**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to refund money owed to family after the resident expired for 1 out of 3 clients sampled. (Resident #1) The findings include: During a record review of Resident #1's closed file, it was discovered that on [DATE], Resident #1 expired and had a balance of $2,275.00 with the facility after all accounts were settled. On [DATE] at approximately 11:20 AM, the resident's Power of Attorney (POA) was called for an interview. She stated she had been calling the facility to inquire about the refund on a weekly basis for several months after the resident's death. She also stated it was confirmed by the Business Office Manager that money was in fact owed to the family and the money would be refunded soon and sent to her. The POA stated this never happened. Despite repeated calls and emails to local and corporate contacts, she never received a call back. On [DATE] at 11:47 AM, an interview was held with the Business Office Manager and the Facility Administrator. When asked about the refund, the Business Office Manager stated that she was aware it was very late. She had done her part by sending the request to corporate to process the refund, but it had not been done. The Business Office Manager stated that she has been in that position since [DATE] and has been working on getting this refund done since, but does not have the capability to actually sign off on the refund. The process is to send the request to corporate accounts payable, but that position was vacant for a while. The Facility Administrator stated, I understand her frustration, this did take so much longer than it should have. She also stated that that is not the usual time frame, and all refunds should go out within 30 days. On [DATE] at approximately 2:00 PM, the facility received a check from the corporate office and the Administrator stated that she was going to insure the resident's family received the refund. A review of the facility's Procedure called, Conveyance on Residents Funds Upon Death, revealed that the facility will process a refund within 30 days as provided by State law. A review of the admission Packet stated on the second page, under section C. Security deposits C/3 Moneys paid on behalf of the Resident for services not used shall be refunded to the Residents within thirty (30) days after discharge provided financial balances due for all charges have been paid in full. Any outstanding balanced owed to the facility will be deducted from the refund. In the event of a Residents death, all refund checks will be made out to the Residents estate.

Based on observation and interview, the facility failed to ensure resident furniture was maintained in good repair for 4 of 59 residents observed (Residents #31, #36, #42, #46). The findings include: On 4/18/2022 at approximately 12:00 PM, an initial interview and observation was conducted with Resident #31. The wardrobe closet in Resident #31's room was dented, had pieces of wood protruding, and had a door that was hanging by only one hinge. When asked about the condition of the wardrobe Resident #31 stated, Yeah, it's been like that for a while. The drawer below the closet is hard to open because the door is hanging like that. On 4/18/2022 at approximately 12:30 PM, an initial interview and observation was conducted with Resident #36. The door of Resident #36's wardrobe closet had been completely removed and was sitting beside the wardrobe. When asked about the condition of the wardrobe Resident #36 stated, The door was only hanging by one hinge and I couldn't get into the drawer below it. They weren't fixing it, so I just took matters into my own hands and asked for a screwdriver and removed the door myself. On 4/20/2022 at approximately 9:20 AM, Residents #42 and #46 were observed in their room. The wardrobe closet was observed to have double doors and lower double drawers. At the midsection of both of the double doors, the veneer was separated from the rest of the door, and both of the drawers were very difficult to open. On 4/21/2022 at approximately 8:50 AM, Resident #42 voiced that it was difficult to open the bottom drawer of the closet. On 4/20/2022 at approximately 2:00 PM, an interview was conducted with the Administrator who confirmed she was aware of the damaged furniture. She reported a request had been made to corporate office for replacements. The surveyor informed her some undamaged wardrobes were observed in unoccupied rooms during a tour of the building. She stated she would look into trying to move some unbroken furniture into any rooms currently inhabited by residents.