Failure to Honor Resident Financial Rights and Guardian Authority
Summary
The deficiency involves the facility’s failure to honor a resident’s right to manage his own financial affairs through his court‑appointed guardian and responsible party (RP). The resident was an adult male with Down syndrome, severe intellectual disabilities, speech disturbances, and documented memory problems, who had been determined incapacitated and had a guardian of the person and estate per Letters of Guardianship from a Texas probate court. His face sheet and admission packet identified an RP and guardian, and the RP had signed the admission documents, including the section authorizing the facility to hold, safeguard, and manage personal funds. The resident’s MDS and care plan documented impaired cognitive function and developmental delay, with interventions to monitor changes in decision‑making ability and mental status. Despite this, the Regional Manager completed and signed Social Security form SSA‑787 to change management of the resident’s benefits to the facility, thereby filing for the facility to become the resident’s representative payee without consulting or obtaining consent from the court‑appointed guardian. In a telephone interview, the Regional Manager stated she filed for the facility to become representative payee by mistake, did not know the resident had a guardian, and acted after seeing paperwork on the DON’s table. The facility’s own policy on resident representatives stated that when a resident is determined incompetent by a court, the court‑appointed representative exercises the resident’s rights to the extent judged necessary by the court, but this was not followed in this case. The facility also failed to ensure proper authorization for the resident’s Medicaid application for 2025. The Medicaid application was signed and dated by the Business Office Manager, who later reported that the RP, while hospitalized, verbally asked her to complete and sign the form because it was about to expire. The Business Office Manager stated she copied the prior year’s signature page and changed the date, acknowledging she had no written documentation or witness to support the verbal consent and that there was no policy allowing facility staff to sign the RP’s signature. Interviews with the DON, Business Office Manager, and Interim Administrator showed that financial responsibilities were handled by the Business Office Manager, that there were no interventions in place to prevent recurrence if she was absent, and that leadership did not know what would trigger a change in representative payee or what processes existed to prevent such changes when a guardian was already in place.
Penalty
Resources
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A resident with intact cognition and diagnoses including HTN heart disease, adult failure to thrive, anemia, and nicotine dependence was placed on money management after repeated smoking-in-room incidents. Progress notes and staff interviews showed the facility restricted access to the resident’s trust funds as a consequence for unsafe smoking behavior, even though policy stated residents have the right to manage their own financial affairs and spending money.
The facility failed to obtain written authorization to open a resident trust account for one resident and failed to ensure another resident could access her funds. One resident with lumbar fracture, HTN, and alcohol dependence was discharged, but the chart lacked the required authorization even though the trust account showed a balance. Another resident with DM, CKD, and HTN reported not receiving her Social Security money for two months and not knowing who to contact, while staff said authorizations should be in the chart and residents access money through the Administrator or Admissions staff.
Resident personal funds were not accessible after hours or on weekends for multiple residents. Several residents said they could only withdraw money during weekday business hours, while RN and LPN staff stated they had no access on night shift and would tell residents to wait until morning. An admin staff member said evening and night shift supervisors were aware of the process, but more training was needed, and the Administrator stated residents should have access after hours and on weekends.
Failure to Safeguard and Account for Resident Funds: The facility did not properly manage resident money for multiple residents. A cognitively intact resident’s $56,481 Social Security check was deposited into a facility-owned account, and the Administrator described repaying it in weekly installments while also claiming the resident owed the facility money without a matching ledger balance. Envelopes for three other residents showed inaccurate totals and missing funds, and an Administrator stated a deceased resident’s $47 was placed into the bingo fund after the family had left belongings behind.
A facility failed to honor residents’ right to manage their financial affairs when two cognitively intact residents could only access trust funds during limited posted banking hours. Interviews showed residents were redirected to set weekday and weekend times, weekend staff directed requests to the nurse or posted hours, and an RN confirmed residents could not access money after business office hours on weekdays. The DON verified funds were only available at specific times, despite stating residents should be able to access their money when they wanted it.
The facility failed to ensure resident fund management authorizations were signed and witnessed when accounts were set up for residents. Three residents reviewed for personal funds had unwitnessed authorizations, including residents with dementia, stroke-related impairment, and lung cancer, and the BOM verified the missing witness signatures.
Resident Funds Restricted as Punishment for Smoking Non-Compliance
Penalty
Summary
The facility failed to protect a resident’s right to manage personal financial affairs by placing the resident on a money management program as a consequence for smoking in the room. The resident, R4, had diagnoses including hypertensive heart disease without heart failure, adult failure to thrive, pain in the right hip, anemia, neuralgia and neuritis, retention of urine, nicotine dependence, and cigarette non-compliance. The MDS documented a BIMS score of 15, indicating intact cognition. R4’s care plan and progress notes documented repeated incidents of smoking inside the room. After smoking materials were confiscated, the resident was placed on money/cigar management, and the restriction was extended after additional incidents. The progress notes stated that money management was initiated or extended as a consequence of the resident smoking in the room, and that the resident was closely monitored and directed to designated smoking areas. Staff interviews confirmed that the facility used money management as a response to smoking non-compliance. The administrator stated that residents who smoke in their rooms may be educated and counseled, and that repeated offenses may result in money management so the resident may not be able to take cash out from the trust fund. The DON stated that R4’s funds were restricted for a period of time after repeated smoking incidents. The social services director described money management as a tool used to control access to funds and cigarettes, and the business office manager confirmed that the facility was managing R4’s trust fund while the resident was in the facility. The facility policy stated residents have the right to manage their own financial affairs and handle their spending money, while also describing money management as an intervention for hazardous smoking behavior.
Resident Trust Funds and Access to Money
Penalty
Summary
The facility failed to obtain an authorization to open a resident trust fund account for Closed resident record CR66. CR66 was admitted with diagnoses including lumbar fracture, hypertension, and alcohol dependence. His clinical nurse notes indicated he was discharged on 2/6/26 with all personal belongings taken with him, medications reviewed with him and the home nurse, and social services calling current prescriptions to the pharmacy. However, review of his record did not include an authorization to open a resident trust fund account, even though the facility trust fund account dated 5/20/26 showed a balance of $35.04 for CR66. The facility also failed to ensure Resident R18 had access to her funds. R18’s record showed diagnoses including diabetes, chronic kidney disease, and hypertension, and her clinical record and social services notes did not document concerns with accessing money from the business office. During a resident council interview, two of nine residents voiced concerns about accessing their money. R18 stated she had not received her Social Security money for the prior month and the current month, did not know who to talk to, and wanted to know what was happening with her check. The regional business office manager stated resident fund account authorizations should be in residents’ charts and that residents access money through the Administrator or, if unavailable, Admissions staff. The Nursing Home Administrator confirmed the facility failed to obtain the required authorization for CR66, and surveyors informed the NHA that the facility failed to ensure R18 had access to her funds.
Resident Personal Funds Not Accessible After Hours or on Weekends
Penalty
Summary
The facility failed to ensure that residents with personal funds accounts had access to their accounts after business hours and on weekends for 7 of 10 sampled residents. During interviews, Resident 121 said money could be obtained whenever wanted except on Saturday and Sunday because the doors were locked on weekends. Resident 135 said they had been told they could withdraw up to $100 at the front desk on weekends, but no one was there on weekends and during the week money could only be withdrawn before 3 PM. Resident 15 said money could only be withdrawn during normal business hours because no one was in the administrative area at night, and Resident 3 said access was limited to Monday through Friday from 8 AM to 4 PM because the office door was closed on weekends. Resident 232 said they could plan ahead if money was needed on the weekend, and Resident 4 said they could not access money on Saturday or Sunday because the cashier did not work weekends and money could not be obtained after 3:00 PM on Friday night. Resident 14 also said money could only be withdrawn during business hours and had to be planned ahead for weekends. Staff N and Staff O stated they did not have access to resident trust money on night shift and would tell residents to wait until morning or speak with social work. Staff P said evening and night shift supervisors were aware of the process for accessing resident personal funds after hours and that more training was needed, while the Administrator stated residents should have access after hours and on weekends.
Failure to Safeguard and Account for Resident Funds
Penalty
Summary
The facility failed to act as a fiduciary for resident funds by not safeguarding and properly managing Medicaid resident money for five residents. The report states that Resident #5 was cognitively intact with a BIMS score of 15 and had diagnoses including narrowing of the lumbar spinal canal with pain, weakness in the legs, incomplete spinal cord injury at C7, and adjustment disorder. A Social Security hearing reminder and a U.S. Treasury check payable to Resident #5 in the amount of $56,481.00 were found in the record, and the back of the check showed it had been endorsed for deposit only into a facility bank account. During interview, Resident #5 stated the check had been mistakenly deposited into a facility-owned account in July 2025 and that the Administrator said the facility would repay the money in weekly installments, which Resident #5 described as creating an interest-free loan for the facility. The Administrator later stated Resident #5 owed the facility around $39,000.00, but the ledger provided did not show bed charges or an outstanding balance of that amount, and the Administrator said there had not been any discussion with Resident #5 about a past due balance. The Administrator also stated the facility’s electronic accounting system was never correct and that accounting was done on paper. In a later interview, the Administrator stated only two residents had Resident Trust Accounts, while other residents had checks sent to the facility and family members came to get their $40.00, with no signatures required when picking up residents’ checks. The report also identified problems with resident envelopes for Resident #8, Resident #9, and Resident #10. These residents had varying cognitive and functional status, including moderate cognitive impairment for Resident #8 and Resident #10, and cognitive intactness with dementia listed for Resident #9. During observation, their envelopes showed totals on the outside with updated amounts written below, but no entries documenting fund removal. When Activities counted the money, the amounts in the envelopes did not match the written totals, and Activities had no knowledge of where the missing money was. LPN #1 stated that resident funds were kept in a locked metal box, that totals were written on envelopes when money was deposited or removed, and that receipts and change should be returned and added back, but also stated several envelopes in the box did not have an accurate accounting of the funds. For Resident #13, the report states the resident died while on hospice and had $47.00 in $1 bills. The Administrator said the family had left many belongings behind and, after a long time had passed, she took the $47.00 and told the Activity Director to put it into the bingo fund. The Administrator later said a relative came and picked up an envelope for Resident #13 that contained $12.00, indicating the resident had more than one envelope. The facility policy required resident trust funds to be managed, documented, safeguarded, and audited, and the resident rights policy stated residents had the right to manage personal affairs or receive an accounting upon request.
Resident Trust Funds Not Available Outside Scheduled Hours
Penalty
Summary
The facility failed to honor residents’ right to manage their financial affairs by not having appropriate funds available for two cognitively intact residents who wanted to withdraw money outside of the facility’s scheduled withdrawal hours. One resident stated they could obtain five dollars on weekends by going to the nurse’s station and could withdraw money Monday through Friday only from 1:00 p.m. to 2:00 p.m., and that if the time was missed, the money could not be obtained. Another resident stated the facility kept money for him and that he could access it only during set weekday hours, from 8:00 a.m. to 9:00 a.m. and from 1:00 p.m. to 2:00 p.m., and that he could not take money out on weekends. Staff interviews confirmed the restricted access to resident funds. The BOC stated the business office had posted banking hours Monday through Friday from 8:00 a.m. to 9:00 a.m. and from 1:00 p.m. to 2:00 p.m., with weekend and holiday access through the 1st floor nursing station during posted times, and that residents requesting money outside those hours would be redirected unless leaving the building and needing money right away. Weekend staff stated they would direct residents to the nurse or to the posted times, and an RN verified that after the business office closed Monday through Thursday, residents would not be able to access their money. The DON verified funds were available only during specific times and stated residents should be able to access their money when they wanted it. The policy stated resident trust cash was available during set banking hours, on weekends and holidays through the Charge Nurse at specified times, and outside banking hours in an emergency through the Charge Nurse.
Unwitnessed Resident Fund Management Authorizations
Penalty
Summary
The facility failed to ensure resident account management authorizations were signed and witnessed when setting up accounts managed by the facility for residents. This deficiency involved three residents out of five reviewed for personal funds, and the report states that the facility census was 151. The issue was identified during record review and interview, and the Business Office Manager verified that the authorizations were not witnessed. Resident #56 had diagnoses including schizoaffective disorder, dementia, anxiety, and depression, and the Resident Fund Manage Service authorization and agreement to handle resident funds showed the facility signed as the resident's representative payee without a witness. Resident #62 had diagnoses including cerebral infarction, alcohol induced persisting dementia, anxiety, and depression, and the same type of authorization also lacked a witness. Resident #154 had diagnoses of malignant neoplasm of the lung, anxiety, and depression, and the authorization signed by the resident's power of attorney likewise had no witness.
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