**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that self-administration of medications was determined to be clinically appropriate for 1 of 1 residents (R32). R32 was observed with an inhaler sitting on his bedside table. R32 did not have an order to self-administer medications, nor did he have an assessment completed to determine his competency for self-administering medications. This is evidenced by: The facility policy titled, Administering Medications, dated 2001, revision date April 2019, states, in part: Medications are administered in a safe and timely manner, and as prescribed . 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely . R32 was admitted to the facility on [DATE] and has diagnoses that include Chronic Obstructive Pulmonary Disease (COPD), Generalized Anxiety Disorder, Depression Unspecified, Anxiety Disorder Unspecified, Acute Respiratory Failure with Hypoxia (a condition where the body's tissues do not receive enough oxygen), and Shortness of Breath. R32's Minimum Data Set (MDS), dated [DATE], indicated that R32 had a Brief Interview for Mental Status (BIMS) score of 14, indicating R32 is cognitively intact. Section GG of the MDS indicated that R32 requires partial to moderate assistance for all Activities of Daily Living (ADLs). R32's Care Plan, dated 1/10/25, states in part: Focus: The resident has altered respiratory status/difficulty breathing . Intervention: Administer medications/puffers as ordered. Monitor for effectiveness and side effects . R32's Physician Orders include, in part: Albuterol Sulfate Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 4 hours as needed for shortness of breath, wheezing or cough. Start date: 1/10/25. No end date. A review of R32's Medication Administration Record (MAR) in the electronic medical record for January and February indicated the medication was administered every day without any missed medications. The medication was signed out as being given by the nurses each day. Of note: R32 does not have a physician's order to self-administer medications, nor was there a competency assessment anywhere in R32's medical record for self-administering of medications. On 2/10/25 at 10:22 AM, Surveyor interviewed R32 in his room and observed an inhaler sitting on the table next to him. Surveyor asked R32 if he always had his inhaler in his room with him. R32 replied yes, he kept the inhaler at his bedside in case he felt short of breath. R32 indicated he used the same inhaler at home. On 2/11/25 at 4:12 PM, Surveyor interviewed LPN E (Licensed Practical Nurse) about R32's medications. Surveyor asked LPN E what the criteria is for a resident to have medications in their rooms. LPN E stated residents can have medications in their rooms if they are alert and oriented and able to sit up independently. Surveyor asked LPN E if R32 was allowed to have medications at bedside. LPN E replied yes, he was. Surveyor asked LPN E if any assessments had been done to ensure R32's competency for self-administering his own medications. LPN E stated they didn't do any assessments. Surveyor asked LPN E if R32 had a physician's order to self-administer medications. LPN E replied she wasn't sure. LPN E searched her medication cart in Surveyor's presence and could not find an inhaler for R32. LPN E stated, it must be in his room. On 2/12/25 at 11:07 AM, Surveyor interviewed DON B (Director of Nursing) and asked her what her expectation was for a resident to keep medications at their bedside. DON B indicated that if a resident shows interest in wanting to self-administer their own medications, they complete a self-administer assessment that is then reviewed at their weekly risk management meeting. DON B elaborated that if the resident is deemed competent, they would have a lock box given to them to store the medication in their room safely. Surveyor asked DON B who was responsible for completing the self-administer assessments with the resident. DON B replied that it is delegated to the nurses on the unit but that herself and the ADON (Assistant Director of Nursing) are also involved in the process. Surveyor asked DON B if R32 had a self-administer assessment. DON B reviewed R32's electronic medical record and stated that she did not see one. Surveyor asked DON B if R32 had a physician's order to self-administer medications. DON B reviewed his medical record and indicated she did not see one. Surveyor shared her observation of R32 having an inhaler in his room on his bedside table. Surveyor asked DON B if R32 should have a self-administer assessment for competency and a signed physician's order to have medications at bedside. DON B stated yes, he should have those in order to administer his medications independently and safely. The facility's failure to adequately assess and supervise medication administration enabled the resident to keep medications at the bedside and self-administer without demonstrating competency to do so.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure coordination of care and the hospice communication process was followed for 1 of 2 sampled residents (R61) and 2 of 2 supplemental residents (R55 and R320) for hospice services. R61, R55, and R320 were admitted to hospice services and the facility failed to obtain hospice documentation. Evidenced by: The facility policy titled Hospice Program dated 7/2017 states in part .12. Our facility has designated Social Services to coordinate care provided to the resident by our facility staff and the hospice staff .He or she is responsible for the following: d. Obtaining the following information from the hospice: (1) The most recent hospice plan of care specific to each resident .(4) Name and contact information for hospice personnel involved in hospice care of each resident .(6) Hospice medication information specific to each resident .13. Coordinated care plans for resident receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental, and psychosocial well- being . Example 1 R320 was admitted to the facility on [DATE]. R320 was receiving hospice services at home prior to admission to the facility, and those services continued in the facility. R320's terminal diagnosis is severe protein malnutrition. Surveyor reviewed R320's EHR (Electronic Health Record) and was not able to find any documentation of R320's hospice enrollment, admission assessment, care plan, orders, or visit notes since admission to the facility. Example 2 R55 was admitted to the facility on [DATE]. R55 was receiving hospice services at home and those services continued in the facility. R55's terminal diagnosis is dementia d/t (due to) Parkinson's. Surveyor reviewed R55's EHR (Electronic Health Record) and was not able to find any documentation of R55's hospice enrollment, admission assessment, care plan, orders, or visit notes since admission to the facility. Example 3 R61 was admitted to the facility on [DATE] and signed on to receive hospice services the same day. R61's terminal diagnosis is sepsis. Surveyor reviewed R61's EHR (Electronic Health Record) and was not able to find any documentation of R61's hospice enrollment, admission assessment, care plan, orders, or visit notes. On 2/11/25 at 3:34 PM, Surveyor interviewed RN F (Registered Nurse). Surveyor asked RN F how the facility receives documentation from the hospice provider, RN F reported that the hospice typically faxes their notes and medical records puts them in the resident's EHR. Surveyor asked RN F to review R61's EHR to locate any hospice notes or documentation. RN F reported that there were no notes scanned in. Surveyor asked RN F if the expectation is that the hospice provider would fax notes to the facility, RN F stated yes. Surveyor asked RN F whose responsibility is it to follow up on the hospice notes, RN F stated that it would be the responsibility of the nurse working the shift. On 2/11/25 at 3:54 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the expectation is for documentation of hospice visits, DON B reported that the expectation is that hospice would complete their assessment and either fax the notes or document in the resident's EHR. Surveyor asked DON B how staff know what the resident's hospice plan of care, visit frequency, and orders are if there is no documentation in the resident's EHR from the hospice provider, DON B states that the hospice nurse communicates each of their visits with the floor nurse or charge nurse. On 2/11/25 at 4:07 PM, Surveyor interviewed RN G (hospice RN). Surveyor asked RN G what the process is when they visit a resident at the facility, RN G states they meet with the resident, and if there are any concerns they will talk to the facility's nurse. Surveyor asked RN G if they fax their notes to the facility or document in the resident's EHR, RN G reported that they do a face to face with the nurse but do not fax their documentation. Surveyor asked RN G how they communicate the care plan with the facility, RN G stated that they only fax it if the facility asks for it. Surveyor asked RN G how the facility knows the frequency of visits, RN G reported that they should know that R61 is seen twice a week for nursing, once a month for Social Worker, and once a week for the Chaplain. Surveyor asked RN G how the facility staff would know that, RN G reported that is should be on the admitting orders. It is important to note that Surveyor reviewed R61, R55, and R320's medical records and there was no documentation of admission orders, admission assessments, nursing visit notes, Social Worker visit notes, Chaplain visit notes or the hospice plan of care. Of note: the facility obtained the appropriate documentation from the hospice provider for R61, R55 and R320 after Surveyor requested it. On 2/12/25 at 10:00 AM, Surveyor interviewed SW H (Social Worker). Surveyor asked SW H what their role is with a resident receiving hospice services, SW H reported that they make the referral, coordinate the initial visit, and update the team regarding the enrollment. Surveyor asked SW H who is responsible for ensuring that the facility receives the hospice visit notes, care plan, enrollment forms, and medication list, SW H reported that the hospice provider faxes the information over, and the documents get scanned into the EHR. SW H reported that they took for granted that they were getting the information and that no one checked.

Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 58 residents who reside in the facility. Surveyor observed multiple staff wearing hairnets incorrectly. Surveyor observed staff not wearing a beard restraint. Surveyor observed staff enter the kitchenette area while the cook was serving food, not wearing hairnets. The facility policy, Meal Service Delivery from Unit Kitchens, dated February 2025, states, in part; .Hair Restraints .Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. Hair nets are required by any employee in the kitchen while food is being prepared or served. All other employees assisting with meal service must have hair pulled back . On 2/10/25 at 11:59 AM, Surveyor observed dietary staff serving food. The dietary staff's hairnet was only covering her hair that was in a bun and the rest of hair was not covered. Surveyor observed 3 different staff go in the kitchenette area while dietary was serving lunch. Surveyor observed staff get items from fridge and wash their hands at the sink while not wearing a hairnet. On 2/10/25 at 12:45PM, Certified Nursing Assistant D (CNA) indicated they do not need to wear hairnets when going in the kitchenette. CNA D indicated the cook who is serving the food needs to wear a hairnet, but not the other staff that are in the kitchenette. On 2/11/25 at 9:06AM, Surveyor observed Dietary Aide I not wearing a beard restraint while working in the kitchen. On 2/12/25 at 8:47AM, Surveyor observed dietary staff serving food. Dietary staff was wearing a hairnet but had her bangs out of the hair net. On 2/11/25 at 9:15AM, Dietary Manager C (DM) indicated staff should wear beard restraints when in the kitchen and provided Dietary Aide I a beard restraint. DM C indicated staff should wear hair restraints properly and it should cover all of hair. DM C indicated if serving and/or cooking is occurring in the kitchenettes, staff should wear hair restraints when in the kitchenettes. If a staff needs something from the kitchenette area when serving is going on the staff should ask the dietary staff for assistance and not go in the kitchenette area. The facility failed to maintain a safe and sanitary environment in which food is prepared, stored, and distributed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure all alleged violations involving misappropriation are reported immediately to other officials including the State Agency in accordance with State law through established procedures for 1 of 3 residents (R1) reviewed for misappropriation. The facility became aware of an allegation of misappropriation for R1 on 7/14/23. The allegation was not reported to the State Agency within 24 hours. This is evidenced by: The facility policy titled, Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, with an effective date of 2/15/17, states, in part: .d. Misappropriation. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent .Reporting and Response: Abuse Policy Requirements - It is the policy of this facility that abuse allegations (abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported immediately, but no later than 24 hours, to the Administrator or designee of the facility and to other officials including to the State Survey Agency in accordance with State law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility .External Reporting .a. Initial reporting of Allegations - If an incident or allegation is considered reportable, the Administrator or designee will make an initial (immediate or within 24 hours) report to the State Agency (F-62617). A follow-up investigation will be submitted to the State Agency within five (5) working days (F-62447) . R1 was admitted to the facility 5/24/23 with diagnoses including: atrial fibrillation, sick sinus syndrome, diabetes, osteoporosis, acute kidney failure, and pathological fracture, right femur. R1's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/30/23, indicates R1 has a Brief Interview for Mental Status (BIMS) score of 15 indicating R1 is cognitively intact. R1 is her own person. On 8/7/23 at 9:20 AM, Surveyor talked to Family Member E. Family Member E indicated the family discovered $548.46 worth of charges on R1's credit card that R1 did not make. Family Member E indicated R1's daughter emailed the facility to notify them of these charges on 7/14/23 at 8:54 AM. Family Member E indicated there were local and online charges that were made. Family Member E indicated there were several purchases from Pizza [NAME]. Family Member E went to Pizza [NAME] and explained that R1 was a victim of fraudulent charges and Pizza [NAME] provided receipts. Family Member E indicated on one of the receipts it had a person's name and a phone number. Family Member E indicated this name and phone number was from a housekeeping staff at the facility. Family Member E indicated the first charge that was made was while R1 resided at the rehab unit at the facility. Family Member E indicated that on 7/17/23 the housekeeping staff was still working at the facility and the police arrested the staff. Family Member E indicated she had a meeting with the Administrator, HR (Human Resources,) and DON (Director of Nursing) sometime last week and they finally apologized and stated they were not going to be reporting it to the state agency because it was too late to report. Family Member E provided Surveyor copies of the email that was sent to facility on 7/14/23, Pizza [NAME] receipts, and credit card statement. Surveyor reviewed documents. Family Member F emailed Executive Assistant D on 7/14/23 at 8:53 AM. The email stated, in part; Good Morning, my mother, ., was recently the victim of credit card theft/fraud. I am afraid it is probably related to (Facility Name.) On Wednesday, July 12th, I wanted to reconcile my mother's credit card bill and discovered $548.46 worth of charges that clearly were not hers. The fraudulent charges began June 26th while she was in the rehab portion of (Facility Name.) The card itself was not stolen, but someone must have written down her card number and identifying information. The card was used to purchase food locally and order deliveries from websites. The credit card company stopped the payments and is issuing her a new card. I wanted you to know what has happened. There may be other residents at risk as well. On 8/7/23 at 11:30 AM, Executive Assistant D indicated receiving the email from R1's family member on 7/14/23. Executive Assistant D indicated she forwarded the email to DON B (Director of Nursing.) On 8/7/23 at 2:23PM, Surveyor interviewed HR Director C (Human Resource Director.) HRD C indicated that 7/17/23 was the first time he was made aware of the accusation of misappropriation. HRD C indicated DON B provided him R1's credit card statement and the local Pizza [NAME] receipts. HRD C indicated after he reviewed the documents HRD C called the NHA A (Nursing Home Administrator) and then contacted the local law enforcement. HRD C indicated Housekeeper G's name and phone number was on one of the Pizza [NAME] receipts. HRD C indicated that Housekeeper G was working on 7/17/23. HRD C provided Surveyor Housekeeper G's time punches for 7/17/23 which showed 7:30AM-12:00PM for time worked. Of note, Housekeeper G was removed from duty on 7/17/23 once the facility confirmed a receipt contained a staff member, Housekeeper G's name. On 8/7/23 at 3:08 PM, DON B indicated abuse should be initially reported within 24 hours for the Skilled Nursing Facility (SNF,) investigated, and the final report should be submitted within five business days. DON B indicated for Assisted Living (AL,) abuse should be reported in five business days. DON B indicated they consulted with their legal team and the legal team directed the facility to report the misappropriation through AL since that is where R1 was residing at the time the facility became aware of the allegation. DON B indicated Executive Assistant D forwarded the email from Family Member F on 7/14/23 to DON B. DON B indicated the email would have come to her sometime in the afternoon, because it was at end of day discussion. DON B indicated she tried to call the family to get more information on 7/14/23. On 7/14/23 late afternoon, DON B emailed Family Member F and Family Member F emailed back saying she would call DON B on Monday, 7/17/23. On 7/17/23 around 8:30AM-8:45AM, Family Member F called DON B. DON B asked Family Member F if the family was going to involve law enforcement. Family Member F indicated they were gathering receipts. Family Member F emailed DON B Pizza [NAME] receipts and the credit card statement around 9:00 AM. DON B indicated HR Director C reviewed receipts and that HR Director C felt like a staff member may have been involved. DON B indicated they notified NHA A (Nursing Home Administrator) and then contacted law enforcement. Surveyor and DON B reviewed email from Family Member F to facility on 7/14/23. Surveyor asked if this was the email that was forwarded on to DON B. DON B indicated yes. Surveyor asked DON B in the email does the family believe the charges occurred from someone at the facility? DON B indicated yes. Surveyor asked if the family believes that it is someone at the facility would it be considered an accusation of misappropriation? DON B indicated yes. Surveyor asked DON B if this accusation should have been reported within 24 hours after the facility learned about the accusation? DON B indicated it is DON B's understanding that for AL guidelines the accusation should be thoroughly investigated and then sent in within five days. DON B indicated SNF guidelines were not followed because their legal department directed facility to follow AL guidelines. On 8/7/23 at 4:05 PM, DON B indicated the final self-report was sent on 8/4/23. DON B indicated there were no other notifications made to State agency regarding the investigation of misappropriation. It is important to note, the facility was made aware of an accusation of misappropriation on 7/14/23 and did not report to state agency for 16 business days, on 8/4/23. Housekeeper G, the alleged perpetrator, only worked in the nursing home. The facility failed to take immediate action upon discovery of the misappropriation and failed to protect other residents upon discovery.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure an alleged misappropriation was thoroughly investigated and the results of the investigation were reported to the State Agency within five working days of the incident for 1 of 3 residents reviewed for misappropriation (R1). The facility was made aware of an allegation of misappropriation for R1. The facility failed to complete a thorough investigation into this allegation. This is evidenced by: The facility policy titled, Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, with an effective date of 2/15/17, states, in part: .d. Misappropriation. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent .Investigation: Abuse Policy Requirements - It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse including injuries of unknown source, exploitation, and misappropriation of property) are promptly and thoroughly investigated. Procedure - The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The information gathered is given to administration .c. Investigation Regarding Misappropriation - a complete an active search for missing item(s) including documentation of investigation is conducted. The investigation will consist of at least the following: A review of the completed grievance report An interview with the person or persons reporting the incident Interviews with any witnesses to the incident A review of the resident medical record if indicated A search of the resident room (with resident permission) An interview with staff members having contact with the resident during the relevant periods or shifts of the alleged incident Interviews with resident's roommate, family members, and visitors A root-cause analysis of all circumstances surrounding the incident R1 was admitted to the facility 5/24/23 with diagnoses including atrial fibrillation, sick sinus syndrome, diabetes, osteoporosis, acute kidney failure, and pathological fracture, right femur. R1's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/30/23, indicates R1 has a Brief Interview for Mental Status (BIMS) score of 15 indicating R1 is cognitively intact. R1 is own person. On 8/7/23 at 9:20 AM, Surveyor talked to Family Member E. Family Member E indicated the family discovered $548.46 worth of charges on R1's credit card that R1 did not make. Family Member E indicated R1's daughter emailed the facility to notify them of these charges on 7/14/23 at 8:54 AM. Family Member E indicated there were local and online charges that were made. Family Member E indicated there were several purchases from Pizza [NAME]. Family Member E went to Pizza [NAME] and explained that R1 was a victim of fraudulent charges and Pizza [NAME] provided receipts. Family Member E indicated on one of the receipts it had a person's name and a phone number. Family Member E indicated this name and phone number was from a housekeeping staff at the facility. Family Member E indicated the first charge that was made was while R1 resided at the rehab unit at the facility. Family Member E indicated that on 7/17/23 the housekeeping staff was still working at the facility and the police arrested the staff. Family Member E indicated she had a meeting with the Administrator, HR (Human Resources) and DON (Director of Nursing) sometime last week and they finally apologized and stated they were not going to be reporting it to the state agency because it was too late to report. Family Member E provided Surveyor copies of the email that was sent to facility on 7/14/23, Pizza [NAME] receipts, and credit card statement. Surveyor reviewed documents. Family Member F emailed Executive Assistant D on 7/14/23 at 8:53 AM. The email stated, in part; Good Morning, my mother, ., was recently the victim of credit card theft/fraud. I am afraid it is probably related to (Facility Name). On Wednesday, July 12th, I wanted to reconcile my mother's credit card bill and discovered $548.46 worth of charges that clearly were not hers. The fraudulent charges began June 26th while she was in the rehab portion of (Facility Name). The card itself was not stolen, but someone must have written down her card number and identifying information. The card was used to purchase food locally and order deliveries from websites. The credit card company stopped the payments and is issuing her a new card. I wanted you to know what has happened. There may be other residents at risk as well. On 8/7/23 at 10:00 AM, Surveyor met with R1 who is now residing at the Assisted Living section of the facility. R1 indicated she heard someone got into her purse while she was staying at the nursing home. R1 indicated her daughter and daughter-in-law have been looking into the incident. R1 indicated it was a previous staff person who made purchases on her credit card. R1 indicated she never talked to this staff person and doesn't know what she looks like. R1 stated, I couldn't imagine someone doing something like this. R1 indicated she feels safe at the Assisted Living but doesn't think she would feel safe staying at the nursing home. Surveyor asked if she was at the rehab section of the SNF (Skilled Nursing Facility). R1 indicated yes. On 8/7/23 at 11:30 AM, Executive Assistant D indicated receiving the email from R1's family member on 7/14/23. Executive Assistant D indicated she forwarded on the email to DON B (Director of Nursing). On 8/7/23 at 2:23PM, HRD C (Human Resource Director) indicated 7/17/23 was the first time he was made aware of the accusation of misappropriation. HRD C indicated DON B provided him R1's credit card statement and the local Pizza [NAME] receipts. HRD C indicated after he reviewed the documents HRD C called the NHA A (Nursing Home Administrator) and then contacted the local law enforcement. HRD C indicated Housekeeper G's name and phone number was on one of the Pizza [NAME] receipts. HRD C indicated that Housekeeper G was working on 7/17/23. HRD C indicated it all happened fast, however he was not able to verify the time the police officer arrived or how long Housekeeper G continued working. HRD C provided Surveyor Housekeeper G's time punches for 7/17/23 which showed 7:30 AM-12:00 PM for time worked. HRD C indicated the clock out time was manually entered. On 8/7/23 at 3:08 PM, DON B indicated misappropriation should be initially reported within 24 hours for the Skilled Nursing Facility (SNF), investigated and the final report should be submitted within five business days. DON B indicated for Assisted Living (AL) abuse should be reported in five business days. DON B indicated Executive Assistant D forwarded the email from Family Member F on 7/14/23 to DON B. DON B indicated the email would have come to her sometime in the afternoon, because it was at end of day discussion. DON B indicated she tried to call the family to get more information on 7/14/23. On 7/14/23 late afternoon DON B emailed Family Member F and Family Member F emailed back saying she would call DON B on Monday, 7/17/23. On 7/17/23 around 8:30 AM-8:45 AM, Family Member F called DON B. DON B asked Family Member F if the family was going to involve law enforcement. Family Member F indicated they were gathering receipts. Family Member F emailed DON B Pizza [NAME] receipts and the credit card statement around 9:00 AM. DON B indicated HRD C reviewed receipts and that HRD C felt like a staff member may have been involved. DON B indicated they notified NHA A and then contacted law enforcement. DON B indicated when the police arrived at the facility, they wanted to talk with R1 first. DON B indicated that interview took about 30 minutes and DON B stayed for the entire interview. After the interview, DON B went down to the rehab unit and Housekeeper G was not on the unit. Surveyor asked when was Housekeeper G pulled from unit? DON B indicated she would have to go by what HRD C said. Surveyor asked if DON B would expect Housekeeper G to be pulled from the unit as soon as it was realized she was potentially involved. DON B indicated yes. DON B indicated as far as she knows there is no documentation of when Housekeeper G was removed from the unit. DON B indicated again that she would go by what HRD C stated for the time frame. Surveyor asked DON B what constitutes for a thorough investigation? DON B indicated interviewing resident and family, establishing a timeline, and if there are other people that can be affected. DON B indicated with law enforcement involved this was a unique situation. DON B indicated they would have interviewed the accused employee as well, but in this situation the police arrested the employee. DON B indicated she had met with Housekeeper G's supervisor and the supervisor indicated Housekeeper G only worked in C-pod unit (rehab). DON B indicated R1 was in C-pod when she was in rehab. Surveyor asked if the dates of the fraudulent purchases coincide with when R1 was in rehab. DON B indicated yes. DON B indicated there were only two residents on the rehab unit that still resided there because there is heavy turnover with residents. DON B indicated the two residents on that unit voiced no concerns. Surveyor asked if any other residents were interviewed in the building and if Housekeeper G could potentially go into other rooms. DON B indicated, I have not seen that, I have seen her on C-pod and at the café, and I am generally out on my units and have not seen her loitering anywhere. DON B indicated residents in other areas of the building were not interviewed. DON B indicated at the July Resident Council meeting misappropriation was discussed and that Social Worker H led the meeting. Surveyor asked DON B if other direct care staff were interviewed regarding misappropriation. DON B indicated, I cannot say specifically that I did in all areas. Surveyor asked if the staff on C-pod (rehab) were interviewed. DON B indicated, No, the resident wasn't in that area, so I was down in Assisted Living. The only reason I can think of is that the investigation was actively being reviewed by law enforcement and so I had a concern with tampering with an active investigation . Surveyor reviewed Resident Council Meeting minutes 7/24/23, Social Services: No concerns. Resident rights reviewed: Self-determination On 8/7/23 at 4:01 PM, SW H (Social Worker) indicated she led the Resident Council Meeting on 7/24/23. Surveyor asked if SW H could remember if there were other things discussed besides self-determination. SW H indicated, That was all that was discussed. They were very quiet. Surveyor asked if misappropriation of funds was discussed. SW H stated, No. The facility failed to interview all residents and staff to ensure there was not additional concerns regarding misappropriation of resident funds.