**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not report a resident's allegations of misappropriation and/or exploitation to the State of Wisconsin or local authorities immediately upon the resident reporting the alleged misappropriation. The facility's failure to report the allegations affected 1 of 1 residents (R1) who reported incidents of missing items and funds from her accounts. R1 reported missing items from her room and funds from her Direct Express government funded debit card on numerous occasions that the facility did not report to the State of Wisconsin or local authorities. The facility's failure to respond caused R1 distress and psychosocial harm of prolonged crying, increased anxiety and agitation, removal from activities, distress, disturbed sleep, and hospitalization due to suicidal ideation The facility's failure to report the resident misappropriation created a finding of immediate jeopardy that began on 03/20/23. Surveyor notified Nursing Home Administrator (NHA) A and Director of Nursing (DON) B of the immediate jeopardy on 06/21/23 at 3:42 pm. On 06/01/23, the facility discovered the misappropriation and exploitation of 16 residents including R1 was being done by a facility Social Worker, reported the resident misappropriation, and took steps to correct the deficient practice and ensure compliance at the time of the survey. Based on this determination, the IJ was removed and corrected on 06/06/23. This is being cited as past noncompliance. Findings Include: Surveyor reviewed the Facility Reported Incident (FRI) submitted to the state of Wisconsin Department of Health Services. On 06/01/23, the facility identified 16 residents, including R1, who had been the victims of misappropriation of funds by a facility Social Worker (SW C.) Surveyor requested and reviewed the facility policy Abuse, Neglect, Exploitation of residents, Misappropriation, Injuries of Unknown Origin and Reporting of Crimes dated 10/20/22 which states in part: Identification: Staff will immediately report any suspicious event that may constitute .exploitation, misappropriation, occurrence of a crime. The facility will report the allegation to the state agency and law enforcement in accordance with state and federal law. Reporting and Response: Allegations will be reported to the Administrator immediately. The facility shall report all alleged violations and substantiated incidents to the state agency and all other agencies as required and will take all necessary corrective actions depending on the results of the investigation. The facility and/or staff shall report suspicion of a crime to local authorities and/or agencies as required. Reporting to law enforcement of reasonable suspicion of crimes: Reporting Requirements: In general: Each covered individual shall report to the state agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual receiving care from the facility. Examples of situations that would likely be considered crimes include but are not limited to .Theft/robbery .Identity theft fraud or forgery . On 6/19/23 at 10:10 am, Surveyor spoke with NHA A and Director of Nursing (DON) B about the FRI and R1's report of misappropriation. NHA A explained R1's reports of misappropriation were reported to the Social Services office. There was informal communication between facility staff via email but nothing formal prior to the FRI reported to the State of Wisconsin on 6/01/23. At this time the facility had determined Social Worker (SW) C was misappropriating money from residents. This was the first reporting of the incident. The police were first contacted with the discovery on 6/01/23. There was no reporting based on what SW C reported to Administration. The facility did not contact the police. The facility should have reported to the State of Wisconsin and notified the police. R1's record shows she was committed to facility due to mental illness and probable harm to self or others with recent overact or patterns of recent acts on 1/04/23. R1 had previous stays at the facility that were voluntary admissions. R1 was admitted to the secured wing from the hospital admissions wing. R1's most recent quarterly Minimum Data Set (MDS) completed 4/12/23 notes she understands, is understood, and has a BIMS of 15 indicating she is cognitively intact. R1 experiences hallucinations and delusions and has depressive mood indicators. R1's diagnosis includes schizo-affective disorder, bi-polar (primary type.) R1's record shows she is her own decision maker and guardian of estate. R1 receives $714.00 each month for SSDI. R1 did not have an account for petty cash at the facility. Surveyor reviewed R1's Psych Consult information and noted the following: Behaviors monitored: 1. Physical: anxiety, sweating, pacing, bouncy knee 2. Verbal: Paranoid/delusional 3. Other: Internal Stimuli/hearing voices Documentation shows R1 had 39 behaviors in April. This is a significant increase from March, after R1 reported the missing money and items, and the highest monthly count since R1's admission. Surveyor review of R1's [NAME] County Human Services counseling notes: 3/21/23: reports crying almost daily, voices have not been bothering her as much, believes she is addicted to on-line shopping app, buying things from app. Almost daily .tearful and requested to end session . 4/04/23: believes father may be stealing things from her, hopeless, tearful, guarded, expressed a lot of anger . 4/18/23: identified anxiety, unsure if she can pay for her brace on her own .anxiety about not knowing how much money in bank account, she does not know how to check her money but concerned the app is stealing money from her for browsing . 5/23/23: discussed increased depression, more sick last 2 weeks, wants to go to different hospital as no one likes her here, does not feel safe, conspiring against her. Increased paranoia and agitation. Difficulty finishing thoughts. This is the first session she swore in front of writer. Getting CT next week for signs of dementia. 6/09/23: Reports relief of news of SW taking money. It means she is not crazy as she and everyone thought. Identified anger. Discussed hospitalization. Decreased meds, but not sure why, Feels less emotional. Wished she could start ECT now to see if she would benefit from it . 6/13/23: Had ECT and believes it is helping, Feels resentful towards staff regarding SW situation. Discussed how staff did not believe her and she was hospitalized , and she was correct. Surveyor reviewed R1's nurses note and noted the following: 1/29/23: Note from SW C, .the one thing on her mind appears to be when her monthly money will go down to $45.00 per month . 3/01/23: Note from SW C, resident request writer to hold on to her debit card. Writer assured resident the best idea would be to have it placed in the business office. Writer filled out envelope with her signature on it . 3/20/23: Note from CNA, Resident approached staff and stated I was told to talk to you about a card I lost, it is a government funded card. I looked everywhere and can't find it Writer asked if she had it with her when she went shopping but resident could not remember. Asked if she wanted her to help look for it. Resident responded sure. Writer was unable to find the direct express card identified as green in color. Resident stated she will call and cancel card. Although resident reported a missing debit card to staff there is no evidence the police or state agency were notified. 3/21/23: Note from SW C, writer reminded resident her card is kept safe in business office. Resident did not remember this but was relieved. 4/02/23: Note from SW C, continues to experience overall instability in mental health. Her mental health has improved since her admission but can be unpredictable sometimes on an hourly basis. Mental health symptoms continue to include delusional thoughts, paranoia and responding to internal stimuli. Resident out to eat at culvers ., given her debit card before she left. When she returned, she returned her card to be locked safely, reviewed notes and see resident concerns about how much money was left on her card balance. This writer theorizes resident feels she should have money because benefits come on the first, the first fell on weekend day and it is possible she did not receive the funds . 4/02/23: Note from RN, Resident made comments last evening regarding her debit card .reassured card is locked in office, and no one has access. Resident comment she was just panicking and accepted reassurance from staff 4/04/23: Note from SW C, resident continues to experience overall instability with her mental health, continues to experience depression, anger, voices that do interfere with daily routine and cause her distress. Writer has met with resident one on one past two days. Resident angry and made accusations directed at care staff Writer reminded resident she can trust writer .Resident did make a statement about possibly having a rep-payee to help her with her finances . 4/07/23: Note from SW E, to tobacco outlet to withdraw $100.00, resident request cards to be locked in business office. SW and nurse signed envelope confirming debit card placement 4/07/23: Debit card in Narc drawer for resident better access. (RN note). 4/12/23: 1:45 Note from RN, Resident came to med room yelling It's not funny, I only have $70.00 left in my account since last week Someone is stealing my money, walked away crying, refusing to listen to staff, repeating someone is stealing my money .SW to unit to speak with her. 4/12/23: 2:57, Note from SW C, continues to experience overall instability with mental health. Resident continues to experience depression and anger; voices interfere with daily routine causing distress .Had a very difficult with increased mental health symptoms today. Received a call from nursing staff very upset about money. I thought I was doing good with my money; I should have more. Crying during first part of meeting. Writer asked investigative questions about, and resident appears to be having some delusional thoughts . Resident believes dad using money and taking packages she orders . Reminded card is locked, and she is the only one with the pin. Resident states she is never going to get better. Asked if she wants to contact police and said No. I am just not thinking very clearly. There is no evidence the facility notified the State of Wisconsin or police when R1 reported someone was stealing her money on 4/12/23. 4/19/23: Note from CNA, Resident tearful about a phone call she made. SW made aware. 4/20/23: Note from CNA, left at this time for Walmart with Social Worker 4/20/23: Note from RN, Made accusations regarding her credit card. While talking with writer resident had a flat affect, aggressive tone, jumped from topic to topic, walking very slowly throughout shift, displayed paranoid thoughts. Talked with HN (Head Nurse/RN) and NHA (Nursing Home Administrator) about it. Although the facility shared an exchange of email regarding the situation there is no evidence the State of Wisconsin or police were notified. The emails state: 4/20/23: RN F: R1 came out of her room .had a small flat bag and asked where she could put it where it would be safe and no one could get to, the most safest untouchable spot where no average just anybody could get to it .R1 stated over the last two months a lot of her items have gone missing and her card was missing and it had over 2,000 missing from it and that was from the business department and still does not know how it happened .R1 stated she just got a new card and there is already money missing and she does not know how she is going to prove it . 4/20/23: NHA A: R1 is basically saying someone is using her debit card. With that said, can you please investigate in the morning? It should be easy to rule out by helping her check her balance .R1 seems extremely unwell . 4/21/23 SW C: We will investigate this. Unfortunately, R1 still is unwell. 4/21/23: SW E: We gave R1 a lock box this morning. She said SSDI told her they can see specific people that use her card. I asked her if she meant the store that the stolen purchases were coming from and she said no, they can see people on each transaction. She mentioned an [name] has used her card, but denied it was a resident Resident also mentioned she had misplaced her cream-colored small wallet that held her ID and insurance cards .Found wallet in the bottom of her purse . Nurses Notes continued: 4/21/23: Note from CNA, was heard this morning talking to a peer about how things are missing in her room. SW and CSA [Client Service Assistant] are notified about her concerns. There is no evidence the State of Wisconsin or local authorities were notified of R1's report of items missing in her room. 4/21/23: Note from SW C, This writer and CSA staff staffed resident case and recent accusations this morning. A cumulative review of all fact-based information confirms resident accusations of someone using her debit card are unfounded. Resident mental health remains extremely unpredictable, and she continues to experience delusions, paranoid, voices and frequent mood swings. Received a new debit card today in a sealed envelope. Delivered personally with CSA witness. Reminded to put in lock box. No one has access to the debit card pin. Resident receiving numerous packages from online ordering. Also sent money in the mail to her family. Resident stated, I shop online impulsively when I am anxious. Resident interviewed and social services did not argue with her delusions .Made referral to MD to access the need for rep payee regarding continued concerns spending/financial accusations .IDT will look into evaluation for dementia . 4/21/23: Email from SW E to Physician: Resident is in need of a rep-payee. She is accusing people of stealing her money, but she is spending it. She is forgetting and we are worried she may have some memory impairments . 5/03/23: Note from SW E, resident expressed just put me in the hospital, I don't want to be here anymore, they think I am going to hurt people, denied having these thoughts. 5/04/23: Note from CNA, Appears to be in sad mood today .Declined playing cards . 5/05/23: (RN D, R1, SW C, MD) tearful/depressed, crying often, agitation decreased. Resident concerns with complaints of depression/anxiety. Medication changes. 5/08/23: Note from SW E, resident would like to cash a large check from her brother. Declined cashing at Walmart and voiced she would like to open a bank account. Resident does not have a bank. Resident returned NHC lock box stating she does not need it. 5/10/23: tearful, declined outing, too much pain 5/11/23: Due for assistance renewal, sought CSA help. 5/11/23: Note from CNA, Very frustrated and sensitive upon waking .even coming to the point of bawling when she couldn't get her leg brace on. 5/12/23: (Charge Nurse) Resident came to write stating she needed to go to the bank today urgently as her card has been compromised .Writer stated she needed to talk with SW and CSA about it. Writer spoke with SW/CSA and they informed resident to call her bank to see if she can put a hold/freeze on it. Writer spoke with resident who changed story of card compromised to she needed to money in the bank .so she does not become compromised .Resident upset . 5/14/23: resident reports having nightmare 5/16/23: Note from SW E, Appeared in CSA office and was visibly crying and upset, expressed she would rather be in jail then stay at [NAME], felt staff are trying to entrap her. Adamant about not staying at [NAME] as she does not feel safe here .Paranoia and behaviors increasing .Nursing made aware of resident comments and agitated mood . 5/21/23: resident reports not sleeping, wants to talk with psychiatrist about it . 5/22/23: Note from SW E, Appeared more emotional and tearful today. Reported depression worse .believes apartment ended lease due to non-payment . 5/23/23: Note from SW E, resident experienced an acute change in mental status today that prompted a call to [NAME] County Crisis and subsequent move to more restrictive environment on the [NAME] admissions unit (hospital). Resident demanded to speak to SS (Social Services). Resident appeared upset and crying .Thought process was difficult to follow, became very angry and verbally aggressive .Demanded to leave .Yelled while continuously crying .repeated anger over medications that were discontinued .unable to process and evaluate information .Concerns of self-harm .Crisis team contacted .Today was the most unstable that this writer has witnessed resident mental health while working with her as a SW. Hospital notes per outpatient treating psychiatrist, evaluated need for returning to inpatient setting from skilled nursing facility. Mental health is decompensating, endorsing suicidal ideations and need for more intensive acute care then outpatient setting for further treatment and stabilization . 6/06/23: readmitted . 6/07/23: Noted distress related to ongoing financial investigation. 6/07/23: Note from SW E, Resident received mail from Citibank and kept personal copy. Shortly after receiving mail came to writer's office distressed. Nursing staff was notified of resident's distress and a prn had already been given 10-15 minutes prior to receiving the mail. 6/08/23: Resident request daughter become rep-payee .Resident stated I am committed here; I will not do shock therapy .Resident mood was a mix of anger and frustration . 6/10/23: Note from CNA, heard resident talking in room and it was getting louder .Resident heard saying Why can't I go to a different hospital; I don't want to be in this hospital. You can let me go to a different one, you are punishing me based on what pothers are saying about me. I don't want ECT, they will have to take me kicking and screaming and why can't I go to stores. Resident crying harder and becoming louder. Nurse notified to see if resident can have a prn. 6/10/23: Adjusting to unit, gotten very little sleep, increased anxiety related to ECT appointment and financial investigation . 6/11/23-6/13/23 No emotional distress 6/12/23: Note from SW E, writer and resident called Direct Express per detective request .Resident was able to cancel her card and obtain information for detective .Resident was upset but remained calm . 6/12/23: Quiet with return from ECT 6/16/23: Charge Nurse: Resident opened 2 letters from SSDI with writer, allowed writer to scan letters. Originals given to resident .Letter stated she will receive a check now sent to her in person so she can take it to the bank and cash it .No concerns over letter. 6/18/23: In room most of the day, resident keeping to self. Appears anxious, but stated she is feeling ok .Ate well and made needs known. On 06/19/23 at 9:45 am, Surveyor spoke with R1. R1 reported she noticed in late winter her monies were going fast. R1 believed it was due to payments made to the facility. The facility thought she was delusional and making up the missing monies. R1 further expressed she never received a May deposit from Social Security Disability Income (SSDI.) R1 called Direct Express, the card account where her SSDI is directly deposited, cancelled her card, and requested a new card. R1 called the social services office and spoke with Social Worker (SW) C as she did not have much money and it was not making sense to her. R1 indicated this is why she went to the hospital in May. R1 expressed she was in the hospital for 2 weeks. In the hospital they wouldn't talk to her about her monies and wouldn't let her check her accounts. R1 expressed she experienced constant sadness/hurting, would cry constantly, and was anxious and depressed about it. R1 was told her medications were not effective. The facility changed her medications and discussed ECT (electroconvulsive therapy) with her. R1 expressed tomorrow will be 3rd treatment of ECT. R1 reported she is feeling better, mostly because people are listening to me. R1 expressed the incident caused her to cry a lot. R1 further expressed she wants her money returned to account, and she wants to be able to manage her money like she always has. R1 indicated there is still money not accounted for and they say insurance will cover it. R1 expressed at one point she was not good at all about this, couple weeks ago, when went to admissions (hospital.) She was very angry, and this did not help. Further expressing she was yelling at staff that she never yelled at before. Surveyor noted R1 with visibly shaking hands and tone of voice when talking with Surveyor about incident of stolen money by SW C in the presence of head nurse/Registered Nurse (RN) D. Following the interview with R1, Surveyor spoke with RN D about R1's behavior. RN D expressed she had worked with R1 during her several stays at the facility. During the incident R1 was yelling at her; R1 had never done that before. On 6/19/23 at 10:10 am, Surveyor spoke NHA A and Director of Nursing (DON) B about the FRI and R1's report of misappropriation. NHA A explained R1's reports of misappropriation were reported to the Social Services office. There was informal communication between facility staff via email but nothing formal prior to the FRI reported to the State of Wisconsin on 6/01/23. This was the first reporting of the incident. The police were first contacted with the discovery on 6/01/23. This was not reported based on what SW C reported to Administration. The facility did not investigate further or contact the police. The facility should have reported to the State of Wisconsin and notified the police. On 6/20/23 at 3:40 pm, Surveyor again spoke with NHA A. NHA A expressed it was SW C's job to report the incident to NHA A so an investigation could be started, and police could be informed. He did not. It should have been investigated and reported and it was not. These failures created a situation of immediate jeopardy that began on 03/20/23. On 06/01/23, the facility identified the misappropriation and exploitation being done by Social Worker C and took steps to correct the deficient practice and ensure compliance at the time of the survey. Based on this determination, the IJ was removed on 06/06/23 and corrected on 06/06/23 when the facility implemented the following: 06/01/23: NHA A removed Social Worker from premises and turning in all work-related items. Marshfield Police Department notified. Department of Quality Assurance facility reported incident filed. 06/02/23: Collected staff witness statements. Adult Protective Services referral was made and Department of Safety and Professional Services Letter/email sent to representative payees requesting to send statements of checks sent to facility from January to current to compare resident's records. Letter/email sent to representatives of new procedure to send resident funds. Replaced mailbox at front to a locked mail slot. 06/05/23: Mail policy updated. 06/06/23 Email to staff of education of Misappropriation of Funds Email education to staff of new mail procedure. Guardians and representative payees called and updated on events. Impacted residents care planned for trauma informed care. Offered counseling to impacted residents. Monitored impacted residents for psychosocial distress. On 6/06/23, when the facility provided all staff education on the policy titled Exploitation of residents, Misappropriation, Suspicion of Crimes dated 10/20/22. The policy includes procedures for reporting to the State of Wisconsin and local authorities. 06/07/23: SW C was terminated from facility in writing. 06/08/23: Policies updated of Check Cashing, Incoming Checks Updated residents on financial investigation at resident council. The 5-day investigation and report submitted to DQA. Mail log audits will be conducted monthly at the QAPI meeting and reviewed at the next quarterly in QA meeting. Financial audits will be conducted with a separate financial personal possession log for each resident. Will review monthly with each resident for three months, and then quarterly at care conferences thereafter if there are no issues identified, it will be filed in the resident chart, as well as a copy in the business office. Will review this process at the next three monthly QAPI meetings and again at our quarterly meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not thoroughly investigate a resident's report of misappropriation and/or exploitation. The facility's failure to thoroughly investigate the report of misappropriation allowed a facility Social Worker to continue to misappropriate and exploit other residents. The facility's failure to thoroughly investigate affected 1 of 1 residents (R1.) R1's repeated allegations of missing items and monies from her Direct Express debit card were not thoroughly investigated by the facility. Lack of facility investigation allowed a facility Social Worker (SW C) to continue to misappropriate resident funds. The misappropriation caused R1 distress and psychosocial harm of prolonged crying, increased anxiety and agitation, removal from activities, distress, disturbed sleep, and hospitalization due to suicidal ideation. The facility's failure to thoroughly investigate a resident report of misappropriation created a finding of immediate jeopardy that began on 3/20/23. Surveyor notified Nursing Home Administrator (NHA) A and Director of Nursing (DON) B of the immediate jeopardy on 6/21/23 at 3:42 pm. On 06/01/23, the facility discovered the misappropriation and exploitation being done by the Social Worker and took steps to correct the deficient practice and ensure compliance at the time of the survey. Based on this determination, the IJ was removed and corrected on 06/06/23. This is being cited as past noncompliance Findings Include: Surveyor reviewed the facility policy titled Exploitation of residents, Misappropriation Suspicion of Crimes dated 10/20/22 which states in part: ~Policy Statement: The facility staff will conduct an investigation of any alleged or suspected . exploitation of residents or misappropriation of property . The Administrator is responsible for oversight of abuse prohibition standard. Surveyor reviewed the Facility Reported Incident (FRI) submitted to the state of Wisconsin Department of Health Services on 06/01/23. This was the first reporting of SW C's misappropriation of resident funds. The facility identified 16 residents, including R1, who were victims of misappropriation and/or exploitation by SW C. Surveyor requested and reviewed the facility policy titled Abuse, Neglect, Exploitation of residents, Misappropriation, Injuries of Unknown Origin and Reporting of Crimes dated 10/20/22 which states in part: Identification: Staff will immediately report any suspicious event that may constitute .exploitation, misappropriation, occurrence of a crime. Investigation: ~The facility will conduct an internal investigation and report the results of the investigation to enforcement agency in accordance with state law including the states survey and certification agency within five working days of the incident occurring or according to state law. ~The facility will immediately begin a thorough investigation of any reported incident, collect information that corroborates or disproves the incident and document the findings for the incident. 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 facility will document the investigation and the reasons for conclusion. The information gathered will be given to the administration and grievance officer. ~Investigations will be prompt, comprehensive and responsive to the situations and contain founded conclusions. Investigations will include, but is not limited to the following: Notification of physician and family, Identification and removal of the alleged person or persons, type of alleged abuse, when and where the incident occurred, interview and or written statements from individuals with first-hand knowledge of the incident, follow up resolution, measures to prevent repeated incidents, all materials and documentation of the pertinent data to the authorities will be legally required . ~Actions taken during the investigation will based on outcomes of the investigation On 6/19/23 at 10:10 am, Surveyor spoke with NHA A and Director of Nursing (DON) B about the FRI and R1's report of misappropriation. NHA A explained R1's reports of misappropriation were reported to the Social Services office. There was informal communication between facility staff via email but nothing formal prior to the FRI reported to the State of Wisconsin on 6/01/23. At this time the facility had determined Social Worker (SW) C was misappropriating money from residents. This was the first reporting of the incident. The police were first contacted with the discovery on 6/01/23. There was no reporting based on what SW C reported to Administration. The facility did not contact the police. The facility should have reported to the State of Wisconsin and notified the police. R1's record shows she was committed to facility due to mental illness and probable harm to self or others with recent overact or patterns of recent acts on 1/04/23. R1 had previous stays at the facility that were voluntary admissions. R1 was admitted to the secured wing from the hospital admissions wing. R1's most recent quarterly Minimum Data Set (MDS) completed 4/12/23 notes she understands, is understood, and has a BIMS (Brief Interview for Mental Status) score of 15 indicating she is cognitively intact. R1 experiences hallucinations and delusions and has depressive mood indicators. R1's diagnosis includes schizo-affective disorder, bi-polar (primary type). R1's record shows she is her own decision maker and guardian of estate. R1 receives $714.00 each month for SSDI. R1 did not have an account for petty cash at the facility. Surveyor reviewed R1's Psych Consult information and noted the following: Behaviors monitored: 1. Physical: anxiety, sweating, pacing, bouncy knee 2. Verbal: Paranoid/delusional 3. Other: Internal Stimuli/hearing voices Documentation shows R1 had 39 behaviors in April. This is a significant increase from March, after R1 reported the missing money and items, and the highest monthly count since R1's admission. Surveyor review of R1's [NAME] County Human Services counseling notes: 3/21/23: reports crying almost daily, voices have not been bothering her as much, believes she is addicted to on-line shopping app, buying things from app. Almost daily .tearful and requested to end session . 4/04/23: believes father may be stealing things from her, hopeless, tearful, guarded, expressed a lot of anger . 4/18/23: identified anxiety, unsure if she can pay for her brace on her own .anxiety about not knowing how much money in bank account, she does not know how to check her money but concerned the app is stealing money from her for browsing . 5/23/23: discussed increased depression, more sick last 2 weeks, wants to go to different hospital as no one likes her here, does not feel safe, conspiring against her. Increased paranoia and agitation. Difficulty finishing thoughts. This is the first session she swore in front of writer. Getting CT next week for signs of dementia. 6/09/23: Reports relief of news of SW taking money. It means she is not crazy as she and everyone thought. Identified anger. Discussed hospitalization. Decreased meds, but not sure why, Feels less emotional. Wished she could start ECT now to see if she would benefit from it . 6/13/23: Had ECT and believes it is helping, Feels resentful towards staff regarding SW situation. Discussed how staff did not believe her and she was hospitalized , and she was correct. Surveyor reviewed R1's nurses note and noted the following: 1/29/23: Note from SW C, .the one thing on her mind appears to be when her monthly money will go down to $45.00 per month . 3/01/23: Note from SW C, resident request writer to hold on to her debit card. Writer assured resident the best idea would be to have it placed in the business office. Writer filled out envelope with her signature on it . 3/20/23: Note from CNA, Resident approaches staff and stated I was told to talk to you about a card I lost, it is a government funded card. I looked everywhere and can't find it Writer asked if she had it with her when she went shopping but resident could not remember. Asked if she wanted her to help look for it. Resident responded sure. Writer was unable to find the direct express card identified as green in color. Resident stated she will call and cancel card. Although resident reported a missing debit card there is no investigation for this allegation. 3/21/23: Note from SW C, writer reminded resident her card is kept safe in business office. Resident did not remember this but was relieved. 4/02/23: Note from SW C, continues to experience overall instability in mental health. Her mental health has improved since her admission but can be unpredictable sometimes on an hourly basis. Mental health symptoms continue to include delusional thoughts, paranoia and responding to internal stimuli. Resident out to eat at culvers ., given her debit card before she left. When she returned, she returned her card to be locked safely, reviewed notes and see resident concerns about how much money was left on her card balance. This writer theorizes resident feels she should have money because benefits come on the first, the first fell on weekend day and it is possible she did not receive the funds . 4/02/23: Note from RN, Resident made comments last evening regarding her debit card .reassured card is locked in office, and no one has access. Resident comment she was just panicking and accepted reassurance from staff 4/04/23: Note from SW C, resident continues to experience overall instability with her mental health, continues to experience depression, anger, voices that do interfere with daily routine and cause her distress. Writer has met with resident one on one past two days. Resident angry and made accusations directed at care staff Writer reminded resident she can trust writer .Resident did make a statement about possibly having a rep-payee to help her with her finances . 4/07/23: Note from SW E, to tobacco outlet to withdraw $100.00, resident request cards to be locked in business office. SW and nurse signed envelope confirming debit card placement 4/07/23: Debit card in Narc drawer for resident better access. (RN note). 4/12/23: 1:45 Note from RN, Resident came to med room yelling It's not funny, I only have $70.00 left in my account since last week Someone is stealing my money, walked away crying, refusing to listen to staff, repeating someone is stealing my money .SW to unit to speak with her. 4/12/23: 2:57, Note from SW C, continues to experience overall instability with mental health. Resident continues to experience depression and anger; voices interfere with daily routine causing distress .Had a very difficult with increased mental health symptoms today. Received a call from nursing staff very upset about money. I thought I was doing good with my money; I should have more. Crying during first part of meeting. Writer asked investigative questions about, and resident appears to be having some delusional thoughts . Resident believes dad using money and taking packages she orders . Reminded card is locked, and she is the only one with the pin. Resident states she is never going to get better. Asked if she wants to contact police and said No. I am just not thinking very clearly. There is no evidence the facility did an investigation when R1 stated someone was stealing her money on 4/12/23. 4/19/23: Note from CNA, Resident tearful about a phone call she made. SW made aware. 4/20/23: Note from CNA, left at this time for Walmart with Social Worker 4/20/23: Note from RN, Made accusations regarding her credit card. While talking with writer resident had a flat affect, aggressive tone, jumped from topic to topic, walking very slowly throughout shift, displayed paranoid thoughts. Talked with HN (Head Nurse/RN) and NHA (Nursing Home Administrator) about it. Although the facility shared an exchange of email regarding the situation there is no evidence a thorough investigation was done to rule out misappropriation. The emails state: 4/20/23: RN F: R1 came out of her room .had a small flat bag and asked where she could put it where it would be safe and no one could get to, the most safest untouchable spot where no average just anybody could get to it .R1 stated over the last two months a lot of her items have gone missing and her card was missing and it had over 2,000 missing from it and that was from the business department and still does not know how it happened .R1 stated she just got a new card and there is already money missing and she does not know how she is going to prove it . 4/20/23: NHA A: R1 is basically saying someone is using her debit card. With that said, can you please investigate in the morning? It should be easy to rule out by helping her check her balance .R1 seems extremely unwell . 4/21/23 SW C: We will investigate this. Unfortunately, R1 still is unwell. 4/21/23: SW E: We gave R1 a lock box this morning. She said SSDI told her they can see specific people that use her card. I asked her if she meant the store that the stolen purchases were coming from and she said no, they can see people on each transaction. She mentioned an [name] has used her card, but denied it was a resident Resident also mentioned she had misplaced her cream-colored small wallet that held her ID and insurance cards .Found wallet in the bottom of her purse . Nurses Notes continued: 4/21/23: Note from CNA, was heard this morning talking to a peer about how things are missing in her room. SW and CSA [Client Service Assistant] are notified about her concerns. There is no evidence of an investigation after R1 made the allegation of missing items on 4/21/23. 4/21/23: Note from SW C, This writer and CSA staff staffed resident case and recent accusations this morning. A cumulative review of all fact-based information confirms resident accusations of someone using her debit card ore unfounded. Resident mental health remains extremely unpredictable, and she continues to experience delusions, paranoid, voices and frequent mood swings. Received a new debit card today in a sealed envelope. Delivered personally with CSA witness. Reminded to put in lock box. No one has access to the debit card pin. Resident receiving numerous packages from online ordering. Also sent money in the mail to her family. Resident stated, I shop online impulsively when I am anxious. Resident interviewed and social services did not argue with her delusions .Made referral to MD to access the need for rep payee regarding continued concerns spending/financial accusations .IDT will look into evaluation for dementia . 4/21/23: Email from SW E to Physician: Resident is in need of a rep-payee. She is accusing people of stealing her money, but she is spending it. She is forgetting and we are worried she may have some memory impairments . 5/03/23: Note from SW E, resident expressed just put me in the hospital, I don't want to be here anymore, they think I am going to hurt people, denied having these thoughts. 5/04/23: Note from CNA, Appears to be in sad mood today .Declined playing cards . 5/05/23: (RN D, R1, SW C, MD) tearful/depressed, crying often, agitation decreased. Resident concerns with complaints of depression/anxiety. Medication changes. 5/08/23: Note from SW E, resident would like to cash a large check from her brother. Declined cashing at Walmart and voiced she would like to open a bank account. Resident does not have a bank. Resident returned NHC lock box stating she does not need it. 5/10/23: tearful, declined outing, too much pain 5/11/23: Due for assistance renewal, sought CSA help. 5/11/23: Note from CNA, Very frustrated and sensitive upon waking .even coming to the point of bawling when she couldn't get her leg brace on. 5/12/23: (Charge Nurse) Resident came to write stating she needed to go to the bank today urgently as her card has been compromised .Writer stated she needed to talk with SW and CSA about it. Writer spoke with SW/CSA and they informed resident to call her bank to see if she can put a hold/freeze on it. Writer spoke with resident who changed story of card compromised to she needed to money in the bank .so she does not become compromised .Resident upset . 5/14/23: resident reports having nightmare 5/16/23: Note from SW E, Appeared in CSA office and was visibly crying and upset, expressed she would rather be in jail then stay at [NAME], felt staff are trying to entrap her. Adamant about not staying at [NAME] as she does not feel safe here .Paranoia and behaviors increasing .Nursing made aware of resident comments and agitated mood . 5/21/23: resident reports not sleeping, wants to talk with psychiatrist about it . 5/22/23: Note from SW E, Appeared more emotional and tearful today. Reported depression worse .believes apartment ended lease due to non-payment . 5/23/23: Note from SW E, resident experienced an acute change in mental status today that prompted a call to [NAME] County Crisis and subsequent move to more restrictive environment on the [NAME] admissions unit (hospital). Resident demanded to speak to SS (Social Services). Resident appeared upset and crying .Thought process was difficult to follow, became very angry and verbally aggressive .Demanded to leave .Yelled while continuously crying .repeated anger over medications that were discontinued .unable to process and evaluate information .Concerns of self-harm .Crisis team contacted .Today was the most unstable that this writer has witnessed resident mental health while working with her as a SW. Hospital notes per outpatient treating psychiatrist, evaluated need for returning to inpatient setting from skilled nursing facility. Mental health is decompensating, endorsing suicidal ideations and need for more intensive acute care then outpatient setting for further treatment and stabilization . 6/06/23: readmitted . 6/07/23: Noted distress related to ongoing financial investigation. 6/07/23: Note from SW E, Resident received mail from Citibank and kept personal copy. Shortly after receiving mail came to writers' office distressed. Nursing staff was notified of resident's distress and a prn had already been given 10-15 minutes prior to receiving the mail. 6/08/23: Resident request daughter become rep-payee .Resident stated I am committed here; I will not do shock therapy .Resident mood was a mix of anger and frustration . 6/10/23: Note from CNA, heard resident talking in room and it was getting louder .Resident heard saying Why can't I go to a different hospital; I don't want to be in this hospital. You can let me go to a different one, you are punishing me based on what others are saying about me. I don't want ECT, they will have to take me kicking and screaming and why can't I go to stores. Resident crying harder and becoming louder. Nurse notified to see if resident can have a prn. 6/10/23: Adjusting to unit, gotten very little sleep, increased anxiety related to ECT appointment and financial investigation . 6/11/23-6/13/23 No emotional distress 6/12/23: Note from SW E, writer and resident called Direct Express per detective request .Resident was able to cancel her card and obtain information for detective .Resident was upset but remained calm . 6/12/23: Quiet with return from ECT 6/16/23: Charge Nurse: Resident opened 2 letters from SSDI with writer, allowed writer to scan letters. Originals given to resident .Letter stated she will receive a check now sent to her in person so she can take it to the bank and cash it .No concerns over letter. 6/18/23: In room most of the day, resident keeping to self. Appears anxious, but stated she is feeling ok .Ate well and made needs known. On 06/19/23 at 9:45 am, Surveyor spoke with R1. R1 reported she noticed in late winter her monies were going fast. R1 believed it was due to payments made to the facility. The facility thought she was delusional and making up the missing monies. R1 further expressed she never received a May deposit from Social Security Disability Income (SSDI.) R1 called Direct Express the card account where her SSDI was directly deposited, cancelled her card, and requested a new card. R1 called the social services office and spoke with Social Worker (SW) C as she did not have much money and it was not making sense to her. R1 indicated this why she went to the hospital in May. R1 expressed she was in the hospital for 2 weeks. In the hospital they wouldn't talk to her about her monies and wouldn't let her check her accounts. R1 expressed she experienced constant sadness/hurting, would cry constantly, and was anxious and depressed about it. R1 was told her medications were not effective. The facility changed her medications and discussed ECT (electroconvulsive therapy) with her. R1 expressed tomorrow will be 3rd treatment of ECT. R1 reported she is feeling better, mostly because people are listening to me. R1 expressed the incident caused her to cry a lot. R1 further expressed she wants her money returned to account, and she wants to be able to manage her money like she always has. R1 indicated there is still money not accounted for and they say insurance will cover it. R1 expressed at one point she was not good at all about this, couple weeks ago, when went to admissions (hospital.) She was very angry, and this did not help. Further expressing she was yelling at staff that she never yelled at before. Surveyor noted R1 with visibly shaking hands and tone of voice when talking with Surveyor about incident of stolen money by SW C, in the presence of head nurse/Registered Nurse (RN) D. Following the interview with R1, Surveyor spoke with RN D about R1's behavior. RN D expressed she had worked with R1 during her several stays at the facility. During the incident R1 was yelling at her. R1 had never done that before. On 6/19/23 at 10:10 am, Surveyor spoke with NHA A and Director of Nursing (DON) B about the FRI and R1's report of misappropriation. NHA A explained R1's reports of misappropriation were reported to the Social Services office. There was informal communication between facility staff via email but nothing formal for an investigation was completed prior to the FRI on 6/1/23. This was not investigated based on what SW C reported to Administration. The facility did not investigate further. The facility should have investigated this allegation of misappropriation. On 6/20/23 at 3:40 pm, Surveyor again spoke with NHA A. NHA A expressed it was SW C's job to report the incident to NHA A so an investigation could be started, and police could be informed. He did not. It should have been investigated and reported and it was not. These failures created a situation of immediate jeopardy that began on 03/20/23. On 06/01/23, the facility identified the misappropriation and exploitation being done by Social Worker C and took steps to correct the deficient practice and ensure compliance at the time of the survey. Based on this determination, the IJ was removed on 06/06/23 and corrected on 06/06/23 when the facility implemented the following: 06/01/23: NHA A removed Social Worker C from the premises and had him turn in all work-related items. Marshfield Police Department notified. Department of Quality Assurance facility reported incident filed. 06/02/23: Collected staff witness statements. Adult Protective Services referral was made and referral made to the WI Department of Safety and Professional Services Letter/email sent to representative payees requesting to send resident's statements of checks sent to facility from January to current to compare resident records. Letter/email sent to representatives of new procedure to send resident funds. Replaced mailbox at front to a locked mail slot. 06/05/23: Mail policy updated. 06/06/23 Email to staff of education of Misappropriation of Funds Email education to staff of new mail procedure. Guardians and representative payees called and updated on events. Impacted residents care planned for trauma informed care. Offered counseling to impacted residents. Monitored impacted residents for psychosocial distress. On 6/06/23, when the facility provided all staff education on the policy titled Exploitation of residents, Misappropriation, Suspicion of Crimes dated 10/20/22. The policy includes procedures for reporting to the State of Wisconsin and local authorities. 06/07/23: SW C was terminated from facility in writing. 06/08/23: Policies updated of Check Cashing, Incoming Checks Updated residents on financial investigation at resident council. The 5-day investigation and report submitted to DQA. Mail log audits will be conducted monthly at the QAPI meeting and reviewed at the next quarterly in QA meeting. Financial audits will be conducted with a separate financial personal possession log for each resident. Will review monthly with each resident for three months, and then quarterly at care conferences thereafter if there are no issues identified, it will be filed in the resident chart, as well as a copy in the business office. Will review this process at the next three monthly QAPI meetings and again at our quarterly meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure residents were free of misappropriation and/or exploitation. The facility's failures of not investigating and not reporting to the State of Wisconsin or local authorities when alleged misappropriation was first reported by R1 on 3/20/23 allowed a facility Social Worker to continue to misappropriate resident funds and exploit resident information for personal gain. This affected 16 of 31 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, and R16) and caused R1 psychosocial harm of prolonged crying, increased anxiety and agitation, removal from activities, distress, disturbed sleep, and hospitalization due to suicidal ideation. R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, and R16 had misappropriation of funds with personal checks cashed, funds diverted, forged checks, and missing identification cards, and/or exploitation of personal information, which was obtained to create email accounts, g-mail accounts, apply for loans/credit cards, ATM withdrawals, cash application transfer of funds and homestead act claims for funds by the facility Social Worker (SW) C. The facility's failure to respond to a resident's report of misappropriation created a finding of immediate jeopardy that began on 3/20/23. Surveyor notified Nursing Home Administrator (NHA) A and Director of Nursing (DON) B of the immediate jeopardy on 6/21/23 at 3:42 pm. On 06/01/23, the facility discovered the misappropriation and exploitation being done by the Social Worker and took steps to correct the deficient practice and ensure compliance at the time of the survey. Based on this determination, the IJ was removed and corrected on 06/06/23. This is being cited as past noncompliance. Findings Include: Surveyor reviewed the Facility Reported Incident (FRI) submitted to the Wisconsin Department of Health Services. The facility identified residents had misappropriation of funds with personal checks cashed, funds diverted, forged checks, and missing identification cards; as well as exploitation of personal resident information to obtain email accounts, loans, credit cards, ATM withdrawals, cash app transfer of funds, and homestead act claims for funds. The facility identified the concern on 6/01/23 when R5's representative payee was contacted about a check that was requested weeks earlier. The facility investigation identified 16 of 31 residents were affected. The facility determined Social Worker (SW) C was the staff member misappropriating the funds. The facility policy titled Abuse, Neglect, Exploitation of residents, Misappropriation, Injuries of Unknown Origin and Reporting of Crimes dated 10/20/22 in part states: Policy Statement: .The Administrator is responsible for oversight of abuse prohibition standard. Purpose: To prohibit and prevent abuse, neglect, exploitation of residents or misappropriation of property and injuries of unknown origin. Definitions: Exploitation is defined as unfair treatment or use of a resident or the taking advantage of a resident for personal gain . Misappropriation of resident property, including identifying information, means deliberate or intentional taking, carrying away, using, transferring, concealing or retaining possession, misplacement, exploitation, or wrongful, temporary or permanent use of resident's belongings, movable property or money or of a negotiable security without the residents consent .Additionally, Wisconsin State Regs, DHS 13 further defines misappropriation as obtaining property of a resident by intentionally deceiving the resident with false representation which is known to be false, made with intent to defraud, and which does defraud the person to whom it is made. False Representation includes a promise made with the intent not to perform it if promise is part of a false of fraudulent scheme. Protection: All residents will be protected from harm . Example 1: R1's record shows she was committed to facility due to mental illness and probable harm to self or others with recent overact or patterns of recent acts on 1/04/23. R1 had previous stays at the facility that were voluntary admissions. R1 was admitted to the secured wing from the hospital admissions wing. R1's most recent quarterly Minimum Data Set (MDS) completed 4/12/23 notes she understands, is understood, and has a BIMS (Brief Interview of Mental Status) of 15 indicating she is cognitively intact. R1 experiences hallucinations and delusions and has depressive mood indicators. R1's diagnosis includes schizo-affective disorder, bi-polar (primary type.) R1's record shows she is her own decision maker and guardian of estate. R1 receives $714.00 each month for SSDI. R1 did not have an account for petty cash at the facility. Surveyor reviewed R1's Psych Consult information and noted the following: Behaviors monitored: 1. Physical: anxiety, sweating, pacing, bouncy knee 2. Verbal: Paranoid/delusional 3. Other: Internal Stimuli/hearing voices Documentation shows R1 had 39 behaviors in April. This is a significant increase from March, after R1 reported the missing money and items, and highest since R1's admission. Surveyor review of R1's [NAME] County Human Services counseling notes: 3/07/23: feeling more comfortable on pathways . 3/21/23: reports crying almost daily, voices have not been bothering her as much, believes she is addicted to on-line shopping app, buying things from app. Almost daily .tearful and requested to end session . 4/04/23: believes father may be stealing things from her, hopeless, tearful, guarded, expressed a lot of anger . 4/18/23: identified anxiety, unsure if she can pay for her brace on her own .anxiety about not knowing how much money in bank account, she does not know how to check her money but concerned the app is stealing money from her for browsing . 5/23/23: discussed increased depression, more sick last 2 weeks, wants to go to different hospital as no one likes her here, does not feel safe, conspiring against her. Increased paranoia and agitation. Difficulty finishing thoughts. This is the first session she swore in front of writer. Getting CT next week for signs of dementia. 6/09/23: Reports relief of news of SW taking money. It means she is not crazy as she and everyone thought. Identified anger. Discussed hospitalization. Decreased meds, but not sure why, Feels less emotional. Wished she could start ECT now to see if she would benefit from it . 6/13/23: Had ECT and believes it is helping, Feels resentful towards staff regarding SW situation. Discussed how staff did not believe her and she was hospitalized , and she was correct. Surveyor reviewed R1's nurses note and noted the following: 1/29/23: Note from SW C .the one thing on her mind appears to be when her monthly money will go down to $45.00 per month . 3/01/23: Note from SW C, resident request writer to hold on to her debit card. Writer assured resident the best idea would be to have it placed in the business office. Writer filled out envelope with her signature on it . 3/20/23: CNA note, Resident approaches staff and stated I was told to talk to you about a card I lost, it is a government funded card. I looked everywhere and can't find it Writer asked if she had it with her when she went shopping but resident could not remember. Asked if she wanted her to help look for it. Resident responded sure. Writer was unable to find the direct express card identified as green in color. Resident stated she will call and cancel card. Although resident identified a missing debit card no investigation was initiated or conducted or that police or state agency were notified to prevent misappropriation and exploitation from occurring to residents. 3/21/23: Note from SW C, writer reminded resident her card is kept safe in business office. Resident did not remember this but was relieved. 4/02/23: Note from SW C, continues to experience overall instability in mental health. Her mental health has improved since her admission but can be unpredictable sometimes on an hourly basis. Mental health symptoms continue to include delusional thoughts, paranoia and responding to internal stimuli. Resident out to eat at culvers ., given her debit card before she left. When she returned, she returned her card to be locked safely, reviewed notes, and see resident concerns about how much money was left on her card balance. This writer theorizes resident feels she should have money because benefits come on the first, the first fell on weekend day and it is possible she did not receive the funds . 4/02/23: Note from RN, Resident made comments last evening regarding her debit card .reassured card is locked in office, and no one has access. Resident comment she was just panicking and accepted reassurance from staff Again, there is no evidence of investigation regarding R1's debit card or verification R1's debit card was located in the business office to ensure that misappropriation or exploitation was not occurring. 4/04/23: Note from SW C, resident continues to experience overall instability with her mental health, continues to experience depression, anger, voices that do interfere with daily routine and cause her distress. Writer has met with resident one on one past two days. Resident angry and made accusations directed at care staff Writer reminded resident she can trust writer .Resident did make a statement about possibly having a rep-payee to help her with her finances . 4/07/23: Note from SW E, to tobacco outlet to withdraw $100.00, resident request cards to be locked in business office. SW and nurse signed envelope confirming debit card placement . 4/07/23: Note from RN, Debit card in Narc drawer for resident better access. 4/12/23: 1:45 Note from RN, Resident came to med room yelling It's not funny, I only have $70.00 left in my account since last week Someone is stealing my money, walked away crying, refusing to listen to staff, repeating someone is stealing my money .SW to unit to speak with her. 4/12/23: 2:57 Note from SW C, continues to experience overall instability with mental health. Resident continues to experience depression and anger; voices interfere with daily routine causing distress .Had a very difficult with increased mental health symptoms today. Received a call from nursing staff very upset about money. I thought I was doing good with my money; I should have more. Crying during first part of meeting. Writer asked investigative questions about, and resident appears to be having some delusional thoughts . Resident believes dad using money and taking packages she orders . Reminded card is locked, and she is the only one with the pin. Resident states she is never going to get better. Asked if she wants to contact police and said No. I am just not thinking very clearly. There is no evidence the facility conducted an investigation into R1's allegation of someone stealing her money or notified State of Wisconsin or police to ensure misappropriation was not occurring for R1 or other residents. 4/19/23: Note from CNA, Resident tearful about a phone call she made. SW made aware. 4/20/23: Note from CNA, left at this time for Walmart with SW. 4/20/23: Note from RN, Made accusations regarding her credit card. While talking with writer resident had a flat affect, aggressive tone, jumped from topic to topic, walking very slowly throughout shift, displayed paranoid thoughts. Talked with HN (Head Nurse/RN) and NHA (Nursing Home Administrator) about it. Although the facility shared an exchange of email regarding the situation there is no evidence a thorough investigation was conducted or the State of Wisconsin/police were notified when R1 made accusations regarding her credit card. The inaction allowed misappropriation to continue for the residents. The email states: 4/20/23: RN F: R1 came out of her room .had a small flat bag and asked where she could put it where it would be safe and no one could get to, the most safest untouchable spot where no average just anybody could get to it .R1 stated over the last two months a lot of her items have gone missing and her card was missing and it had over 2,000 missing from it and that was from the business department and still does not know how it happened .R1 stated she just got a new card and there is already money missing and she does not know how she is going to prove it . 4/20/23: NHA A: R1 is basically saying someone is using her debit card. With that said, can you please investigate in the morning? It should be easy to rule out by helping her check her balance .R1 seems extremely unwell . 4/21/23 SW C: We will investigate this. Unfortunately, R1 still is unwell. 4/21/23: SW E: We gave R1 a lock box this morning. She said SSDI told her they can see specific people that use her card. I asked her if she meant the store that the stolen purchases were coming from and she said no, they can see people on each transaction. She mentioned an [name] has used her card, but denied it was a resident Resident also mentioned she had misplaced her cream-colored small wallet that held her ID and insurance cards .Found wallet in the bottom of her purse . Nurses Notes continued: 4/21/23: Note from CNA, was heard this morning talking to a peer about how things are missing in her room. SW and CSA [Client Service Assistant] are notified about her concerns. There is no evidence of an investigation into what items R1 alleges are missing. 4/21/23: Note from SW C: This writer and CSA staff staffed resident case and recent accusations this morning. A cumulative review of all fact-based information confirms resident accusations of someone using her debit card are unfounded. Resident mental health remains extremely unpredictable, and she continues to experience delusions, paranoid, voices, and frequent mood swings. Received a new debit card today in a sealed envelope. Delivered personally with CSA witness. Reminded to put in lock box. No one has access to the debit card pin. Resident receiving numerous packages from online ordering. Also sent money in the mail to her family. Resident stated, I shop online impulsively when I am anxious. Resident interviewed and social services did not argue with her delusions .Made referral to MD to access the need for rep payee regarding continued concerns spending/financial accusations .IDT will look into evaluation for dementia . 4/21/23: Email from SW E to Physician: Resident is in need of a rep-payee. She is accusing people of stealing her money, but she is spending it. She is forgetting and we are worried she may have some memory impairments . 5/03/23: Note from SW E: resident expressed just put me in the hospital, I don't want to be here anymore, they think I am going to hurt people, denied having these thoughts. 5/04/23: Note from CNA, Appears to be in sad mood today .Declined playing cards . 5/05/23: (RN D, R1, SW C, MD) tearful/depressed, crying often, agitation decreased. Resident concerns with complaints of depression/anxiety. Medication changes. 5/08/23: Note from SW E, resident would like to cash a large check from her brother. Declined cashing at Walmart and voiced she would like to open a bank account. Resident does not have a bank. Resident returned NHC lock box stating she does not need it. 5/10/23: tearful, declined outing, too much pain 5/11/23: Due for assistance renewal, sought CSA help. 5/11/23: Note from CNA, Very frustrated and sensitive upon waking .even coming to the point of bawling when she couldn't get her leg brace on . 5/12/23: Note from Charge Nurse, Resident came to writer stating she needed to go to the bank today urgently as her card has been compromised .Writer stated she needed to talk with SW and CSA about it. Writer spoke with SW/CSA, and they informed resident to call her bank to see if she can put a hold/freeze on it. Writer spoke with resident who changed story of card compromised to she needed to put money in the bank .so she does not become compromised .Resident upset . 5/14/23: resident reports having nightmare 5/16/23: Note from SW E, Appeared in CSA office and was visibly crying and upset, expressed she would rather be in jail then stay at [NAME], felt staff are trying to entrap her. Adamant about not staying at [NAME] as she does not feel safe here .Paranoia and behaviors increasing .Nursing made aware of resident comments and agitated mood . 5/21/23: resident reports not sleeping, wants to talk with psychiatrist about it . 5/22/23: Note from SW E, Appeared more emotional and tearful today. Reported depression worse .believes apartment ended lease due to non-payment . 5/23/23: Note from SW E, resident experienced an acute change in mental status today that prompted a call to [NAME] County Crisis and subsequent move to more restrictive environment on the [NAME] admissions unit (hospital.) Resident demanded to speak to SS (Social Services.) Resident appeared upset and crying .Thought process was difficult to follow, became very angry and verbally aggressive .Demanded to leave .Yelled while continuously crying .repeated anger over medications that were discontinued .unable to process and evaluate information .Concerns of self-harm .Crisis team contacted .Today was the most unstable that this writer has witnessed resident mental health while working with her as a SW. Hospital notes per outpatient treating psychiatrist, evaluated need for returning to inpatient setting from skilled nursing facility. Mental health is decompensating, endorsing suicidal ideations and need for more intensive acute care then outpatient setting for further treatment and stabilization . 6/06/23: readmitted . 6/07/23: Noted distress related to ongoing financial investigation. 6/07/23: Note from SW E, Resident received mail from Citibank and kept personal copy. Shortly after receiving mail came to writer's office distressed. Nursing staff was notified of resident's distress and a prn had already been given 10-15 minutes prior to receiving the mail. 6/08/23: Resident request daughter become rep-payee .Resident stated I am committed here; I will not do shock therapy .Resident mood was a mix of anger and frustration . 6/10/23 Note from CNA, heard resident talking in room and it was getting louder .Resident heard saying Why can't I go to a different hospital; I don't want to be in this hospital. You can let me go to a different one, you are punishing me based on what others are saying about me. I don't want ECT, they will have to take me kicking and screaming and why can't I go to stores. Resident crying harder and becoming louder. Nurse notified to see if resident can have a prn. 6/10/23: Adjusting to unit, gotten very little sleep, increased anxiety related to ECT appointment and financial investigation . 6/11/23-6/13/23 No emotional distress 6/12/23: Note from SW E, writer and resident called Direct Express per detective request .Resident was able to cancel her card and obtain information for detective .Resident was upset but remained calm . 6/12/23: Quiet with return from ECT 6/16/23: Charge Nurse: Resident opened 2 letters from SSDI with writer, allowed writer to scan letters. Originals given to resident .Letter stated she will receive a check now sent to her in person so she can take it to the bank and cash it .No concerns over letter. 6/18/23: In room most of the day, resident keeping to self. Appears anxious, but stated she is feeling ok .Ate well and made needs known. On 6/19/23 at 9:45 am, Surveyor spoke with R1. R1 reported she noticed in late winter her monies were going fast. R1 believed it was due to payments made to the facility. The facility thought she was delusional and making up the missing monies. R1 further expressed she never received a May deposit from Social Security Disability Income (SSDI.) R1 called Direct Express card account where her SSDI was directly deposited, cancelled her card, and requested a new card. R1 called social services office and spoke with Social Worker (SW) C as she did not have much money and it was not making sense to her. R1 indicated this is why she went to the hospital in May. R1 expressed she was in the hospital for 2 weeks. In the hospital they wouldn't talk to her about it and wouldn't let her check her accounts. R1 expressed she experienced constant sadness/hurting, would cry constantly and was anxious and depressed about it. R1 was told her medications were not effective. The facility changed her medications and discussed ECT (electroconvulsive therapy) with her. R1 expressed tomorrow will be her 3rd treatment of ECT. R1 reported she is feeling better, mostly because people are listening to me. R1 expressed the incident caused her to cry a lot. R1 further expressed she wants her money returned to account, and she wants to be able to manage her money like she always has. R1 indicated there is still money not accounted for and they say insurance will cover it. R1 expressed she was not good at all, at one point about this, couple weeks ago, when went to admissions (hospital.) She was very angry, and this did not help. Further expressing she was yelling at staff that she never yelled at before. Surveyor noted R1 with visibly shaking hands and tone of voice when talking with Surveyor about incident in the presence of head nurse/Registered Nurse (RN) D. Following the interview with R1, Surveyor spoke with RN D about R1's behavior. RN D expressed she had worked with R1 during her several stays at the facility. During the incident R1 was yelling at her. R1 had never done that before. Surveyor reviewed the facility's investigation. The investigation showed R1 had an email account created in her name, debit/bank cards missing, homestead credit applied for, mail diverted, cash apps opened in her name, credit cards opened in her name, and her government funded Direct Express affected. Example 2: R2 was admitted to the facility 9/19/22 and discharged from the facility on 6/12/23. R2's most recent quarterly MDS completed 3/28/23 notes she understands, is understood, and is cognitively intact. R2 has no depressive mood indicators. She experiences hallucinations and delusions. Her diagnoses include Parkinson's disease and psychotic disorder. R2 nurse's notes show upon discharge: 6/12/23: R2 updated on TracFone and new phone number. Did not appear to have any emotional distress regarding the financial investigation. Facility's investigation shows R2 was impacted by SW C's misappropriation/exploitation by an email account being created in her name, credit card and loan applications, and a Venmo account created in her name. Example 3: R3 was admitted to the facility 7/07/23. R3's most recent quarterly MDS completed 5/02/23 notes he understands, is understood, and is cognitively intact. R3 has no depressive mood indicators. He experiences hallucinations and delusions. His diagnosis includes schizophrenia. On 6/19/23 at 9:30 am, Surveyor spoke with R3 regarding his impact from SW C's misappropriation. R3 indicated he had a check cashed by SW C and he did not receive the money. R3 expressed he is doing okay and has been offered meetings/counseling regarding the situation, which he has declined. Facility's investigation shows R3 was impacted by SW C's misappropriation/exploitation by an email account being created in his name and a forged check in the amount of $500.00. Example 4: R4 was admitted to the facility 12/14/22. R4's most recent quarterly MDS completed 4/29/23 notes she understands, is understood, and is cognitively intact. R4 has no depressive mood indicators. She experiences delusions. Her diagnosis includes seizure disorder and schizophrenia. R4's nurses notes from 6/01/23 to present show distress from financial investigation. On 6/19/23 at 9:35 am, Surveyor spoke with R4 regarding her impact from SW C's misappropriation. R4 indicated she had $200.00 in cash taken and $200.00 from her savings. R4 expressed the situation is a bummer but she is fine. She was offered counseling/meetings to express her feelings/share information. R4 further expressed she believes the facility is doing what they can. Facility's investigation shows R4 was impacted by SW C's misappropriation/exploitation by an ATM/debit card missing, personal mail diverted, cash, and a family members Social Security. Example 5: R5 was admitted to the facility 3/24/23 and discharged on 6/13/23. R5's most recent admission MDS completed 3/30/23 notes she understands, is understood, and is cognitively intact. R5 has depressive mood indicators. She experiences no delusions or hallucinations. Her diagnoses include anxiety, manic depression, and psychotic disorder. R5's nurses notes from 6/01/23 to discharge show distress from financial investigation. 6/13/23 note shows R5 was given $200.00 cash from the facility liability insurance due to missing check. Facility's investigation shows R5 was impacted by SW C's misappropriation/exploitation by a forged check, email created in her name, homestead credit applied for in her name, a loan applied for in her name, and a cash app created in her name. Example 6: Facility's investigation shows R6 was impacted by SW C's misappropriation/exploitation by the following: $300 of her cash kept in lock box in SW C's office, had cash App account opened, received credit card statement in mail on Monday, June 5 from Capital One. R6 and guardian state she does not have a credit card. SW C's computer activity appears to show he applied for the card in her name, created Gmail account in her name, applied for Homestead credit on IRS, missing ID and wallet, [NAME] Fargo Personal Loan-owes around $3k and life insurance policy cashed out. Example 7: Per the facility's investigation, R7 was impacted by SW C's misappropriation/exploitation by the following: personal mail was diverted and R7's social security information was found in SW C's office. Example 8: Per the facility's investigation, R8 was impacted by SW C's misappropriation/exploitation by the following: $700.00 in cash found in lock box hidden in office and g-mail account created in his name. Example 9: Per the facility's investigation, R9 was impacted by SW C's misappropriation/exploitation by the following: Check signed over to SW C which he cashed at bank. Check in the amount of $300.00. Example 10: Per the facility's investigation, R10 was impacted by SW C's misappropriation/exploitation by the following: G-mail account created in resident name and loan application in R10's name. Example 11: Per the facility's investigation, R11 was impacted by SW C's misappropriation/exploitation by the following: G-mail account opened in his name. Example 12: Per the facility's investigation, R12 was impacted by SW C's misappropriation/exploitation by the following: G-mail account created in resident name. Example 13: Per the facility's investigation, R13 was impacted by SW C's misappropriation/exploitation by the following: G-mail account created in resident name and chime card (a secured card designed for people who are trying to build credit.) Example 14: Per the facility's investigation, R14 was impacted by SW C's misappropriation/exploitation by the following: E-mail account created in resident name. Example 15: Per the facility's investigation, R15 was impacted by SW C's misappropriation/exploitation by the following: E-mail account created in resident name and filed homestead tax credit in her name. Example 16: Per the facility's investigation, R16 was impacted by SW C's misappropriation/exploitation by the following: E-mail account created in resident name. On 6/19/23 at 8:30 AM, Surveyor spoke with Head Nurse/RN D and DON B about the facility investigation into SW's misappropriation and exploitation of the impacted residents. DON B expressed there has been no arrest of SW C at this point and there is an ongoing criminal investigation. At this time the total amount of monies involved for each resident is not completely known due to the criminal investigation. The facility discovered the misappropriation on 6/01/23 when R5's representative payee was contacted about a check. The check was traced to the bank where it was cashed. The signature on the check did not match R5's signature. The facility then identified R15, R6, R1, R5, and R3 had loans and credit cards applied for and social security funds affected. All 5 residents had no guardian of estate. The facility then discovered residents were paying other residents via cash apps through email or g-mail accounts that were created by SW C. In addition, monies were being taken out at ATMs and credit unions. SW C started getting resident mail which was not in turn being delivered to residents. The police were called immediately, and State of Wisconsin was informed on 6/01/23 when the misappropriation was discovered. SW C was noted to be acting uncommon, running to his office and ransacking it. SW C was suspended at that point and his office was checked. A bank statement and $700.00 cash were found in his office. Further investigation found R3 and R9 had signed over checks to SW C. Information Technology (IT) did an initial computer search of SW C's computer and tracked from January to present SW C had created 8 resident fake g-mail accounts and applied for credit cards in numerous resident names. SW C had downloaded an application which showed when mail is being delivered to the facility, so he knew what mail was coming in to divert it. The facility updated several of their policies including their mail process. Facility staff were educated on the policy changes as well as the abuse policy (6/06/23.) Residents' care plans were developed, and nursing assessed each resident for distress related to the situation daily. Residents were also offered counseling and meetings to discuss their feelings about the situation. Adult Protective Services was contacted and is working with guardians to do credit checks. On 6/19/23 at 10:10 am, Surveyor spoke to NHA A and Director of Nursing (DON) B about the FRI and R1's report of misappropriation. NHA A explained R1's reports of misappropriation were reported to the Social Services office. There was informal communication between facility staff via email but nothing formal prior to the FRI reported to the State of Wisconsin on 6/01/23. There was no formal investigation based on what SW C reported to Administration. The facility did not investigate further or contact the police. The facility should have investigated further, reported to the State of Wisconsin, and notified the police. The failure to do so allowed misappropriation to continue for 16 residents. On 6/20/23 at 3:40 pm, Surveyor again spoke with NHA A about R1's safekeeping of her debit card and the facility obligation to investigate R1's allegations. NHA A expressed R1 is her own person and guardian of estate. R1's debit card was placed in the business office per resident request on 3/21/23; it had previously been in resident possession. At one point the Activity Director went to the business office to obtain card for an outing, and it was not there. SW C had it in his desk. NHA A indicated the nurse updated SW C with R1's reports. Further expressing it was his job to report it to NHA A so an investigation could be started, and police could be informed; and he did not. Should have been investigated and reported and it was not. There was facility exchange of email about the situation on 4/21/23 but no formal investigation was initiated based [TRUNCATED]