Health inspection·November 19, 2025

F602, Title 42, Section 483.12. Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Title 22, Section 72523- Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to endure that patient related goals and facility objectives are achieved. Title 22, Section 72529 - Safeguards for Patients' Monies and Valuables (d) The facility shall make reasonable efforts to safeguard patients' property and valuables that are in possession of the patient. On 9/12/25 at 10:10 a.m., an unannounced visit was conducted at the facility to investigate a facility reported incident regarding a staff member taking money from Resident 1's personal bank accounts without consent. As a result of the investigation, the Department determined that the facility failed to protect Resident 1 from misappropriation of property and exploitation resulting in financial loss totaling to $12,773 and emotional distress to Resident 1. A review of Resident 1's admission records indicated Resident 1 was admitted to the facility in February 2024 with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), and problems related to housing and economic circumstances. Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 1 had moderate cognitive impairment. A review of Resident 1's "Theft/Loss Report," dated 9/9/25 and completed by Resident 1's cousin, indicated, "Description of Missing Item(s): wallet w/ [with] ID [identification card], ATM card [automated teller machine card, a card that enables access to financial accounts through a bank machine]...Facility Action Taken to Find Missing Item:...SS [Social Services] ask [Resident 1] where and when the last [sic] [Resident 1] saw her wallet. [Resident 1] mentioned the money..." A review of Resident 1's SBAR (situation, background, assessment, recommendation - a communication tool used by healthcare workers when there is a change of condition among the residents), dated 9/9/25, indicated, "...1. [Resident 1] alleged staff [MRC - Medical Records Coordinator] took her wallet. 2. [Resident 1] Alleged a staff [MRC] borrowed money from [Resident 1] and never paid [Resident 1] back..." A review of Resident 1's Interdisciplinary Team (IDT) Notes, dated 9/10/25, indicated, "...On 9/9/25 at about 2:30pm, [Resident 1's] cousin reported to SSD [Social Services Director] that allegedly one of the staff [MRC] borrowed $2000 from [Resident 1] and did not pay [Resident 1] back..." A review of Resident 1's Psychosocial Note, dated 9/10/25, indicated, "...[Resident 1's cousin] went on to tell [SS] that he believed a staff member [MRC] borrowed $2000 and promised repayment...[SS] interview [sic] [Resident 1] to confirm the cousin report. [Resident 1] agreed with the statement [Resident 1's] cousin made. While talking about its [sic] [Resident 1] started to cry." A review of Resident 1's Psychosocial Note, dated 9/11/25, indicated, "...[SS] went with [Resident 1] to the Bank to get the bank statements. while at the bank [Resident 1] started to breakdown and started crying. [Resident 1] got the statement, and it shows that someone has been taking money from [Resident 1's] account for that past 6 months..." A review of Resident 1's Psychosocial Note, dated 9/12/25, the note indicated, "...This morning, SS checked in with [Resident 1] to see how [Resident 1] was doing. [Resident 1] became emotional and began to cry..." A review of Resident 1's Physician Note, dated 9/12/25, the note indicated, "...I [physician] was notified of an incident about employee [MRC] stealing patient money. [Resident 1] tells me [Resident 1] trusted the employee and believed [MRC] was helping [Resident 1]; however, [Resident 1] found out [MRC] was taking [Resident 1's] money without her permission..." During a telephone interview on 9/12/25 at 12:27 p.m., MRC stated, "I gave [Resident 1] a black wallet because [Resident 1] was holding the cards on [Resident 1's] hands...I gave it around May for [Resident 1's] birthday..." The MRC further stated, "...[Resident 1] has it [wallet] and doesn't want to show it to the cousin because [cousin] will take it..." The MRC stated that she never owed money to Resident 1, and Resident 1 did not give her access to Resident 1's wallet, online accounts, cards or PIN numbers (personal identification number, a secret numerical code used to verify identity for secure transactions and access to accounts). In contrast to MRC's statement that she did not have access to Resident 1's bank accounts, a review of Resident 1's savings account bank statement, dated 2/19/25 to 3/19/25, indicated MRC's name withdrawing money from Resident 1's account. The statement indicated the following withdrawal dates with MRC's name with the corresponding amount withdrawn, with a total of $8,530: - 2/20/25 - $200 - 2/21/25 - $200 - 2/21/25 - $500 - 2/21/25 - $100 - 2/21/25 - $300 - 2/24/25 - $300 - 2/24/25 - $400 - 2/24/25 - $500 - 2/24/25 - $500 - 2/24/25 - $500 - 2/24/25 - $1,000 - 2/24/25 - $500 - 2/24/25 - $500 - 2/26/25 - $500 - 2/26/25 - $500 - 2/27/25 - $500 - 3/3/25 - $300 - 3/3/25 - $500 - 3/3/25 - $200 - 3/3/25 - $500 - 3/7/25 - $30 During a review of Resident 1's checking account bank statement, dated 2/25/25 to 3/25/25, the following withdrawals were identified indicating MRC's name with the corresponding amount withdrawn, with a total of $1,560: - 2/27/25 - $300 - 3/3/25 - $500 - 3/3/25 - $300 - 3/3/25 - $300 - 3/5/25 - $100 - 3/6/25 - $60 During a review of Resident 1's checking account bank statement, dated 3/26/25 to 4/24/25, the following withdrawals were identified indicating MRC's name with the corresponding amount withdrawn, with a total of $2,683: - 3/26/25 - $50 - 3/26/25 - $10 - 4/3/25 - $1,350 - 4/3/25 - $600 - 4/3/25 - $650 - 4/7/25 - $23 A total of $12,773 was withdrawn from Resident 1's account with MRC's name linked/identified with the withdrawals. During a concurrent interview and record review on 9/12/25 at 1:12 p.m., the SSD stated that Resident 1's cousin reported on 9/9/25 that Resident 1's wallet was missing. The SSD stated that he spoke with Resident 1 and was told that MRC borrowed $2000 from Resident 1. The SSD stated he went with Resident 1 to the bank and requested bank statements. The SSD confirmed that based on the bank statements, money was being sent to MRC online and that MRC had access to Resident 1's online banking. When asked how the SSD confirmed that MRC was transferring money from Resident 1's account to MRC's own account, the SSD stated, "...because [MRC] name was there [on the bank statements]..." The SSD stated Resident 1 cried upon seeing the bank statements and that Resident 1 denied that Resident 1 was aware of the transactions. During a concurrent observation and interview on 9/12/25 at 2:39 p.m. with Resident 1 in her room, Resident 1 stated, "Somebody told me that they've taken some money from my account...I thought that they are going to give it back but they didn't...It was a girl named [MRC's name]...[MRC] worked here...I [Resident 1] got close to [MRC], [MRC] found my wallet in my purse, and [MRC] told me [MRC] had it and that [MRC] took some of the money and [MRC] took the card...[MRC] said she would pay me back but [MRC] didn't...It happened a few months ago...[MRC] said she needed it and that [MRC] would give it back..." When asked how she felt about what happened, Resident 1 stated, "Not good." Resident further stated, "[MRC] told me [MRC] had some of the money and that [MRC] would return it...Spoke with the bank, they thought it was me [Resident 1] withdrawing the money...I was stupid..." Resident 1 was observed crying and stated, "I feel like I can't stop crying." During an interview on 9/12/25 at 2:53 p.m., the Administrator (ADM), stated she saw the bank statements and confirmed that the staff member's name was in the transactions. The ADM stated, "...they [staff] know that they cannot receive gifts from residents...it was happening since February..." The ADM further stated Resident 1 was crying and Resident 1 cannot accept that Resident 1 trusted MRC and stated, "...[Resident 1] trusted the individual [MRC]...according to [Resident 1], [Resident 1] had a debit card and shared the pin to [MRC]..." The ADM further stated, "...we have zero tolerance that will involve residents in a disadvantaged position...expectation is to ensure residents are free from any type of abuse." During an interview on 9/12/25 at 3:22 p.m., the Director of Nursing (DON), stated she was told by Resident 1 that MRC borrowed money from Resident 1 by debit card a couple of months ago. The DON was told by Resident 1 that Resident 1 gave the card and pin number, and that Resident 1 made a mistake and did not know MRC was "...going to take that much..." The DON stated Resident 1 was consistent with her allegations. The DON further stated Resident 1 cried when Resident 1 saw the bank statements. The DON stated, "This is very unfortunate...The expectation is to protect the residents from any type of abuse including financial abuse." During a review of the facility's policy and procedure (P&P) titled "P-AN01 Abuse Prevention and Management," revised 5/30/24, the P&P indicated, "...i. "Exploitation" is defined as taking advantage of a resident for personal gain, using manipulation, intimidation, threats, or coercion...k. "Misappropriation of resident property" and "financial abuse" are defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent..." During a review of the facility's P&P titled "AN01 Abuse Prevention and Management, revised 5/30/25, the P&P indicated, "The Facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment..." Therefore, the facility failed to protect Resident 1 from misappropriation of property and exploitation when a staff member took money from Resident 1's personal bank accounts without consent resulting in financial loss totaling to $12,773 and emotional distress to Resident 1. This violation had a direct relationship to the health, safety, or security of long-term care facility residents.