for the facility's failure to protect residents from the misappropriation of resident property with regard to the mismanagement of the resident trust fund accounts for 11 of 11 residents and for the conveyance of funds after death for six (6) of six (6) discharged residents.

Both a standard survey and complaint investigation were conducted from 7/31/12 to 8/10/12; an extended survey was conducted from 8/2/12 to 8/4/12. Please note that additional investigation occurred at the facility on 08/10/12 regarding conveyance of personal funds upon death. During the survey, the facility was found not to be in substantial compliance with Medicare and Medicaid requirements. An Immediate Jeopardy (IJ) and/or Substandard Quality of Care (SQC) was identified on 8/1/12 at 5:55 p.m.; the Business Office Manager and Nurse Consultant were subsequently notified of the IJ at 6:10 p.m. (as the facility Administrator was hospitalized at that time). The IJ was determined to begin on 8/1/12. The facility submitted an Allegation of Compliance (AoC) on 8/3/12 at 11:57 a.m.; it was determined not to be acceptable. A second AoC was submitted on 8/3/12 at 3:23 p.m.; it was determined not to be acceptable. The IJ was not removed upon exit from the facility on 8/10/12, and is considered ongoing. Based on record review, staff interview, and policy review, and the systematic failure to prevent misappropriation of the residents' trust funds/resident property and to convey personal funds after death, the facility was not administered in a manner to maintain the highest practicable mental and psychosocial well-being for 11 of 11 residents with regard to resident trust funds (Residents #1, #7, #10, #11, #15, #17, #19, #20, #21, #22, and #23) and to convey funds after death for six (6) of six (6) Residents (Residents #15, #19, #20, #21, #22, and #23). Findings include: Cross refer to F-159 for the facility's failure to ensure for the proper management of Resident Trust Funds for 11 of 11 Residents reviewed for Misappropriations of Resident Trust Funds, failure to provide quarterly receipts, and failure to pay a Medicare supplement policy for a Resident with a trust fund account. Cross refer to F-160 for the facility's failure to ensure resident trust fund accounts were dispersed upon death for six (6) of six (6) discharge records reviewed. Cross refer to F-224 for the facility's failure to protect residents from the misappropriation of resident property with regard to the mismanagement of the resident trust fund accounts for 11 of 11 residents and for the conveyance of funds after death for six (6) of six (6) discharged residents.

Based on record review, staff interview, policy review, the facility failed to protect residents from misappropriation of resident property when failing to properly manage the resident trust fund accounts for 11 of 11 residents (Residents #1, #7, #10, #11, #15, #17, #19, #20, #21, #22, and #23) and to convey funds after death for six (6) of six (6) residents (Residents #15, #19, #20, #21, #22, and #23). Both a standard survey and complaint investigation were conducted from 7/31/12 to 8/2/12, and an extended survey was conducted from 8/2/12 to 8/4/12. During the survey, the facility was found not to be in substantial compliance with Medicare and Medicaid requirements. An Immediate Jeopardy (IJ was identified on 8/1/12 at 5:55 p.m.; the Business Office Manager and Nurse Consultant were subsequently notified of the IJ at 6:10 p.m. (as the facility Administrator was hospitalized at that time). The IJ was determined to begin on 8/1/12. The facility submitted an Allegation of Compliance (AoC) on 8/3/12 at 11:57 a.m.; it was determined not to be acceptable. A second AoC was submitted on 8/3/12 at 3:23 p.m.; it was determined not to be acceptable. The IJ was not removed upon exit from the facility on 8/4/12, and is considered ongoing. Findings include: Cross refer to F-159 for the facility's failure to ensure for the proper management of Resident Trust Funds for 11 of 11 Residents reviewed for Misappropriation of Resident Trust Funds, failure to provide quarterly statements, and failure to pay a Medicare supplement policy for a Resident with a trust fund account. Cross refer to F-160 for the facility's failure to ensure resident trust fund accounts were dispersed upon death for six (6) of six (6) discharge records reviewed.

Based on record review, staff interview, policy review, the facility failed to protect residents from misappropriation of resident property when failing to properly manage the resident trust fund accounts for 11 of 11 residents (Residents #1, #7, #10, #11, #15, #17, #19, #20, #21, #22, and #23) and to convey funds after death for six (6) of six (6) residents (Residents #15, #19, #20, #21, #22, and #23). Both a standard survey and complaint investigation were conducted from 7/31/12 to 8/2/12, and an extended survey was conducted from 8/2/12 to 8/4/12. During the survey, the facility was found not to be in substantial compliance with Medicare and Medicaid requirements. An Immediate Jeopardy (IJ was identified on 8/1/12 at 5:55 p.m.; the Business Office Manager and Nurse Consultant were subsequently notified of the IJ at 6:10 p.m. (as the facility Administrator was hospitalized at that time). The IJ was determined to begin on 8/1/12. The facility submitted an Allegation of Compliance (AoC) on 8/3/12 at 11:57 a.m.; it was determined not to be acceptable. A second AoC was submitted on 8/3/12 at 3:23 p.m.; it was determined not to be acceptable. The IJ was not removed upon exit from the facility on 8/4/12, and is considered ongoing. Findings include: Cross refer to F-159 for the facility's failure to ensure for the proper management of Resident Trust Funds for 11 of 11 Residents reviewed for Misappropriation of Resident Trust Funds, failure to provide quarterly statements, and failure to pay a Medicare supplement policy for a Resident with a trust fund account. Cross refer to F-160 for the facility's failure to ensure resident trust fund accounts were dispersed upon death for six (6) of six (6) discharge records reviewed.

Both a standard survey and complaint investigation were conducted from 7/31/12 to 8/10/12; an extended survey was conducted from 8/2/12 to 8/4/12. Please note that additional investigation occurred at the facility on 08/10/12 regarding conveyance of personal funds upon death. During the survey, the facility was found not to be in substantial compliance with Medicare and Medicaid requirements. An Immediate Jeopardy (IJ) and/or Substandard Quality of Care (SQC) was identified on 8/1/12 at 5:55 p.m.; the Business Office Manager and Nurse Consultant were subsequently notified of the IJ at 6:10 p.m. (as the facility Administrator was hospitalized at that time). The IJ was determined to begin on 8/1/12. The facility submitted an Allegation of Compliance (AoC) on 8/3/12 at 11:57 a.m.; it was determined not to be acceptable. A second AoC was submitted on 8/3/12 at 3:23 p.m.; it was determined not to be acceptable. The IJ was not removed upon exit from the facility on 8/10/12, and is considered ongoing. Findings Include: A record review of the Facility Surety Bond revealed a total coverage value amount of $30,000.00. A record review of the Consultant Accountant's current estimate of the amount of funds which had been misappropriated totaled over $37,000.00. Based on the systematic failure of the misappropriation of resident trust funds, as well as the lack of determination of the pervasive nature of the problem by the facility, as of the date of this survey, the amount of the current surety bond ($30,000) failed to provide the total coverage value of the misappropriated funds (estimated $37,000).

Both a standard survey and complaint investigation were conducted from 7/31/12 to 8/10/12; an extended survey was conducted from 8/2/12 to 8/4/12. Please note that additional investigation occurred at the facility on 08/10/12 regarding conveyance of personal funds upon death. During the survey, the facility was found not to be in substantial compliance with Medicare and Medicaid requirements. An Immediate Jeopardy (IJ) and/or Substandard Quality of Care (SQC) was identified on 8/1/12 at 5:55 p.m.; the Business Office Manager and Nurse Consultant were subsequently notified of the IJ at 6:10 p.m. (as the facility Administrator was hospitalized at that time). The IJ was determined to begin on 8/1/12. The facility submitted an Allegation of Compliance (AoC) on 8/3/12 at 11:57 a.m.; it was determined not to be acceptable. A second AoC was submitted on 8/3/12 at 3:23 p.m.; it was determined not to be acceptable. The IJ was not removed upon exit from the facility on 8/10/12, and is considered ongoing. Findings Include: A record review of the Facility Surety Bond revealed a total coverage value amount of $30,000.00. A record review of the Consultant Accountant's current estimate of the amount of funds which had been misappropriated totaled over $37,000.00. Based on the systematic failure of the misappropriation of resident trust funds, as well as the lack of determination of the pervasive nature of the problem by the facility, as of the date of this survey, the amount of the current surety bond ($30,000) failed to provide the total coverage value of the misappropriated funds (estimated $37,000).

Based on Record Review, Policy Review and Staff Interview, the facility failed to ensure resident trust fund accounts were dispersed upon death for six (6) of six (6) discharge records reviewed (Residents #15, #19, #20, #21, #22, and #23). Both a standard survey and complaint investigation were conducted from [DATE] to [DATE]; an extended survey was conducted from [DATE] to [DATE]. Please note that additional investigation occurred at the facility on [DATE] regarding conveyance of personal funds upon death. During the survey, the facility was found not to be in substantial compliance with Medicare and Medicaid requirements. An Immediate Jeopardy (IJ) and/or Substandard Quality of Care (SQC) was identified on [DATE] at 5:55 p.m.; the Business Office Manager and Nurse Consultant were subsequently notified of the IJ at 6:10 p.m. (as the facility Administrator was hospitalized at that time). The IJ was determined to begin on [DATE]. The facility submitted an Allegation of Compliance (AoC) on [DATE] at 11:57 a.m.; it was determined not to be acceptable. A second AoC was submitted on [DATE] at 3:23 p.m.; it was determined not to be acceptable. The IJ was not removed upon exit from the facility on [DATE], and is considered ongoing. Findings Include: Resident #15 Record review of Resident #15 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of her Death Certificate revealed [DATE] as her date of death . Record review of the Significant Change MDS, with an ARD of [DATE], revealed her cognitive status as severely impaired with decisions never/rarely made. Interview on [DATE] at 3:30 pm with the Office Manager and RN Consultant acknowledged the family of Resident #15 questioned the Trust Fund Coordinator about a bill they had received. Contact with the Responsible Party for Resident #15 was attempted on [DATE] at 6:00 p.m.; contact was made on [DATE] at 3:28 p.m. He stated, "I did have problems with them. I would ask for receipts and they wouldn't give them. Then they would send a bill saying we owed $3000 dollars. But her checks were going to the facility. I couldn't understand that. I'm a Certified Public Accountant and the numbers didn't add up. They didn't correct it until she passed away in February 2012. We paid the $800 dollars then. I'm still sending money because the Beauty Shop Lady said Mother owed a couple hundred dollars. I have a spread sheet and my cancelled checks. I'll email them to you." Resident #19 Closed Record review of Resident #19 revealed she moved into the home on [DATE] with [DIAGNOSES REDACTED]. Review of her Death Certificate revealed [DATE] as her date of death . Record review of the Resident #19's significant change MDS with an ARD of [DATE] revealed her cognitive status as severely impaired. Interview on [DATE] at 9:30 a.m. with the Business Office Manager acknowledged Resident #19 did participate in the facility Resident Trust. Interview on [DATE] at 11:50 a.m. with the Responsible Party revealed he did receive a check from the facility after his Mother passed but admitted he didn't follow her Resident Trust close enough to notice any discrepancies. Interview on [DATE] at 3:30 p.m. with the Business Office Manager and the Registered Nurse (RN) Consultant acknowledged all Residents who participated in the Resident Trust fund were affected by the misappropriation of funds. Resident #20 Closed Record review of Resident #20 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #20's MDS Discharge Assessment, with an ARD of [DATE], revealed her cognitive status was independent consistent and reasonable. Resident #20 was discharged from the facility on [DATE]. Interview with the Business Office Manager on [DATE] at 9:34 a.m. acknowledged Resident #20 participated in the facility Resident Trust fund. Interview on [DATE] at 12:19 p.m. with the Responsible Party for Resident #20 acknowledged concerns with the money deposited for Resident. She stated, "I sent money down there but it was spent. They never gave me any receipts for things. I sent $250 dollars total for two months. It went quick. I sent a check but never got a receipt. I never got anything after she passed." Resident #21 Closed Record review of Resident #21 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #21's MDS Discharge Assessment, with an ARD of [DATE], revealed her cognitive status was severely impaired. Interview on [DATE] at 9:35 a.m. with the Business Office manager acknowledged Resident #21 participated in the facility Resident Trust fund. Interview on [DATE] at 12:15 p.m. with the Responsible Party of Resident #21 acknowledged that there was not much money deposited; she believed she did get some receipts, but was not sure of the total number. She also acknowledged she got a notice in [DATE] that there was a $10 dollar refund. Her mother died in [DATE]. Resident #22 Closed Record review of Resident #22 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the date of Resident #22's death was [DATE]. Record review of Resident #22's Quarterly MDS, with an ARD of [DATE], revealed a cognitive status of moderately impaired. During an interview on [DATE] at 10:16 a.m. with the Business Office Manager, she acknowledged Resident #22 did participate in the Resident Trust fund. Contact with the Responsible Party for Resident #22 was attempted by telephone on [DATE] at 11:55 a.m. All of the telephone contact numbers were disconnected. There was no documented evidence to prove any funds were dispersed after Resident #22's death. Resident #23 Closed Record review of Resident #23 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #23's Admission MDS, with an ARD of [DATE], revealed a cognitive status of independent decision making. During an interview on [DATE] at 9:40 a.m. with the Business Office Manager, she acknowledged Resident #23 did participate in the facility Resident Trust fund. Contact with the Responsible Party for Resident #23 was attempted by telephone on [DATE] at 12:04 p.m. There was no answer to either telephone number called, with no answering machines. There was no documented evidence to prove any funds were dispersed after her death on [DATE]. There was no documented evidence to prove the amount of the dispersed funds was accurate. Interview on [DATE] at 3:30 p.m. with the Business Office Manager and the Registered Nurse (RN) Consultant acknowledged all Residents who participated in the Resident Trust fund were affected by the misappropriation of funds.

Based on Record Review, Policy Review and Staff Interview, the facility failed to ensure resident trust fund accounts were dispersed upon death for six (6) of six (6) discharge records reviewed (Residents #15, #19, #20, #21, #22, and #23). Both a standard survey and complaint investigation were conducted from [DATE] to [DATE]; an extended survey was conducted from [DATE] to [DATE]. Please note that additional investigation occurred at the facility on [DATE] regarding conveyance of personal funds upon death. During the survey, the facility was found not to be in substantial compliance with Medicare and Medicaid requirements. An Immediate Jeopardy (IJ) and/or Substandard Quality of Care (SQC) was identified on [DATE] at 5:55 p.m.; the Business Office Manager and Nurse Consultant were subsequently notified of the IJ at 6:10 p.m. (as the facility Administrator was hospitalized at that time). The IJ was determined to begin on [DATE]. The facility submitted an Allegation of Compliance (AoC) on [DATE] at 11:57 a.m.; it was determined not to be acceptable. A second AoC was submitted on [DATE] at 3:23 p.m.; it was determined not to be acceptable. The IJ was not removed upon exit from the facility on [DATE], and is considered ongoing. Findings Include: Resident #15 Record review of Resident #15 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of her Death Certificate revealed [DATE] as her date of death . Record review of the Significant Change MDS, with an ARD of [DATE], revealed her cognitive status as severely impaired with decisions never/rarely made. Interview on [DATE] at 3:30 pm with the Office Manager and RN Consultant acknowledged the family of Resident #15 questioned the Trust Fund Coordinator about a bill they had received. Contact with the Responsible Party for Resident #15 was attempted on [DATE] at 6:00 p.m.; contact was made on [DATE] at 3:28 p.m. He stated, "I did have problems with them. I would ask for receipts and they wouldn't give them. Then they would send a bill saying we owed $3000 dollars. But her checks were going to the facility. I couldn't understand that. I'm a Certified Public Accountant and the numbers didn't add up. They didn't correct it until she passed away in February 2012. We paid the $800 dollars then. I'm still sending money because the Beauty Shop Lady said Mother owed a couple hundred dollars. I have a spread sheet and my cancelled checks. I'll email them to you." Resident #19 Closed Record review of Resident #19 revealed she moved into the home on [DATE] with [DIAGNOSES REDACTED]. Review of her Death Certificate revealed [DATE] as her date of death . Record review of the Resident #19's significant change MDS with an ARD of [DATE] revealed her cognitive status as severely impaired. Interview on [DATE] at 9:30 a.m. with the Business Office Manager acknowledged Resident #19 did participate in the facility Resident Trust. Interview on [DATE] at 11:50 a.m. with the Responsible Party revealed he did receive a check from the facility after his Mother passed but admitted he didn't follow her Resident Trust close enough to notice any discrepancies. Interview on [DATE] at 3:30 p.m. with the Business Office Manager and the Registered Nurse (RN) Consultant acknowledged all Residents who participated in the Resident Trust fund were affected by the misappropriation of funds. Resident #20 Closed Record review of Resident #20 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #20's MDS Discharge Assessment, with an ARD of [DATE], revealed her cognitive status was independent consistent and reasonable. Resident #20 was discharged from the facility on [DATE]. Interview with the Business Office Manager on [DATE] at 9:34 a.m. acknowledged Resident #20 participated in the facility Resident Trust fund. Interview on [DATE] at 12:19 p.m. with the Responsible Party for Resident #20 acknowledged concerns with the money deposited for Resident. She stated, "I sent money down there but it was spent. They never gave me any receipts for things. I sent $250 dollars total for two months. It went quick. I sent a check but never got a receipt. I never got anything after she passed." Resident #21 Closed Record review of Resident #21 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #21's MDS Discharge Assessment, with an ARD of [DATE], revealed her cognitive status was severely impaired. Interview on [DATE] at 9:35 a.m. with the Business Office manager acknowledged Resident #21 participated in the facility Resident Trust fund. Interview on [DATE] at 12:15 p.m. with the Responsible Party of Resident #21 acknowledged that there was not much money deposited; she believed she did get some receipts, but was not sure of the total number. She also acknowledged she got a notice in [DATE] that there was a $10 dollar refund. Her mother died in [DATE]. Resident #22 Closed Record review of Resident #22 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the date of Resident #22's death was [DATE]. Record review of Resident #22's Quarterly MDS, with an ARD of [DATE], revealed a cognitive status of moderately impaired. During an interview on [DATE] at 10:16 a.m. with the Business Office Manager, she acknowledged Resident #22 did participate in the Resident Trust fund. Contact with the Responsible Party for Resident #22 was attempted by telephone on [DATE] at 11:55 a.m. All of the telephone contact numbers were disconnected. There was no documented evidence to prove any funds were dispersed after Resident #22's death. Resident #23 Closed Record review of Resident #23 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #23's Admission MDS, with an ARD of [DATE], revealed a cognitive status of independent decision making. During an interview on [DATE] at 9:40 a.m. with the Business Office Manager, she acknowledged Resident #23 did participate in the facility Resident Trust fund. Contact with the Responsible Party for Resident #23 was attempted by telephone on [DATE] at 12:04 p.m. There was no answer to either telephone number called, with no answering machines. There was no documented evidence to prove any funds were dispersed after her death on [DATE]. There was no documented evidence to prove the amount of the dispersed funds was accurate. Interview on [DATE] at 3:30 p.m. with the Business Office Manager and the Registered Nurse (RN) Consultant acknowledged all Residents who participated in the Resident Trust fund were affected by the misappropriation of funds.

CI MS # Based on observation, record review, staff interview, and policy review, the facility failed to ensure the proper management of resident trust funds for 11 of 11 residents reviewed for misappropriations of resident trust funds, failure to provide quarterly statements, and failure to pay a Medicare supplement policy premium for a Resident with a trust fund account (Residents #1, #7, #10, #11, #15, #17, #19, #20, #21, #22, and #23). Both a standard survey and complaint investigation were conducted from [DATE] to [DATE]; an extended survey was conducted from [DATE] to [DATE]. Please note that additional investigation occurred at the facility on [DATE] regarding conveyance of personal funds upon death. During the survey, the facility was found not to be in substantial compliance with Medicare and Medicaid requirements. An Immediate Jeopardy (IJ) and/or Substandard Quality of Care (SQC) was identified on [DATE] at 5:55 p.m.; the Business Office Manager and Nurse Consultant were subsequently notified of the IJ at 6:10 p.m. (as the facility Administrator was hospitalized at that time). The IJ was determined to begin on [DATE]. The facility submitted an Allegation of Compliance (AoC) on [DATE] at 11:57 a.m.; it was determined not to be acceptable. A second AoC was submitted on [DATE] at 3:23 p.m.; it was determined not to be acceptable. The IJ was not removed upon exit from the facility on [DATE], and is considered ongoing. Findings Include: Resident #1 (Complaint MS- ) Record review of Resident #1 revealed a date of birth of [DATE]. She was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed a cognitive status of severely impaired. Observation and interview on [DATE] at 11:05 a.m. revealed Resident #1 in a wheelchair with a waist restraint in place. During an interview on [DATE] at 3:30 p.m. with the Office Manager and Registered Nurse (RN) Consultant, it was revealed that the Administrator was in the hospital, and that the Office Manager and RN Consultant would answer questions regarding the missing money for Resident #1. The Office Manager stated, "During that time the RP (Responsible Party) was out of town. She started out behind in her (Resident #1's) account and the family started bringing in money. On [DATE] we received two (2) payments of $600 which made her account current. The family brought $600 cash and a $600 money order. I gave receipts, but when I got ready to close, the money didn't balance. There were Audits for September through February. We had a lot to do. We had a company that does bank reconciliations. (Terminated Resident Trust Fund Coordinator) was in charge of the trust funds when the money was taken. There are several Residents with funds missing. We are looking at between $25,000 and $37,000. We give receipts now; as opposed to cash, we take checks and money orders. We are still dealing with the problems. The Attorney General's Office is still resolving the issue." During a telephone interview on [DATE] at 3:38 p.m. with the Administrator more details of the Resident Trust Fund concerns were revealed. The Administrator stated, "She (terminated Resident Trust Fund Coordinator) admitted to taking the $1200.00, and that's all she admitted to. She would always say it (the records) is correct. She wouldn't let anybody touch it (the records). I never doubted it because the State came in to check and audit. We didn't do any internal audits. I thought my Office Manager was checking and (terminated Resident Trust Fund Coordinator) provided a spread sheet that made things look ok. I am sixty-nine (69) years old and I don't do computers. I'm really sorry that it happened." An interview was conducted on [DATE] at 10:30 am with Resident #1's Daughter. She stated, "I had requested receipts but they said I'd need to get mother's permission to get information on her account. She (terminated Resident Trust Fund Coordinator) wouldn't tell me about her account. It bothered me because my Mom's [AGE] years old and confused. How could she give me permission to know about her account? My sister is her Responsible Party but she lives in Alabama. I'm here in town; that's why I take care of things. We would bring money for her and they would never give a receipt." The terminated Resident Trust Fund Coordinator was contacted on [DATE]; she requested an in-person interview at a local hotel. She requested the interview to be held at 8:00 p.m.; however, she did not come to the interview. Phone contact with the terminated Resident Trust Fund Coordinator was attempted on [DATE] at 10:00 a.m., with a message left on her personal answering machine requesting a call back. There was no response from terminated Resident Trust Fund Coordinator. Resident #7 Record Review for Resident #7 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Trust Fund account for Resident #7 showed there were discrepancies noted by the accountant. In November of 2008, a check in the amount of $344.00 was deposited in the bank, but was not recorded on the trust fund account. In June of 2009, the resident's family paid $366.00 on the nursing home bill, but that same amount was posted on the trust fund account as being paid from the trust fund. There was no documentation of discrepancies for the current year. On [DATE] at 10:15 a.m., an interview with the Business Office Manager/Bookkeeper confirmed the trust fund account for Resident #7 had discrepancies. She stated the facility was in the process of correcting the discrepancies. She further confirmed the facility's system failed to prevent the misappropriation of resident funds. Resident #10 An observation of Resident #10 on [DATE] at 5:15 p.m. revealed that she was sitting in her room in a wheelchair, neatly dressed. Review of Resident #10's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed that she scored 15 of 15 on the Brief Interview for Mental Status (BIMS), which indicated that she was cognitively intact. An interview with Resident # 10, conducted on [DATE] at 5:15 p.m., confirmed that she had a Trust Fund Account. Review of a statement from (Name of Medicare Supplement), dated [DATE], revealed "Lapse Notice - Your Attention is Needed". It also revealed, "Your insurance coverage has terminated due to non-payment of your required premium". The amount due for policy period [DATE] to [DATE] was $293.00, which was due on [DATE]. Review of a copy of a check for Resident #10's Resident Trust Fund revealed a check, dated [DATE], for (Name of Medicare Supplement) for $293.00. It was written for "Two hundred ninety + No/100". This check was signed by the facility Administrator and the former Resident Trust Fund Coordinator. Resident #11 Record review of Resident #11 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Quarterly MDS, with an ARD of [DATE], revealed her cognitive status was moderately impaired, some confusion in new situations. Observation on [DATE] at 10:18 am revealed Resident #11 was transferring independently into a low wheelchair. She was noted to talk loudly. RN#1 acknowledged Resident #11 was hard of hearing, and indicated her white board and a marker. During an interview on [DATE] at 3:30 p.m., the Office Manager and the RN Consultant acknowledged all of the Residents with Trust Fund accounts were affected by the misappropriation because money was taken from the trust and used to pay for things for other Residents not in the Trust. An interview was conducted with Resident #11 on [DATE] at 2:40 p.m.; she revealed she wasn't aware of any problems with the Trust Fund money. Resident #15 Record review of Resident #15 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Significant Change MDS, with an ARD of [DATE], revealed her cognitive status as severely impaired with decisions never/rarely made. Interview on [DATE] at 3:30 pm with the Office Manager and RN Consultant acknowledged the family of Resident #15 questioned the Trust Fund Coordinator about a bill they had received. Contact with the Responsible Party for Resident #15 was attempted on [DATE] at 6:00 p.m.; contact was made on [DATE] at 3:28 p.m. He stated, "I did have problems with them. I would ask for receipts and they wouldn't give them. Then they would send a bill saying we owed $3,000. But her checks were going to the facility. I couldn't understand that. I'm a Certified Public Accountant and the numbers didn't add up. They didn't correct it until she passed away in February 2012. We paid the $800 then. I'm still sending money because the Beauty Shop Lady said Mother owed a couple hundred dollars. I have a spread sheet and my cancelled checks. I'll email them to you." Resident #17 Resident #17 was not observed, since this Resident had been discharged . Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #17's significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed that she had severely impaired decision-making skills. Review of the facility document, "Personal Fund Authorization", which was not dated, revealed "This is an authorization for Silver Cross Home to hold and dispense my personal funds as my needs require. You are to keep complete records of all deposits and disbursements of these funds, and to make this record available to me or my representative upon request." An interview, conducted on [DATE] at 4:40 p.m. with Resident # 17's family member, revealed the following statements: 1. "My mother had a trust fund, but she never got any trust fund statement." 2. "We would put in cash in the trust fund and (former Resident Trust Fund Coordinator) never gave us a receipt." 3. "When we asked for petty cash, she (terminated Resident Trust Fund Coordinator) would say she lost her keys." This family member was unaware of the actual account balance in the trust fund. Resident #19 Closed Record review of Resident #19 revealed she moved into the home on [DATE] with [DIAGNOSES REDACTED]. Review of her Death Certificate revealed [DATE] as her date of death . Record review of the Resident #19's significant change MDS, with an ARD of [DATE], revealed a cognitive status of severely impaired. An interview was conducted on [DATE] at 9:30 a.m. with the Business Office Manager; she acknowledged Resident #19 did participate in the facility Resident Trust. Interview on [DATE] at 11:50 a.m. with the Resident #19's Responsible Party revealed he did receive a check from the facility after his Mother passed but admitted he didn't follow her Resident Trust close enough to notice any discrepancies. Resident #20 Closed Record review of Resident #20 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #20's MDS Discharge Assessment, with an ARD of [DATE], revealed a cognitive status of independent consistent and reasonable. Interview with the Business Office Manager on [DATE] at 9:34 a.m. acknowledged Resident #20 participated in the facility Resident Trust fund. Interview on [DATE] at 12:19 p.m. with the Responsible Party for Resident #20 acknowledged concerns with the money deposited for Resident. She stated, "I sent money down there but it was spent. They never gave me any receipts for things. I sent $250 dollars total for two months. It went quick. I sent a check but never got a receipt. I never got anything after she passed." Resident #21 Closed Record review of Resident #21 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #21's MDS Discharge Assessment, with an ARD of [DATE], revealed a cognitive status of severely impaired. Interview on [DATE] at 9:35 a.m. with the Business Office manager acknowledged Resident #21 participated in the facility Resident Trust fund. Interview on [DATE] at 12:15 p.m. with the Responsible Party of Resident #21 acknowledged that there was not much money deposited; she believed she did get some receipts, but was not sure of the total number. She also acknowledged she got a notice in [DATE] that there was a $10 dollar refund. Her mother died in [DATE]. Resident #22 Closed Record review of Resident #22 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #22's Quarterly MDS, with an ARD of [DATE], revealed a cognitive status of moderately impaired. During an interview on [DATE] at 10:16 a.m. with the Business Office Manager, she acknowledged Resident #22 did participate in the Resident Trust fund. Contact with the Responsible Party for Resident #22 was attempted by telephone on [DATE] at 11:55 a.m. All of the telephone contact numbers were disconnected. Resident #23 Closed Record review of Resident #23 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #23's Admission MDS, with an ARD of [DATE], revealed a cognitive status of independent decision-making. During an interview on [DATE] at 9:40 a.m. with the Business Office Manager, she acknowledged Resident #23 did participate in the facility Resident Trust fund. Contact with the Responsible Party for Resident #23 was attempted by telephone on [DATE] at 12:04 p.m. There was no answer at either telephone number called, with no answering machines. Interview on [DATE] at 3:30 p.m. with the Business Office Manager and the Registered Nurse (RN) Consultant acknowledged all Residents who participated in the Resident Trust fund were affected by the misappropriation of funds. On [DATE] at 4:15 p.m., an interview was conducted with the facility Office Manager and the Accountant Consultant; during that interview, they provided details of Resident Trust Fund audits. The Office Manager stated, "We made the (Administrator) aware of the concern of her (terminated Resident Trust Fund Coordinator) records. (Administrator) told us not to worry about it. (Consultant Accountant) was aware (the Consultant Accountant nodded in agreement). The Accountant Consultant stated, "I offered to do an audit and she (Administrator) refused. That was over a year ago. My concern was that she was not keeping up with her records." A review of the facility policy titled "Resident Fund Policy", dated [DATE] was conducted. The policy states, "It is the policy of this facility that resident funds will be handled as follows: 1. With written request from the resident for the facility to handle the funds. 2. At no charge to the Resident. 3. Amounts less than $50.00 will be maintained in the facility. 4. Amounts over $50.00 will be deposited in an interest bearing account. 5. Requests for funds less than $50.00 will be honored within the same day. 6. Requests for funds more than $50.00 will be honored within 3 three days. 7. A monthly report of funds will be provided to the Resident and/or family. 8. The facility will maintain a full, complete and separate accounting of each Resident's fund. 9. The facility will notify each Medicaid recipient when the amount in the Resident's account reaches $200.00 less than the SSI (Social Security Income) resource limit for one person (That, if the amount is the account, in addition to the value of the Resident's other nonexempt resources, reaches the SSI resource limit for one person, the Resident may lose eligibility for Medicaid or SSI. In Event of Death: 1. Upon death of the resident with a personal fund with the facility, The facility will convey the Resident's fund within 30 days and a final accounting of those funds to the individual or probate jurisdiction administering the Resident's estate. Procedure for Check and Balance for Resident Funds: 1. The Secretary will receive the payment. 2. A numbered receipt will be given when payment is received. 3. The Bookkeeper will make a deposit, posts to the Resident's account and reconciles the trust fund. 4. The Administrator or designee will check the fund for accuracy. 5. A statement of each Resident's trust fund will be sent to the Resident and/or family monthly." No other policy related to Resident Trust was provided. The facility requested an interview on [DATE] at 1:00 p.m. with the Board of Director's President, Consultant Accountant, and Private Attorney for the Board of Directors; details on Resident Trust Fund concern were revealed during the interview. The Consultant Accountant stated, "2007 was when the money started going missing. Medicaid would come in yearly. I think the State didn't follow-up as clearly as they should. We had no documentation. We had to go to the bank and get deposit information. She (terminated Resident Trust Fund Coordinator) was very smart. She was constantly manipulating money to cover, robbing Peter to pay Paul." The Board President stated, "There were procedures and things that should have taken place that wasn't. She (Administrator) would tell us at the Board Meeting that (terminated Resident Trust Fund Coordinator) would not allow her stuff (records) to be done (internal audit). The statements that should have been mailed quarterly were not sent. We don't have verification of what (amount) was actually taken because receipts were destroyed. It was brought to the Board on [DATE] and again on [DATE]. The Board gave the Consultant Accountant permission to correct the problems. The majority was discharged and closed Residents. We are putting in place audits and monitoring by others that will keep things from happening again." Interview on [DATE] at 5:30 pm with the Board of Directors President, Consultant Accountant, DON, RN Consultant, Private Attorney for the Board of Directors, and the Business Office Manager revealed an attempt to resolve concerns. The Board President stated, "We have a system; it didn't work. We recognize we messed up. We have discussed how to prevent it from happening again."