Based on interview and record review, conducted during a site visit on 03/25/24, it was confirmed the facility failed to ensure implementation of resident services for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

A review of the facility's internal investigations, dated 01/13/24, indicated on 01/13/24 Resident 1 became agitated during a facility power outage and a staff member grasped Resident 1's forearms. In a second instance, on 01/13/24, Resident 1 refused to evacuate to the facility's designated safe-area and a staff member held Resident 1 by the arms to take him/her to the designated safe-area.

A review of Resident 1's behavior support plan, dated 12/04/23, indicated staff are not to make physical contact with Resident 1 while in a combative-state.

In an interview on 03/25/24, Staff 1 (Administrator) stated there were two instances during the facility wide power outage in January where staff made physical contact with Resident 1. In one of those instances Resident 1 was holding the staff member by the collar. Staff 1 indicated s/he has a zero-tolerance policy for staff putting hands on a resident and both staff members were terminated.

The facility failed to ensure implementation of resident services.

The findings were reviewed with and acknowledged by Staff 1 on 03/25/24.

Verbal Plan of Correction: Staff members involved were terminated. All staff have also received in person de-escalation training. on all shifts. An in-service training was conducted for all staff and Resident 1's service plan was reviewed including strategies for getting out of holds without putting hands on residents. At an all-staff another training regarding Resident 1's service plan and ensuring staff know how to get out of holds without putting hands on a resident.  

Based on interview and record review, conducted during a site visit on 03/25/24, it was confirmed the facility failed to show in detail with supporting documentation all monies received on behalf of the resident and the disposition of all funds received, and providing a list showing description and price of items purchased along with payment receipts for items for 1 of 1 sampled resident (#2). Findings include, but are not limited to:

A review of Resident 2's trust transaction history, dated 06/01/23 - 03/25/24, and supporting documentation indicated there were 6 transactions for a total of $107.42 in 2023 from Resident 2's trust account that did not have either supporting resident signed cash vouchers or receipts for items purchased on behalf of Resident 2.

In an interview on 03/25/24, Staff 1 (Administrator) stated the business office manager (BOM) who was in charge of maintaining resident personal incidental fund (PIF) accounts quit after being questioned about transactions on Resident 2's account. The facility completed an audit of Resident 2's account and determined there was missing supporting documentation for funds used on behalf of Resident 2 and the facility has credited Resident 2's account for the sum of those transactions.

The facility failed to show in detail with supporting documentation all monies received on behalf of the resident and the disposition of all funds received, and providing a list showing description and price of items purchased along with payment receipts for items.

The findings were reviewed with and acknowledged by Staff 1 on 03/25/24.

Verbal Plan of Correction: BOM responsible for resident PIF funds no longer works for facility. An audit was conducted of all resident PIF funds to ensure all accounts were rectified and had all necessary supporting documents and any funds that were used without supporting documents were refunded to resident account. Another audit will be conducted next month to ensure any missing funds or unaccounted for funds are refunded to residents.