Deficiency in Resident Financial Security Compliance
Summary
The facility failed to ensure the security of personal funds of residents deposited with them, as evidenced by several deficiencies in their policies and procedures. During the survey, it was found that no personnel were assigned to monitor compliance with resident rights, which is a critical oversight. The resident rights policy and procedure, reviewed with the institutional program director, was found to be hospital-based and not tailored to the specific needs of the facility, as it bore the logo of Episcopal Hospital San [NAME] Metro. Additionally, the policy did not include individualized mechanisms to ensure compliance with CMS Medicare requirements, and it was a generic 13-page document that included all 483.10 resident rights statements in one policy, rather than addressing each area separately. These findings indicate a lack of structure and oversight in ensuring the financial security of residents' personal funds.
Penalty
Resources
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The facility failed to ensure its surety bond named only the residents as the obligee. Review of the prior bond showed the obligee was listed as the residents of Spring Hill Rehabilitation Center or unto the Commonwealth of Pennsylvania, and the NHA confirmed the bond was not limited to residents only.
Resident trust funds were not fully covered by adequate surety bond protection. The business office manager confirmed the resident personal funds account balance totaled $40,688.56 for 34 residents, while the CFO confirmed the bond penalty amount was only $10,000 and said it should have been $100,000. Review of the bond and rider showed the lower coverage was in effect before the rider increased it, despite facility policy requiring a surety bond to secure all resident personal funds.
The facility failed to keep a surety bond large enough to cover resident funds managed by the facility. Review of the resident fund account showed balances above the $200,000 bond amount, and the RNC could not provide documented evidence of a bond covering those balances.
The facility failed to secure resident personal funds with a surety bond large enough to cover the total amount managed for 27 residents. Records showed resident account balances totaled far more than the bond limit, and the Corporate Director of Operations confirmed the bond was below the amount needed when the accounts were reviewed.
Resident trust funds were not secured by a surety bond large enough to cover the total account balance. The BOM stated she handled individual resident cash but did not monitor the full account balance, and the President of Operations confirmed the trust fund balance exceeded the $75,000 bond. The Administrator stated the balance should not exceed the bond amount.
Resident funds were not fully covered by the facility’s surety bond. The BOM and Administrator provided records showing the facility managed funds for 71 residents, while the bond covered only $80,000.00. Bank statements showed the resident funds account repeatedly exceeded that amount, including balances over $115,000 and as high as $195,004.68. The Administrator stated the facility reviewed balances daily but believed the excess amounts did not need to be ensured once the balance later dropped below $80,000.00.
Surety Bond Listed Incorrect Obligee
Penalty
Summary
The facility failed to ensure that the surety bond listed the obligee as only the residents of the facility. Review of the facility’s previous surety bond showed that the obligee was listed as "the residents of Spring Hill Rehabilitation Center or unto the Commonwealth of Pennsylvania," rather than residents only. During an interview, the Nursing Home Administrator confirmed that the facility failed to list the obligee as only the residents of the facility.
Resident Trust Funds Not Fully Covered by Surety Bond
Penalty
Summary
Assure the security of all personal funds of residents deposited with the facility was not maintained because the facility did not ensure resident personal fund accounts were insured with adequate surety bond coverage to cover the total account balance. During interview and document review, the business office manager confirmed the residents' personal funds accounts totaled $40,688.56 for 34 residents. The CFO confirmed the facility's surety bond for resident personal funds identified a penalty amount of $10,000 and stated the bond should cover $100,000, noting they needed to contact their insurance representative for clarification. Review of surety bond number 2653018 showed a $10,000 bond in effect from 7/23/25 through 7/23/26, and a rider dated 4/23/26 showed the bond increased from $10,000 to $100,000 effective 4/23/26. The facility policy stated it would maintain a surety bond to assure the security of all resident personal funds deposited with the facility.
Insufficient Surety Bond Coverage for Resident Funds
Penalty
Summary
The facility failed to ensure the surety bond amount was sufficient to cover the total resident funds held by the facility. A review of the resident fund checking account from January 2026 through March 2026 showed the aggregate resident account fund managed by the facility was $216,243.06 on February 3, 2026, and $208,438.08 on March 3, 2026. The facility’s surety bond, which had been in place since November 1, 2020, was $200,000.00 and did not cover the resident fund balances on those two dates. During an interview on March 18, 2026, at 1:30 PM, the regional nurse consultant reviewed this information and was unable to provide documented evidence that a surety bond was in place in February 2026 or March 2026 to sufficiently cover facility-managed resident funds.
Insufficient Surety Bond for Resident Funds
Penalty
Summary
The facility failed to assure the security of resident personal funds deposited with the facility because it did not have a surety bond covering the total amount of resident funds it managed. Review of the facility’s surety bond showed coverage up to $35,000, while review of the resident accounts listing showed the facility managed funds for 27 residents, with a total balance of $83,396.36. The amount of resident funds exceeded the bond coverage by $48,396.36. During interview, the Corporate Director of Operations confirmed that the facility realized the bond was insufficient when it ran the resident accounts report and that the surety bond limit increase from $35,000 to $100,000 was completed on 02/18/26.
Resident Trust Fund Balance Exceeded Surety Bond
Penalty
Summary
The facility failed to ensure the security of resident personal funds deposited with the facility because the surety bond was not maintained in an amount sufficient to cover the total balance of the resident trust account. A review of the State of Georgia Department of Community Health Long-Term Care Facility Residents' Fund Bond dated 11/1/2024 showed a surety bond of $75,000.00, while the resident trust fund balance was documented at $89,766.98 on 8/31/2025 and remained above the bond amount in September 2025, including balances of $92,763.98, $92,399.48, $92,176.43, $92,006.43, $81,289.91, $77,745.31, $75,463.05, $75,603.05, and $75,214.29. During interview, the BOM stated she was responsible for giving residents cash and was not sure what a surety bond is. She also stated she only handles individual resident trust funds and does not look at the whole balance of the account. The President of Operations confirmed the BOM oversees the total amount of the resident trust fund account and acknowledged that the amount from August 2025 to September 2025 was over the $75,000 surety bond. The Administrator stated his expectation was that the resident trust fund balance should not exceed the surety bond and that the bond should be increased if it does.
Resident Funds Not Fully Covered by Surety Bond
Penalty
Summary
The facility failed to assure the security of resident personal funds deposited with the facility because it did not maintain a surety bond that covered the total amount of resident funds. During review with the BOM, the facility provided a list showing 71 residents whose funds were managed by the facility, along with the most recent bank statement and the surety bond. The surety bond policy indicated the resident funds account was insured for $80,000.00. Bank statements for the resident funds account showed the ledger balance exceeded $80,000.00 on multiple occasions. The balance was documented at $116,270.81, $115,892.81, and $115,657.81 in early December 2025; at $80,669.58 and $80,327.58 in early November 2025; and on fourteen occasions in October 2025, including balances as high as $195,004.68. During interview, the Administrator stated the facility had balances in excess of $80,000.00 and that the corporation reviewed balances each business day, but believed the excess amounts did not need to be ensured once resident liability was removed and the balance dropped below $80,000.00.
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