Health inspection·April 7, 2026

Code of Federal Regulations, Title 42, Section 483.12, Misappropriation of Resident Property 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. Code of Federal Regulations, Title 42, Section 483.10, Resident rights (a) Resident's Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. California Code of Regulations, Title 22, Section 72527, Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (1) To be fully informed, as evidenced by the patient's written acknowledgement prior to or at the time of admission and during stay, of these rights and of all rules and regulations governing patient conduct. (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. California Code of Regulations, 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 2/11/26 at 9:05 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. Based on observation, interview, and record review, the Department determined that the facility failed to protect one of three residents (Resident 1) from misappropriation of property and exploitation, when Certified Nursing Assistant (CNA) 1 solicited and borrowed money from Resident 1, and used Resident 1's debit card for personal use resulting in financial loss of thousands of dollars. This failure resulted in Resident 1's emotional distress and loss of property. Findings: A review of Resident 1's Admission Record (AR) indicated Resident 1 was admitted to the facility on 10/24/24 with diagnoses which included anxiety disorder (excessive fear or worry that interferes with daily life to cause significant distress), depression (serious mental condition characterized by persistent sadness or loss of interest in activities), and limitation of activities due to disability. A review of Resident 1's Activities Care Plan (ACP), revised 7/7/25, indicated, "[Resident 1] has stated a preference for independent self-directed and group activities..." A review of Resident 1's Minimum Data Set (MDS - Federally mandated resident assessment tool), dated 11/25, indicated Resident 1 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident with a scored range of 0-15, 15 with no memory impairment) score of 14, which indicated intact cognition. A review of Resident 1's Activities Progress Notes (APN), dated 1/22/26, indicated, "[Resident 1 verbalized feeling upset and concerned related to recent discovery of financial transactions...[Resident 1] discussed trust placed in CNA and acknowledged difficulty recognizing appropriate financial boundaries with staff." A review of Resident 1's Interdisciplinary Team (IDT) Notes, dated 1/23/26, indicated, "On 1/22/26...[Resident 1] reported concerns regarding a sudden depletion of funds from her bank account. [Resident 1] stated she was informed by her bank that her account balance was low and expressed that her debit card may have been used inappropriately...Facility staff assisted the resident in reviewing her recent bank transactions...multiple transactions were identified associated with cash app, door dash and uber services...[Resident 1] stated she is physically unharmed and expressed concern and temporary emotional upset related to the discovery of financial transactions...During the review, staff observed text message communications between the resident and [CNA 1]." A review of Resident 1's APN, dated 1/23/26, indicated, "[Resident 1] stated she's still upset...Her feelings are hurt and she's disappointed in the situation." A review of Resident 1's APN, dated 1/24/26, indicated, "[Resident 1] stated she was emotional, and upset...[Resident 1] stated she doesn't want to see the person the alleged incident is with." A review of Resident 1's APN, dated 1/27/26, indicated, "[Resident 1] responded she is hurt and disappointed in herself and the alleged staff member in the alleged incident. She is finding it hard to understand why would someone do this. [Resident 1] stated it makes it hard to trust others to this point." A review of Resident 1's APN, dated 1/28/26, indicated, "[Resident 1] is still upset ...resident stated the alleged staff member has ruined her reputation with her bank. A review of Resident 1's APN, dated 1/29/26, indicated, "[Resident 1] has been asleep all day...The writer has went bye (sic) the room multiple times throughout the day...The writer awoke the resident at last visit and [Resident 1] said she wanted to just sleep and did not feel up to doing anything today." During a review of the facility's investigation binder which included an emailed statement completed by Resident 1 dated 1/22/26, the statement indicated Resident 1 alleged CNA 1 accepted, borrowed, and solicited money from Resident 1, and stated "I am physically okay but mentally upset...She's asked me at least five or six times." Resident 1 indicated CNA 1 used Resident 1's debit card without Resident 1's permission. The facility investigation document further confirmed text messages from CNA 1 to Resident 1 requesting money from Resident 1. A review of Resident 1's Nursing Progress Notes (NPN) dated 1/26/26, indicated that Resident 1 was emotionally distressed, betrayed and depressed. Resident 1's NPN further indicated Resident 1 experienced sleep disturbances, social withdrawal and lack of interest in activities and remained mostly in her room. During a concurrent interview and record review on 2/10/26 at 9:20 a.m. with the Administrator (ADM), the facilities investigation binder was reviewed. The ADM stated Resident 1 allowed CNA 1 to use Resident 1's debit card to "get money and buy her things... and loaned money to [CNA 1]." The ADM further stated Resident 1 was "still expressing emotional distress," and the staff receiving money or gifts from residents was against company policy, and that CNA 1 was no longer employed with the facility. During a concurrent observation and interview on 2/10/26 at 2:24 p.m. with Resident 1 in Resident 1's room, Resident 1 reviewed her bank statements and stated CNA 1 had taken thousands of dollars from her bank via debit card and asked her for money via text messages and in person. Resident 1 stated she thought CNA 1 was her friend and sometimes mentioned she would need money because she did not get paid until a certain time. Resident 1 stated, "I let [CNA 1] use my card, but I never gave her permission to take money like this." Resident 1 stated she felt bad and "dumb" for giving CNA 1 her debit card and money. Resident 1 indicated she has remained mostly in her room. Resident 1 further stated she felt pressured and gave money to CNA 1 and was never told (by facility) not to give money to a staff. Resident 1's facial expression appeared sad during the duration of the interview. During an interview on 2/11/26 at 10:30 a.m., Licensed Nurse 1 (LN 1) stated, "It is the expectation for staff not to ask for or receive money from residents and to follow proper reporting channels and asking a resident for money is a reportable incident." LN 1 further stated, "It [asking and receiving money from residents] is not ok and falls in line with financial abuse. We [the facility] do have a protocol not to take money..." During an interview on 2/11/26 at 12:37 p.m., CNA 2 stated, "Staff are trained not to take money from residents or buy resident gifts. CNA 1 taking money from residents is against the facilities abuse policy and not good for the residents." During a concurrent observation and interview on 2/11/26 at 12:48 p.m. with Resident 1 in Resident 1's room, Resident 1 was observed lying in bed with lights off. The cell phone text messages from CNA 1 to Resident 1 were reviewed. Resident 1 confirmed the text messages from CNA 1 showed CNA 1 requested money on 11/28/25, 11/29/25, 12/1/25, 12/11/25, 12/29/25,1/6/26,1/9/26 and 1/12/26. Resident 1 stated, "I feel dumb for trusting her...still sad about it." A review of Resident 1's APN, dated 2/12/26, indicated, "[Resident 1] was asking about clarification in regard to her debit card. She wanted to make sure her bank was sending her another bank card...[Resident 1] stated she is anxious about receiving her new card and rebuilding her relationship with her bank...building trust in people." During an interview on 2/12/26 at 10:14 a.m., Social Services Assistant (SSA) stated Resident 1 was a very social person and after the reported incident with CNA 1, Resident 1 was "somewhat depressed after the incident...was isolated in room," and stated, "Staff taking or receiving money could be a possible abuse..." During an interview on 2/12/26 at 11:05 a.m., the Director of Nursing (DON) stated she expected staff not to borrow money or use residents' property. During a phone interview on 2/13/26 at 10:34 a.m., CNA 1 confirmed she requested and received gifts and money from Resident 1. CNA 1 stated, "I borrowed money from her a couple of times... I did ATM [automated teller machine] withdrawal and no one said I couldn't do that." During a review of the facility's policy and procedure (P&P) titled, "Abuse Prevention Program," revised 12/2016, the P&P indicated, " Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation...As part of the resident abuse prevention program, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff..." Therefore, the facility failed to protect one of three residents (Resident 1) from misappropriation of property and exploitation, when CNA 1 solicited and borrowed money from Resident 1, and used Resident 1's debit card for personal use resulting in financial loss of thousands of dollars. This failure resulted in Resident 1's emotional distress and loss of property. This violation had a direct or immediate relationship to the health, safety, or security of a long-term facility patient.