Failure to Honor Resident Financial Rights and Guardian Authority
Summary
The deficiency involves the facility’s failure to honor a resident’s right to manage his own financial affairs through his court‑appointed guardian and responsible party (RP). The resident was an adult male with Down syndrome, severe intellectual disabilities, speech disturbances, and documented memory problems, who had been determined incapacitated and had a guardian of the person and estate per Letters of Guardianship from a Texas probate court. His face sheet and admission packet identified an RP and guardian, and the RP had signed the admission documents, including the section authorizing the facility to hold, safeguard, and manage personal funds. The resident’s MDS and care plan documented impaired cognitive function and developmental delay, with interventions to monitor changes in decision‑making ability and mental status. Despite this, the Regional Manager completed and signed Social Security form SSA‑787 to change management of the resident’s benefits to the facility, thereby filing for the facility to become the resident’s representative payee without consulting or obtaining consent from the court‑appointed guardian. In a telephone interview, the Regional Manager stated she filed for the facility to become representative payee by mistake, did not know the resident had a guardian, and acted after seeing paperwork on the DON’s table. The facility’s own policy on resident representatives stated that when a resident is determined incompetent by a court, the court‑appointed representative exercises the resident’s rights to the extent judged necessary by the court, but this was not followed in this case. The facility also failed to ensure proper authorization for the resident’s Medicaid application for 2025. The Medicaid application was signed and dated by the Business Office Manager, who later reported that the RP, while hospitalized, verbally asked her to complete and sign the form because it was about to expire. The Business Office Manager stated she copied the prior year’s signature page and changed the date, acknowledging she had no written documentation or witness to support the verbal consent and that there was no policy allowing facility staff to sign the RP’s signature. Interviews with the DON, Business Office Manager, and Interim Administrator showed that financial responsibilities were handled by the Business Office Manager, that there were no interventions in place to prevent recurrence if she was absent, and that leadership did not know what would trigger a change in representative payee or what processes existed to prevent such changes when a guardian was already in place.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to honor residents’ right to manage their financial affairs when two cognitively intact residents could only access trust funds during limited posted banking hours. Interviews showed residents were redirected to set weekday and weekend times, weekend staff directed requests to the nurse or posted hours, and an RN confirmed residents could not access money after business office hours on weekdays. The DON verified funds were only available at specific times, despite stating residents should be able to access their money when they wanted it.
A resident with dementia and bipolar disorder, but intact cognition per BIMS, had a substantial balance in a facility-managed trust fund that included funds transferred from a prior placement. Beginning shortly after admission, the resident repeatedly requested a lump-sum withdrawal to replace damaged clothing and purchase personal items, but over several months received only a partial payment while the remainder was delayed. The BOM, who was new to the role, cited high staff turnover, limited monthly petty cash from corporate, and the ADM’s delay in obtaining approval to cash petty cash checks as reasons for not honoring the resident’s full request, despite acknowledging the resident’s right to access his funds. This resulted in prolonged, unjustified restriction of the resident’s access to his own money, contrary to resident rights and facility policy.
A resident with Alzheimer’s disease, severely impaired cognition, and documented communication problems was discharged with a remaining balance of $179.33 in a personal funds account. The facility’s own Resident Rights policy required that such funds be returned within 30 days of discharge, but the account was not closed and the refund check was not issued until more than a month after discharge. This delay in returning the resident’s personal funds was confirmed by the Regional Business Office Manager and constituted a failure to ensure timely distribution of personal funds after discharge.
Resident Trust Funds Exceeded Medicaid Asset Limit: The facility failed to keep resident trust fund balances under the $2,000 Medicaid asset limit for multiple residents. Record review showed several residents with diagnoses including dementia, CHF, CKD, diabetes, hemiplegia, bipolar disorder, Parkinson’s disease, and traumatic subdural hemorrhage had trust fund balances ranging from $2,769.53 to $9,020.33, and both the BOM and Administrator stated the limit was under $2,000.
A cognitively intact male resident with a history of TIA, who had over $1,200 in a facility-managed trust fund and was care planned as independent, requested access to his personal funds on a Friday afternoon but was denied because key staff had left for the day and the ABOM had forgotten the key to the petty cash box. The resident, who believed he should receive a $75 monthly allowance when he wanted it, did not receive any money until the following Monday. The BOM described a practice of using petty cash for withdrawals during weekday business hours, while the Administrator acknowledged there was no specific written policy governing access to resident funds and no staff available on weekends to provide funds, despite existing written procedures on trust fund transactions and petty cash handling.
The facility failed to honor residents’ rights to manage their personal funds by not providing timely access to trust fund money, especially on weekends, and by not issuing accurate balance statements. A cognitively intact resident reported never receiving a statement and being unable to obtain the full amount needed to pay a phone bill, while two other residents reported not receiving their full monthly $75 allotments when requested, limiting their ability to purchase food and other items. Staff acknowledged that no one was available on weekends to disburse funds, that trust fund records were inaccurate and could not be reliably printed, and that there was no accessible trust fund policy despite a form stating that withdrawals must be documented and quarterly statements provided.
Resident Trust Funds Not Available Outside Scheduled Hours
Penalty
Summary
The facility failed to honor residents’ right to manage their financial affairs by not having appropriate funds available for two cognitively intact residents who wanted to withdraw money outside of the facility’s scheduled withdrawal hours. One resident stated they could obtain five dollars on weekends by going to the nurse’s station and could withdraw money Monday through Friday only from 1:00 p.m. to 2:00 p.m., and that if the time was missed, the money could not be obtained. Another resident stated the facility kept money for him and that he could access it only during set weekday hours, from 8:00 a.m. to 9:00 a.m. and from 1:00 p.m. to 2:00 p.m., and that he could not take money out on weekends. Staff interviews confirmed the restricted access to resident funds. The BOC stated the business office had posted banking hours Monday through Friday from 8:00 a.m. to 9:00 a.m. and from 1:00 p.m. to 2:00 p.m., with weekend and holiday access through the 1st floor nursing station during posted times, and that residents requesting money outside those hours would be redirected unless leaving the building and needing money right away. Weekend staff stated they would direct residents to the nurse or to the posted times, and an RN verified that after the business office closed Monday through Thursday, residents would not be able to access their money. The DON verified funds were available only during specific times and stated residents should be able to access their money when they wanted it. The policy stated resident trust cash was available during set banking hours, on weekends and holidays through the Charge Nurse at specified times, and outside banking hours in an emergency through the Charge Nurse.
Failure to Provide Resident Timely Access to Personal Trust Fund Monies
Penalty
Summary
The facility failed to honor a resident’s right to manage and access his personal funds deposited with the facility. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbance and bipolar disorder, but a recent MDS showed a BIMS score of 15, indicating no cognitive impairment. His care plan identified a risk for low self-esteem and included encouraging his participation in decision-making. The resident’s trust fund account was opened in September 2025, and a large deposit of $6,320 from a previous facility was made in January 2026, bringing his balance to $3,965.39 as of April 21, 2026. The resident reported that since at least October 2025 he had repeatedly requested a lump-sum withdrawal (initially $600) to purchase clothing and silk pillowcases after some of his clothes were damaged in the facility’s laundry, but he received only $150 in February and no further funds despite his ongoing requests. The Business Office Manager (BOM) confirmed that the resident had requested funds, including a $350 request in early 2026, and acknowledged that the resident was owed $375 at the time of the survey. The BOM stated he was new to the position, was still learning his role, and that high staff turnover, including changes in the Administrator (ADM), contributed to delays in providing funds. He explained that he received only $300 in petty cash monthly from corporate, which he used to disburse residents’ trust funds, and that he told the resident he could not provide the full requested lump sum due to petty cash limitations. The BOM reported discussing splitting the withdrawal with regional support and that the new ADM was waiting for corporate approval to cash petty cash checks, resulting in continued delay. The ADM acknowledged that the resident had a right to access his funds and that the resident had been requesting money since at least the end of February, but no additional funds were provided. This pattern of delayed and incomplete disbursement of the resident’s own money, despite his clear, repeated requests and adequate account balance, constituted the failure to properly manage and provide access to his personal funds as required by facility policy and resident rights regulations.
Failure to Timely Return Discharged Resident’s Personal Funds
Penalty
Summary
The facility failed to honor a resident’s right to timely management of personal funds by not returning the resident’s personal funds account balance within 30 days of discharge. The resident, who had Alzheimer’s disease with late onset and severely impaired cognition as evidenced by a BIMS score of three, also had documented communication problems related to Alzheimer’s disease, dementia with behavioral disturbances, and a psychotic disorder with delusions, requiring staff to use simple questions, allow adequate response time, and verify understanding. At the time of discharge, the resident’s fund management services ledger showed an account balance of $179.33. However, the account was not closed and the refund check for the full balance was not issued until 37 days after discharge, contrary to the facility’s Resident Rights policy, which required that resident funds be returned within 30 days. The Regional Business Office Manager confirmed that the account was not closed and the refund was not issued within the required timeframe. This deficiency was identified during a complaint investigation and involved one of three residents reviewed for personal funds accounts, with a facility census of 141.
Resident Trust Funds Exceeded Medicaid Asset Limit
Penalty
Summary
The facility failed to maintain resident trust fund balances under the $2,000 Medicaid asset limit for 10 of 111 sampled residents. Review of the American Council on Aging website showed that in 2026, a single Medicaid nursing home applicant in Tennessee must have assets under $2,000. Medical record and trust fund statement reviews showed multiple residents had balances above that limit, including residents with diagnoses such as atrial fibrillation, dementia, depression, dysphagia, anxiety, hemiplegia, heart failure, diabetes, chronic kidney disease, anemia, bipolar disorder, chronic respiratory failure, Parkinson’s disease, traumatic subdural hemorrhage, malnutrition, and hypertension. Resident trust fund statements dated 4/22/2026 showed balances of $4,945.96 for Resident #11, $7,764.26 for Resident #16, $3,324.09 for Resident #38, $2,950.01 for Resident #86, $5,350.97 for Resident #92, $3,874.46 for Resident #101, $3,931.97 for Resident #110, $2,769.53 for Resident #119, $5,911.60 for Resident #128, and $9,020.33 for Resident #177, all above the $2,000 limit. During interview, the BOM stated the resident trust account limit was $2,000.00, and the Administrator also stated resident trust accounts should be under $2,000.00.
Failure to Provide Timely Access to Resident Personal Funds
Penalty
Summary
The facility failed to honor a resident’s right to manage his personal funds by not providing timely access to money held in the resident trust fund. The resident was an adult male with a history of transient cerebral ischemic attack and an intact cognition status, evidenced by a BIMS score of 14 on a recent MDS, and was care planned as independent in meeting emotional, intellectual, physical, and social needs. His resident statement showed a trust fund balance of $1,250.37. The resident reported that on a Friday he requested some of his money but the facility would not give it to him, and that although he was supposed to receive $75.00 per month, sometimes he did not receive it when he wanted it. The Business Office Manager (BOM) explained that residents’ checks were applied to room and board, with remaining funds deposited into trust accounts, and that Medicaid allowed $75.00 for resident spending. She stated that when residents requested withdrawals, a form was completed and money was taken from a petty cash box, which was replenished as needed, and that residents typically waited no more than about two hours. However, the Assistant Business Office Manager (ABOM) stated that on a Friday afternoon the resident came to the business office requesting his money and was told the BOM had left for the day and would not return until Monday. Although the ABOM had access to petty cash, she had forgotten her key at home, so the resident did not receive any funds that day and did not get his money until the following Monday. The Administrator confirmed there was no specific written policy for providing access to resident funds, that access was limited to business hours on weekdays, and that no one was available on weekends to provide funds, despite the facility’s written procedures addressing resident trust fund transactions and petty cash reconciliation.
Failure to Provide Timely Access and Accurate Accounting of Resident Trust Funds
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to manage their personal financial affairs and to provide timely access to their funds. Three residents with facility-managed trust funds reported not receiving full access to their money upon request and not receiving balance statements. One cognitively intact female resident with major depressive disorder and generalized anxiety disorder stated she had a trust fund but had never been given a statement and did not know her balance. She reported having to ask for money to pay her phone bill and only receiving whatever amount staff said was available, and that she could not request money on weekends. A male resident with moderate cognitive impairment and major depressive disorder reported he was supposed to receive $75 per month but did not receive the full amount at once despite asking, which affected his ability to buy outside food. Another female resident with severe cognitive impairment and a cognitive communication deficit reported she was also supposed to receive $75 per month, but the facility would not give her the full amount when requested because the facility would “run out,” and she used extra money to pay for food. Staff interviews and record review further showed systemic issues with management of resident trust funds. The receptionist stated that residents with trust funds received money through the facility but confirmed that no one was available on weekends to provide residents with their funds. The Administrator and Director of Special Projects acknowledged that residents were not being given their money in a timely manner and emphasized the importance of keeping records of residents’ personal funds, including quarterly statements and withdrawals. The Director of Special Projects reported they could not print trust fund statements because the records would be incorrect and that the facility was not keeping accurate records of trust fund transactions, leaving them without evidence of money disbursements. Although a “Resident Trust Account Authorization Form” referenced quarterly written statements and documentation of withdrawals, the facility was unable to produce a trust fund policy when requested, stating they could not locate one.
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