Based on record review and interview, the facility failed to manage the Resident Trust Accounts for 8 (Resident #2, Resident #6, Resident #8, Resident #11, Resident #43, Resident #49, Resident #54 and Resident #60) of 43 residents' trust accounts reviewed to ensure they did not exceed the allowable Medicaid limit of $2,000. The findings include: Review of the facility's Trial Balance statement showed the following residents' trust accounts contained more than the Medicaid allowable amount of $2,000 which could result in the resident being ineligible for Medicaid benefits: Resident #2 $2,419.13 ($419.13 over the limit) Resident #6 $8,240.66 ($6,240.66 over the limit) Resident #8 $2,740.27 ($740.27 over the limit) Resident #11 $3,647.66 ($1,647.66 over the limit) Resident #43 $2,849.44 ($849.44 over the limit) Resident #49 $4,956.62 ($2,956.62 over the limit) Resident #54 $3,275.56 ($1,275.56 over the limit) Resident #60 $2,063.04 ($63.04 over the limit) During an interview on 7/12/2023 at 8:10 AM, the Regional Business Office Consultant stated regulations showed every resident Medicaid trust account should have no more than $2,000 in it and confirmed Resident #2, Resident #6, Resident #8, Resident #11, Resident #43, Resident #49, Resident #54 and Resident #60's trust accounts had more than the $2,000 allowable limit for Medicaid eligibility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, facility investigation, observation and interview, the facility failed to prevent abuse of 1 resident (Resident #1) of 7 residents reviewed for abuse. The findings included: Review of facility policy Abuse Prevention Program updated 1/19/2017 showed .It is the policy of this facility to prevent resident abuse .Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment .Physical Abuse: Hitting, slapping, pinching, kicking etc . Resident #1 was admitted to the facility on [DATE] with diagnoses including Disorder of Brain, Bipolar Disorder, Dementia and Cirrhosis of Liver. Medical record review of Resident #1's Progress Notes dated 10/1/2022-10/23/2022 showed no behaviors toward others, the resident was being evaluated by group homes for possible transfer. Medical record review of Resident #1's History and Physical dated 10/6/2022 showed .Past medical history: Nontraumatic subarachnoid hemorrhage .Senile degeneration of the brain .Bipolar disorder . Medical record review of Resident #1's admission Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. Delusions were observed during the observation period, with no other behaviors observed. The resident required extensive assistance of 2 physical assist for bed mobility, transfer, toilet use and extensive assist of 1 physical assist for dressing and personal hygiene. Resident #1 required limited assistance of 1 person physical assist for locomotion on and off the unit. Medical record review of Resident #1's Nursing Progress Note dated 10/24/2022 showed .resident was observed receiving physical contact from another resident in hall at front lobby entrance. Resident was immediately removed from situation and assessed, no apparent injuries noted .new order noted to place resident 1:1 [one on one] for closer observation until sent out to hospital. Other new order noted to send resident to ER [emergency room] for medical clearance .neuro [neurological] checks initiated and WNLs [within normal limits] resident denies pain .Report called to ER and ambulance in route . Review of a facility investigation dated 10/24/2022 at 3:23 PM showed .[Resident #2] was seen by the Unit Manager [UM] making physical contact with other resident [Resident #1] and called out for assistance .Unit manager was standing by HR [Human Resource] door on the other side of entry doors in front lobby. Unit Manager statement: 'I turned around from HR door and saw [Resident #2] hitting [Resident #1] [Resident #2] had a closed fist. [Resident #1] was holding his arms up trying to block [Resident #2] .[Resident #2] hit [Resident #1] in the head multiple times .Residents were immediately separated. DON [Director of Nursing] assisted with removing [Resident #2] as I moved [Resident #1] .[Resident #2] said he hit [Resident #1] with walker. [Resident #1] stated [Resident #2] hit him with walker. I did not see [Resident #2] hit [Resident #1] with walker .3:23 PM .both residents placed on 1:1 .3:25 PM .both residents were assessed by DON, UM, ADON [Assistant Director of Nursing] no apparent injuries. Both residents denied pain. [Resident #1] stated 'he hit me in my head' and rubbed on his head but denied pain with no pain indicators. neuro checks initiated on both residents .3:37 PM .administrator notified .3:30 PM .police notified/arrive .new orders noted to send both residents to ER for evaluation .3:35 PM .Police arrived and obtained report. Stated they were not going to arrest [Resident #2] because he had dementia and was 84 yo [years old] .3:55 PM .EMS [Emergency Management Services] X2 arrive and transferred both residents to [hospital] . Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's Disease, Dysphagia, Muscle Wasting and Atrophy, Congestive Heart Failure, Schizophrenia, Psychotic Disorder with Delusions, Hallucinations and Bipolar Disorder. Medical record review of Resident #2's annual MDS dated [DATE] showed a BIMS score of 6 indicating severe cognitive impairment. The resident had verbal behavioral symptoms directed toward others 4 to 6 days, other behavioral symptoms not directed toward others daily, and wandering behaviors daily during the assessment period. The resident required extensive assistance of 2 staff for bed mobility, transfer and toilet use. Extensive assist of 1 for dressing and personal hygiene and limited assistance of 1 for walking. Medical record review of Resident #2's General Progress Note dated 10/17/2022 showed .re admit from [psychiatric hospital] . Medical record review of Resident #2's Nursing Progress Note dated 10/18/2022 showed .follow up from Readmit, Resident has been calm and cooperative, denies pain. Resident self ambulates and walks hallway wanting snacks frequently . Medical record review of Resident #2's Psychiatric Evaluation dated 10/18/2022 showed .Resident readmitted to the facility on [DATE] from inpatient psychiatric hospital. Resident was admitted to psych hospital d/t [due to] increased physical and verbal aggression. Staff reports since he readmitted yesterday, he has not had any aggression or agitation . Medical record review of Resident #2's Social Service Note dated 10/19/2022 at 9:17 AM showed .Resident took house shoes from another resident and wore them all day refusing to take them off when asked. When SSD [Social Service Director] asked him to take them off resident urinated in them. Staff eventually got the house shoes and took them to laundry . Medical record review of Resident #2's General Progress Note dated 10/20/2022 at 3:52 AM showed .resident was in bed sleeping at beginning of shift but when woke up to give meds has been restless and wandering since approx. [approximately] 9:30 PM this shift, has continued to ask staff random questions. Will continue to observe .receives PRN [as needed] medications to help with anxiety and pain . Medical record review of Resident #2's Nursing Progress Note dated 10/24/2022 at 3:23 PM showed .resident observed making physical contact with another resident in front hall near lobby. Staff intervened and separated immediately. Resident assessed with no apparent injuries .New orders noted to place resident 1:1 immediately and to send resident out to hospital for further evaluation . Medical record review of Resident #2's General Progress Note dated 10/24/2022 at 3:55 PM .resident left facility via [by] ambulance . Medical record review of Resident #2's General Progress Note dated 10/24/2022 at 7:00 PM .resident arrived back to facility in stable condition .continue 1:1 observation . Medical record review of Resident #2's General Progress Note dated 10/24/2022 at 9:45 PM .currently resting in bed with 1:1 observation in place. No behaviors noted at this time . Medical record review of Resident #2's Psychiatric Evaluation dated 10/25/2022 showed .Resident had physical altercation with another resident yesterday. He was sent to the ER and then returned after .he was recently discharged from inpatient psych [psychiatric hospital]. Resident does recall this event and stated he was trying to get money from the business office and the other resident would not get out of his way. He has been 1:1 with staff since event. He continues to be restless and requires frequent redirection . During an interview with Resident #1 on 11/7/2022 at 9:05 AM, when asked about the incident he stated .I don't know he just don't like me. He hit me on my back, head, and neck. He hit me with his walker . He stated there had not been an exchange of words except he had been sitting at the lobby glass doors and Resident #2 had said dude move go on and Resident #2 got mad when he had to wait for Resident #1 to move. Resident #1 stated he was not afraid then or now, he was just staying away from Resident #2. During an interview with Licensed Practical Nurse (LPN) #1/UM on 11/8/2022 at 8:05 AM, she stated .I was in the Human Resource [HR] Office on the front lobby side of the glass doors, I turned around to speak to the DON. Out of my side view I saw arms in the air, so I looked, and I realized they were fighting. I ran out of the HR office to the hall. The DON was right behind me. We immediately separated the residents and kept them separated. I stayed in the hallway with [Resident #2]. I saw [Resident #2] hitting [Resident #1] in the head with his hands. [Resident #1] had his hands up trying to protect himself. I asked [Resident #2] what happened. He said he walked up and asked [Resident #1] to move and [Resident #1] said 'no go around'. He was setting with his wheelchair against the glass door on the left. [Resident #2] said he pushed [Resident #1] and he still didn't move so I hit him. I asked him why did he do that and he said because he was in the way, and he wouldn't move .It was [Resident #2's] intention to hit [Resident #1]. His actions were willful. He wanted him out of his way . During an interview with the Social Service Director (SSD) on 11/8/2022 at 12:15 PM, she stated .I went out of my office when the incident occurred. [Resident #1] was upset and a little shaken up from the incident. We brought him in the conference room for a while, he calmed down quickly and was able to return to his room. I checked on him when he returned from the hospital. I see him almost daily and there has been no change in his emotional behavior. He isn't withdrawn, fearful, he is still very outgoing, friendly, and social .The resident remained separated until discharged from the facility .I saw [Resident #2] almost daily, his outbursts prior to this had not been addressed at others, it was mainly about his money. He was so insistent about getting all of his money out his account. He would come to the front office and beat on the door. He wasn't exit seeking he would just want money .I checked on him [Resident #2] every day I was here. He did recall the incident and would say 'I just pushed him out of the way because he wouldn't move' . During an interview with the DON on 11/9/2022 at 2:50 PM, she stated .I was in the conference room which is off the lobby. I heard the unit manager call for help she stated these residents are fighting. I ran around the corner [UM] was entering the door code before I went through the doors. I saw [Resident #2] make physical contact with [Resident #1] with his closed fist to [Resident #1]'s head . During the interview the DON confirmed Resident #2 was witnessed willfully hitting Resident #1 in the head with his fist. Observation of Resident #1 on 11/8/2022 at 3:05 PM, in the hallway just outside his room, showed the resident self-propelling into his room, he was awake, alert, pleasant, and no anxiety or fearful behaviors were observed. During an interview with the Administrator on 11/10/2022 at 9:30 AM, he stated .it was a witnessed event staff did see [Resident #2] hit [Resident #1] with his open hands. [Resident #2] did admit to hitting [Resident #1] . During the interview the Administrator confirmed the facility failed to prevent abuse of Resident #1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, facility investigation and interview, the facility failed to report investigation outcome findings on 1 facility self-reported incident of 2 facility self-reported incidents reviewed. The findings included: Review of a facility policy Abuse Prevention Program updated 1/19/2017 showed .Procedure .When an alleged or suspected case of abuse or neglect is reported to the Administrator, the Administrator, or person in charge of the facility, will notify the following persons or agencies of such incident immediately .Abuse involving one resident upon another resident will be reported to TDH [Tennessee Department of Health]. The investigator will submit a final report of the conclusion of the investigation in writing within five (5) working days of the incident . Resident #1 was admitted to the facility on [DATE] with diagnoses including Disorder of Brain, Bipolar Disorder, Dementia and Cirrhosis of Liver. Medical record review of Resident #1's Progress Notes dated 10/1/2022-10/23/2022 showed no behaviors toward others, resident was being evaluated by group homes for possible transfer. Medical record review of Resident #1's History and Physical dated 10/6/2022 showed .Past medical history: Nontraumatic subarachnoid hemorrhage .Senile degeneration of the brain .Bipolar disorder . Medical record review of Resident #1's admission Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. Delusions were observed during the observation period, with no other behaviors observed. Medical record review of Resident #1's Nursing Progress Note dated 10/24/2022 showed .resident was observed receiving physical contact from another resident [Resident #2] in hall at front lobby entrance. Resident was immediately removed from situation and assessed, no apparent injuries noted .new order noted to place resident 1:1 for closer observation until sent out to hospital. Other new order noted to send resident to ER [emergency room] for medical clearance .neuro [neurological] checks initiated and WNLs [within normal limits] resident denies pain .Report called to ER and ambulance in route . Review of a facility investigation dated 10/24/2022 at 3:23 PM showed .Resident #2 was seen by the Unit Manager [UM] making physical contact with other resident [Resident #1] and called out for assistance .Unit manager was standing by HR [Human Resource] door on the other side of entry doors in front lobby. Unit Manager statement: 'I turned around from HR door and saw [Resident #2] hitting [Resident #1] [Resident #2] had a closed fist. [Resident #1] was holding his arms up trying to block [Resident #2] .[Resident #2] hit [Resident #1] in the head multiple times .Residents were immediately separated. DON assisted with removing [Resident #2] as I moved [Resident #1] .[Resident #2] said he hit [Resident #1] with walker. [Resident #1] stated [Resident #2] hit him with walker. I did not see [Resident #2] hit [Resident #1] with walker .3:23 PM .both residents placed on 1:1 .3:25 PM .both residents were assessed by DON, UM, ADON [Assistant Director of Nursing] no apparent injuries. Both residents denied pain. [Resident #1] stated 'he hit me in my head' and rubbed on his head but denied pain with no pain indicators. neuro checks initiated on both residents .3:37 PM .administrator notified .3:30 PM .police notified/arrive .new orders noted to send both residents to ER for evaluation .3:35 PM .Police arrived and obtained report. Stated they were not going to arrest [Resident #2] because he had dementia and was 84 yo [years old] .3:55 PM .EMS [Emergency Management Services] X2 arrive and transferred both residents to [hospital] . Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's Disease, Dysphagia, Muscle Wasting and Atrophy, Congestive Heart Failure, Schizophrenia, Psychotic Disorder with Delusions, Hallucinations and Bipolar Disorder. Medical record review of Resident #2's annual MDS dated [DATE] showed a BIMS score of 6 indicating severe cognitive impairment. The resident had verbal behavioral symptoms directed toward others 4 to 6 days, other behavioral symptoms not directed toward others daily, and wandering behaviors daily during the assessment period. Medical record review of Resident #2's Nursing Progress Note dated 10/24/2022 at 3:23 PM showed .resident observed making physical contact with another resident in front hall near lobby. Staff intervened and separated immediately. Resident assessed with no apparent injuries .New orders noted to place resident 1:1 immediately and to send resident out to hospital for further evaluation . During an interview with Resident #1 on 11/7/2022 at 9:05 AM, when asked about the incident he stated .I don't know he just don't like me. He hit me on my back, head, and neck. He hit me with his walker . He stated there had been no exchange of words except he had been sitting at the lobby glass doors and Resident #2 had said 'dude move go on' and Resident #2 got mad when he had to wait for him to move. He stated he was not afraid then or now, he was just staying away from Resident #2. During an interview with the ADON on 11/10/2022 at 8:10 AM, she stated .I entered the initial incident documentation in the URIS [system used by facilities to report required events to the State Survey Agency] system. The 5 day follow up was due on 10/31/2022. I entered the conclusion documentation remotely at approximately 6:00 PM on 10/31/2022. However, there is no record of documentation being received by the state within the required 5-day time frame. When we received the email from Nashville on 11/1/2022 the incident was closed. I never questioned that my submission on 10/31/2022 had not been received or I would have called to see why it wasn't there .We had no idea it had not been received until the DON asked me to print the updated report when you [State Surveyor] asked for it . During an interview with the Administrator on 11/10/2022 at 9:30 AM, he stated .As far as the issue of the failure to provide the 5-day outcome to the state on the 31st the regional director of operations and I spoke. She was asking me about the follow up. I explained to her the ADON was doing the input of that data as I was off work, and I would follow up with the ADON. After that conversation I did just that, I followed up with the ADON and she said she would take care of it. That night I followed up with the ADON and she said it had been reported that afternoon. As to why it is not there, I cannot answer that .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview the facility failed to ensure a new falls intervention was implemented after a fall for 1 resident (#28) of 3 residents reviewed for accidents of 30 sampled residents. The findings include: Review of the facility policy, Incidents/Accidents/Falls, undated revealed .The facility will ensure that incidents and accidents that occur involving residents are identified, reported, investigated and resolved .All falls will have a site investigation by appropriate staff .Each fall needs a new intervention rolled out . Medical record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease, Attention Deficit Hyperactivity Disorder, Post-Traumatic Stress Disorder, Diabetes, Dysphagia, Difficulty Walking, and Chronic Pain. Medical record review of a Significant Change Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. Continued review revealed the resident required extensive assistance for bed mobility, dressing, tranfers and toileting. Medical record review of facility documentation dated 2/9/18, revealed .Pt [patient] hit the emergency light in bathroom; had ambulated w/o [without] calling for assistace .pt was on her knees on the floor .negative for any new injuries . Medical record review of the care plan revealed .2/8/18 fall in room. No injuries . Continued review revealed no new intervention was implemented after the fall on 2/8/18. Interview with the Assistant Director of Nursing on 9/6/18 at 9:00 AM, in the conference room, confirmed the facility failed to follow their policy and failed to implement a new intervention to prevent further falls for Resident #28.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview the facility failed to ensure a resident was reevaluated by a Registered Dietician (RD) after a significant change for 1 resident (#28) reviewed for nutrition of 30 sampled residents. The findings include: Review of the facility policy,Screening and Initial Evaluation, undated revealed . A nutritional assessment is completed at least annually .New admits, Annuals and those Resident's with significant changes will be placed on the list for the RD [Registered Dietician] to see on their next visit. The Registered Dietician will review the assessment completed by the DM [Dietary Manager], and complete an in depth nutritional assessment upon admission or significant change would warrant an in depth assessment sooner. Any other resident who is deemed high risk such as those with .dialysis .will be placed on the list for the RD to review at their next visit .A quarterly note will be entered into the health record by the Dining Services Manager (Dietary Manager) .no less that quarterly .The care plan will be updated as changes are made in nutritional interventions as they occur . Medical record review revealed Resident #28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including End Stage Renal Disease, Attention Deficit Hyperactivity Disorder, Post-Traumatic Stress Disorder, Diabetes, Dysphagia and Chronic Pain. Medical record review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact, had a weight loss of 5% or more and was receiving dialysis. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 12 indicating the resident had moderate cognitive impairment. Medical record review of the resident's weight dated 11/3/17 (previous admission) revealed a weight of 122 pounds (lbs). Continued review revealed a readmission weight on 12/23/17 was 92.2 lbs (a decrease of 29.8 lbs) Medical record review of a Registered Dietician assessment dated [DATE] revealed .Screening Factors from MDS .Below desired weight range .Poor intake/Potential < [less than] 75% .Hx [history of] Weight Loss .DX [diagnoses] of Malnutrition .Nutritional Problem #1 .Inadequate oral intake rt [related to] clinical status and dx of anorexia .variable PO [by mouth] intakes of 0-75% not meeting est. [estimated] needs .Nutritional Problem #2 .Need for increased kcal [food calories]/protein consumption rt dialysis resident and open wounds . Medical record review of a RD progress noted dated 12/28/17 revealed .New Re-Admit .with ESRD [End Stage Renal DIsease], dysphagia .anorexia, dehydration, N/V [nausea/vomiting] .CBW [current body weight] 92.2 # [pounds] .BMI .16.9 (suboptimal for age/clinical status) .Ideal body wt [weight] .115# . Medical record review of a Physicians order dated 1/8/18 revealed an order to admit for Resident #28 for hospice services. Medical record review of a Hospice note dated 2/9/18 revealed discontinue weights per hospice for comfort. Interview with the Director of Food Services (Dietary Manager) on 9/6/18 at 10:00 AM, outside the kitchen, confirmed he was not aware until recently that he was responsible for documenting quarterly notes on residents. Continued interview confirmed he did not complete any quarterly notes on Resident #28. Interview with the Director of Nursing on 9/6/18 at 1:30 PM, in the conference room confirmed the facility failed to follow their policy and failed to ensure Resident #28 was re-evaluated quarterly by the RD and Director of Food Services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure expired blood collection tubes were properly disposed of in 1 of 1 storage rooms. The findings include: Observation of the A hall storage room, with Registered Nurse (RN) #1, on [DATE], at 12:05 PM, revealed the following: 97 expired blue top blood collection tubes expired [DATE]. Interview with RN #1, on [DATE], at 12:06 PM, in the A hall storage room confirmed the blood collection tubes were expired and available for resident use.