Failure to Safeguard and Manage Resident Finances
Summary
Facility administration failed to ensure effective and secure management of resident finances, resulting in a lack of oversight and accountability for resident accounts. The Business Office Manager (BOM) maintained a bank account in the facility's name, complete with a debit card and checkbook, which was unknown to the Nursing Home Administrator (NHA) and other management staff. This account was used for various cash withdrawals and purchases, with no effective system in place to determine the purpose or beneficiary of these transactions. Additionally, there was no tracking system for payments received from residents or their representatives, and the administration did not hold the BOM or third-party billing company accountable for the safe and accurate handling of resident funds. Multiple instances were identified where resident funds were mishandled. For example, a check from a resident was deposited into the undisclosed account after the resident had been discharged, and family members reported inaccurate statements, missing receipts, and unexplained balances. In one case, a resident's Social Security payments continued to be withdrawn for care costs after discharge, and the managed care organization (MCO) responsible for payment did not receive the funds, putting the resident at risk of losing benefits. The BOM was listed as the authorized user on the resident's account, preventing the MCO from making necessary changes without police involvement. These issues were compounded by poor communication with the third-party billing company and a lack of transparency with residents and their representatives. The administration did not follow regulations or facility policy regarding the reporting and investigation of suspected misappropriation or exploitation of resident finances. Despite being made aware of potential fraud and misappropriation, upper management advised against submitting a facility-initiated report to the State Agency or police, and a thorough investigation was not conducted. Policies and procedures for accounts payable and receivable were not provided when requested, and staff lacked the necessary education and tools to properly manage resident funds. These failures led to a finding of immediate jeopardy, as residents were placed at risk for misappropriation and exploitation of their funds.
Removal Plan
- The compliance consultant will provide the NHA, DON, new BOM and members of the governing body training about the intent of F835 and their responsibility to operate and manage the facility efficiently and effectively to ensure that the facility is administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The training will also include review of their responsibility to prevent abuse, including misappropriation of resident property and exploitation, identifying, investigating and protecting residents from allegations of abuse and exploitation that has the potential to cause serious injury, harm, impairment, or death. To identify any negative outcome, the DON/SSD/Nurses will complete assessment of all residents. The attending physician/NP of the resident will be notified of any negative findings.
- The NHA and members of the governing body, NHA and Regional Director of Clinical Services will discuss the alleged deficiency and the corrective actions which are described in this plan of removal. The Administrator will notify the Medical Director of the alleged deficiency and immediate actions described in this plan of removal.
- To prevent the recurrence of the alleged deficiency, safeguard and track resident financials to include accounts payable and accounts receivables, an updated process will be implemented. The NHA/corporate regional representative will provide training to the new BOM about the new process. NHA to review and initial/sign off on all new accounts.
- Deposit process will be reviewed and updated to include two signers to accept checks and provide receipt with signatures. Both signers then log receipt of check on the Facility Check Receipt Log. Log will be reviewed weekly by facility NHA.
- Resident fund requests will be reviewed and updated: BOM makes withdrawal from resident's RFMS account and puts the money into the facility's RFMS Petty Cash account. BOM provides resident with requested money at the facility out of the RFMS Petty Cash box. RFMS Petty Cash box will be counted by the NHA and BOM weekly to ensure accuracy. Once RFMS Petty Cash box reaches a certain threshold (set by the NHA based on facility needs), a replenishment check will be requested. RFMS Petty Cash box will be counted. Receipts, G/L log and count will be sent to third-party billing office. Replenishment check will be issued to facility. Replenishment check will then be cashed at local bank. Funds will be counted at facility by two employees. Funds will then be placed back into the RFMS Petty Cash box.
- The policies and procedures related to administration of the facility will be reviewed by the NHA, DON, Medical Director and a representative of the governing body. The compliance consultant will provide the NHA, DON and members of the governing body training about administration of the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. It will be emphasized that the NHA and DON are accountable for all the programs and services in the facility to meet the needs of the residents who reside in the facility. The Administrator and DON are accountable for planning, coordinating and managing all services, including protection of residents from misappropriation of property and exploitation, meeting the reporting and thorough investigation requirements of any allegation related to misappropriation of resident property and exploitation, and are responsible for the overall direction, coordination and evaluation of all care and services provided to the residents in the facility.
- The NHA/DON will provide training to the department heads (Activities, SSD, BOM, Dietary Manager, Therapy Director, Environmental Services and Maintenance staff) about the intent of F835 and their responsibility to operate and manage the facility efficiently and effectively to ensure that the facility is administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The training will also include review of their responsibility to prevent abuse, including misappropriation of resident property and exploitation, identifying, investigating and protecting residents from allegations of abuse and exploitation that has the potential to cause serious injury, harm, impairment, or death.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The NHA and DON failed to manage the facility effectively to protect a resident known to be at risk for elopement. A resident exited the assigned nursing unit unsupervised, and the report states this created an Immediate Jeopardy situation for one of fourteen residents documented as elopement risks. The NHA and DON confirmed the administrative failure during interview.
Ineffective administration led to multiple failures in fall management, staffing, nutrition, immunization education, and abuse prevention. The facility did not follow fall interventions or complete accurate fall assessments and investigations, and two residents sustained serious injuries, including rib fractures and a thoracic burst fracture after an improper transfer. The report also cites inadequate RN coverage, insufficient staffing, missed dialysis transport, inaccurate documentation, falsified bathing records, failure to provide snacks and adaptive equipment, and abuse-related issues including verbal abuse and misappropriation of resident funds and property.
Failure to Timely Report Abuse and Neglect Allegations: The facility failed to maintain an effective system for timely reporting allegations of abuse and neglect after a prior F609 citation for the same issue. Surveyors found nine late reports involving multiple residents, and staff and the administrator acknowledged ongoing difficulty tracking when reports were due, with most late reports occurring during the monitoring period after the earlier deficiency.
A resident with dementia and wandering tendencies was not protected from elopement after staff failed to follow instructions to place a Wander Guard and move him to the Secured Memory Unit. The resident was seen in the lobby, later could not be located, and was found miles from the facility after leaving unsupervised; the front entry door also lacked an operational Wander Guard system.
Failure to Ensure Supervision and Elopement Prevention: The facility failed to consistently supervise and maintain safety interventions to prevent elopement for residents. Review of records, job descriptions, and staff interviews showed the NHA and DON did not effectively manage the facility to ensure proper supervision and elopement prevention interventions were implemented, and they failed to fulfill their essential duties to ensure federal and state guidelines and regulations were followed.
Unqualified Social Service Director Hired: The facility failed to ensure the Social Service Director met the stated qualification of a bachelor's degree and 1 year of social services experience. The Administrator stated the current SSD was still in school and had not completed her degree, while a behavioral health director with a degree only helped with social services at times and was not the SSD. The job description and facility policy did not align with current regulatory requirements, and the facility census was 182 residents.
Failure to Protect a Known Elopement Risk
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility to protect residents from elopement. Review of the facility’s job descriptions showed that the NHA was responsible for supervising department heads, ensuring compliance with regulatory guidelines, and reviewing complaints and trends, while the DON was responsible for directing nursing services, coordinating care, overseeing staffing, and investigating and reporting incidents and complaints. Despite these responsibilities, the facility failed to prevent and protect residents from exiting their assigned nursing unit unsupervised. The deficiency involved Resident R1, who was documented as an elopement risk. Survey findings showed that R1 exited the resident’s assigned nursing unit without supervision. During an interview, the NHA and current DON confirmed that facility administration failed to effectively manage the facility to protect residents from elopement. The report states that this failure created an Immediate Jeopardy situation for one of fourteen residents documented as elopement risks.
Ineffective Administration Affecting Falls, Staffing, Nutrition, Immunizations, and Abuse Prevention
Penalty
Summary
The facility failed to administer operations in a manner that used resources effectively and efficiently, with ineffective administration affecting multiple residents across several care areas. The report states that the facility did not maintain effective systems for fall prevention and accident hazard control, including failure to follow fall interventions and the smoking policy, and failure to complete accurate fall assessments, investigations, and care plans. These issues affected Residents #6, #9, #24, #56, #113, and #115, and the report notes actual harm to Resident #56, who sustained multiple right and left rib fractures, a hematoma to the right chest wall, bruising across the breasts, right flank, back, both arms, both sides of the ribs, and both legs, with no actual determination of the cause of injuries. The report also describes a serious injury to Resident #113 after a fall from bed, when staff inappropriately transferred the resident and she was thrown onto the bed. The resident sustained a thoracic burst fracture and multiple ecchymoses on both hands, wrists, forearms, and upper extremities. In addition, Residents #6, #9, #24, and #115 had falls with inadequate investigations, incomplete documentation, updated care plans, and inaccurate assessments. The facility also failed to provide effective dietary services by not ensuring substantial snacks for the secured memory care unit, honoring food preferences, and providing needed adaptive equipment, affecting Residents #29, #49, #80, #83, #86, #96, and #99. Other findings included inadequate nursing services and staffing, with no RN coverage at least eight hours daily and insufficient staffing to meet resident needs, affecting Residents #6, #12, #13, #16, #39, #40, #45, #88, #93, #99, and #110. The report states that nursing staff did not implement care-planned interventions for Resident #45, did not follow discharge instructions or provide timely incontinence care for Resident #13, did not ensure dialysis transport for Resident #106, did not accurately document advance directives for Resident #93, and did not accurately transcribe a physician order that led to a significant medication error for Resident #88; it also states that bathing documentation for Resident #88 was falsified. Additional deficiencies involved an ineffective immunization program for Residents #9, #24, #32, and #72, and failures in abuse, neglect, misappropriation, and exploitation prevention, including verbal abuse toward Resident #93, misappropriated funds from Resident #61, misappropriated personal property from Resident #117, unnecessary medications for Residents #25 and #30, and delayed abuse reporting and investigations for Residents #56, #82, #93, and #117.
Failure to Timely Report Abuse and Neglect Allegations
Penalty
Summary
The facility failed to ensure an effective system for timely reporting allegations of abuse and neglect after a previous F609 deficiency for the same concern. Based on interview and record review, the facility continued to submit late reports for allegations involving 9 of 19 residents, identified as residents 4, 5, 9, 10, 11, 12, 13, 14, and 16. The report states that the late reporting placed residents at risk for delays in notification, investigation, protection, and response following allegations of abuse or neglect. A prior F609 deficiency dated 1/29/26 showed the facility had already been cited for late reporting of allegations of neglect and abuse for three residents. During an interview on 7/29/26, staff member A stated, "I'm still learning . there's been a lot going on here ." The administrator also stated, ". I need to develop a system, so I know when they are due." The current complaint investigation found that the facility administrator and staff continued to report allegations throughout the plan of correction monitoring period, and eight of the nine late reports occurred between 2/22/26 and 5/22/26.
Failure to Protect Resident from Elopement
Penalty
Summary
The facility administration failed to manage the facility in a manner that protected residents and safeguarded them from elopement. The Administrator and DON job descriptions stated they were responsible for directing and overseeing facility operations in accordance with federal, state, and local regulations, but the facility was aware that the front entry door did not have an operational Wander Guard system and corrective measures were not implemented. The report identified this as an Immediate Jeopardy related to F689 and F835, with the noncompliance beginning on July 16, 2026. Resident 1 was admitted with a dementia diagnosis and an elopement assessment was completed on admission, with staff noting wandering tendencies and that the resident was suitable for the Secured Memory Unit. On July 16, 2026, the resident was seen in his room at 3:30 AM, then in the front lobby at 4:30 AM, and was later unable to be located at 5:45 AM. The elopement protocol was initiated at 6:10 AM, and the resident was found about one hour later three miles from the facility. The Administrator stated the resident had been instructed to be placed on a Wander Guard device and moved to the Secured Memory Unit, but those instructions were not followed. The receptionist also stated she did not recognize the resident as a resident and thought he was a visitor.
Failure to Ensure Supervision and Elopement Prevention
Penalty
Summary
The facility failed to consistently supervise and maintain safety interventions to prevent elopement for residents. Based on review of facility records and job descriptions, and staff interviews, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure proper supervision and elopement prevention interventions were implemented. The NHA job description stated that the NHA directs the overall operations of the care community in accordance with current local, state, and federal regulations to ensure the highest level of quality care is provided to each resident, and the DON job description stated that the DON manages and directs resident care within the nursing department to maintain resident standards of care and ensure each resident functions at his/her highest level. The report states that the NHA and DON failed to fulfill their essential job duties to ensure federal and state guidelines and regulations were followed.
Unqualified Social Service Director Hired
Penalty
Summary
The facility failed to administer the facility by failing to ensure a qualified individual was hired as the social service director. During interview, the Administrator stated the requirement for the social services director was a minimum of a bachelor's degree and 1 year of experience in social services, and stated that the current Social Service Director, V4, was still in school and had not completed her bachelor's degree. The Administrator also stated she did the hiring and hired V4 in collaboration with the facility consultant. The Administrator further stated that a behavioral health director helped with social services at times, but that person had a degree and was not the social service director. The facility's Social Service Director job description listed qualifications of a high school diploma or GED and knowledge of federal and state LTC social service regulations, and the facility policy did not align with current regulatory requirements for the position. The Facility Assessment Tool dated 7/13/26 identified a Social Service Director as a needed resource, and the staffing plan included one social service director, one social service designee, and one behavioral health director. The Facility Data Sheet dated 7/24/26 showed a census of 182 residents.
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