Other·October 23, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for the investigation of facility reported incident #CA00606957. Representing the Department of Public Health: Health Facilities Evaluator Nurse, 35598 The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility.

F602 SS=G Free from Misappropriation/Exploitation CFR(s): 483.12

F602 11/08/2019 §483.12 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. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to protect 1 of 4 sampled residents (Resident 1) from misappropriation of property when Certified Nursing Assistant (CNA) 1 was able to inappropriately obtain money and/or use a debit card belonging to Resident 1. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H00R11 Facility ID: CA030000105 If continuation sheet 1 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056410 (X3) DATE SURVEY COMPLETED 09/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITNEY OAKS CARE CENTER 3529 Walnut Avenue Carmichael, CA 95608 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This failure resulted in money being taken from Resident 1 by unauthorized use of a debit card and caused Resident 1 psychosocial distress. Findings: Review of Resident 1's Face Sheet (admission record), indicated she was admitted to the facility with diagnoses that included right sided weakness due to a stroke and dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). Review of a clinical document titled, "Physician Order Report" included an 8/22/18 order indicating Resident 1 was capable of understanding rights, responsibilities, and informed consent. Review of a document in Resident 1's clinical record titled MDS (Minimum Data Set- an assessment tool), dated 8/26/18, revealed Resident 1 had a mental status score of 15/15 indicating she was cognitively intact with no memory problems. The MDS indicated Resident 1 required extensive assistance with most of her activities of daily living and used a wheelchair for mobility. In an interview with Licensed Nurse (LN) 1 on 10/18/18 at 11:20 a.m., LN 1 stated Resident 1 was "upset" on 10/8/18 and reported to her that certified nursing assistant (CNA) 1 had stolen money from Resident 1. LN 1 stated Resident 1 called CNA 1 and the debit card balance was not what it should be and CNA 1 said she took $200 and was going to pay her back. LN 1 stated, "She [Resident 1] wanted her money back." Review of a document in Resident 1's clinical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H00R11 Facility ID: CA030000105 If continuation sheet 2 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056410 (X3) DATE SURVEY COMPLETED 09/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITNEY OAKS CARE CENTER 3529 Walnut Avenue Carmichael, CA 95608 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE record titled Progress Notes, dated 10/8/18 at 11:50 a.m., by the Social Services Director (SSD), "At approximately 11:00 AM, resident reported that CNA (CNA 1) had taken 200 dollars from her direct express card. Per resident she gave her card to the CNA two days ago to buy products for her hair and some clothes for her grandchildren... Resident states that the information that the CNA had provided does not match as she knows that she has substancia/enough [sic]... money in her direct express card as she had not been spending any money at all... Resident reported she is upset and angry towards the CNA as she never did asked [sic] permission and stole money from her..." Further review of Resident 1's Progress Notes, included an entry dated 10/9/18 at 10:47 a.m., authored by the Director of Nursing for the Interdisciplinary Team which indicated, "bedside discussion with [Resident 1] 10-8-18 at aprox (approximately) 11:00. [Resident 1] shared concern [related to] a particular CNA, [CNA 1's initials] and her 'debit card she had previously given to said CNA'. Relates she had a 'strange feeling that something was off with her money'...[Resident 1] phoned CNA on her personal cell phone evening of Friday 10-518... CNA [CNA 1's initials] continued to say I took 200.00 but I'M (sic) going to replace it... [Resident 1] said CNA came to her [room] and returned her card morning of (sic) [Saturday] 10 -6-18... [Resident 1] did share with SSD [Name], that 'the CNA called her [Resident 1] this morning (10-9-18) about 0700 (7:00 a.m.)' she relates that the CNA said 'you have to help me get out of this, tell them nothing happened, and you must get me out of trouble don't forget I'm your granddaughter..." Review of Resident 1's Progress Notes, dated 10/9/18 at 2:06 p.m. by the SSD, included an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H00R11 Facility ID: CA030000105 If continuation sheet 3 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056410 (X3) DATE SURVEY COMPLETED 09/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITNEY OAKS CARE CENTER 3529 Walnut Avenue Carmichael, CA 95608 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE account of the phone call between Resident 1 and facility staff member (CNA 1) on 10/9/18 at 7:00 a.m., "Resident informed SSD that the CNA states, 'grandma you need to let them stop the investigation, you need to help me because I will be in trouble'... Resident states that she feels angry that she trusted the CNA and the CNA stole her money... Resident states that the CNA programmed her name as 'granddaughter' in her [Resident 1's] cell phone and every time the CNA calls, the name appears as granddaughter..." In an interview with the SSD on 10/17/18 at 3:45 p.m., the SSD stated Resident 1 has a direct express card, used like a debit card, and maintains possession of it. SSD stated Resident 1 does not leave the facility to utilize the card, she stated there was no record of a leave of absence for September or October for Resident 1. SSD stated there were no other known users having access to the card or account. In a telephone interview with CNA 1 on 10/18/18 at 4:30 p.m., CNA 1 stated Resident 1 "gave me cash... $70 or something like that." CNA 1 stated Resident 1 had requested she purchase a jacket. CNA 1 stated the money was received at the "beginning of the month". When CNA 1 was asked again how much money and for what purchase, she stated, "$70, for a jacket and a pair of pants... I think that much." CNA 1 stated there were no witnesses to her receiving cash from Resident 1 or returning any purchased items to Resident 1. CNA 1 acknowledged she and Resident 1 spoke "a lot" on their personal cell phones. CNA 1 acknowledged the calls and using Resident 1's money were inappropriate for a staff member. CNA 1 stated, "No, it's not normal. I'm not supposed to do that." When asked if CNA 1 was still employed by the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H00R11 Facility ID: CA030000105 If continuation sheet 4 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056410 (X3) DATE SURVEY COMPLETED 09/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITNEY OAKS CARE CENTER 3529 Walnut Avenue Carmichael, CA 95608 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility she stated, "No, I just left, decided it was time to go, too much drama." She stated, "If I had known all this would happen, I wouldn't have done it... Gone to the store with that money." An interview was conducted on 10/26/18 at 10:00 a.m. with the SSD, Social Services Assistant (SSA) and Resident 1. Resident 1 stated she gives the debit card to CNA 1 to purchase "hair products, clothes, and cigarettes" for her. Resident 1 stated CNA 1 knows the PIN (Personal Identification Number). Resident 1 stated CNA 1 withdrew $200 monthly in cash to give to the resident. Resident 1 stated she "does it all the time" and indicated it had been occurring over months. Resident 1 stated she used her cell phone to call CNA 1 on her cell phone because there was "just a feeling". Resident 1 stated, "She [CNA 1] borrowed money off my card" and "she [CNA 1] took $200 off the card." During a concurrent observation and interview with the SSD, SSA and Resident 1, in the office of the SSD, on 10/26/18 at 10:30 a.m., Resident 1 called the card services phone number on speaker phone. The balance at the time was $389.36 and the last deposit was on 10/1/18 for $1176, which the SSD and Resident 1 stated reoccurs monthly. The last 10 financial transactions were played over the phone. The transactions from 10/1/18 to 10/26/18 were as follows: "cash purchase of $93.77" on 10/2/18, "ATM withdrawal fee of $0.85" on 10/2/18, "ATM cash withdrawal of $503.50" on 10/2/18, "cash purchase of $80.26" on 10/5/18, and "cash purchase of $110.09" on 10/5/18. During the same interview on 10/26/18 at 10:45 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H00R11 Facility ID: CA030000105 If continuation sheet 5 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056410 (X3) DATE SURVEY COMPLETED 09/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WHITNEY OAKS CARE CENTER 3529 Walnut Avenue Carmichael, CA 95608 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE a.m., Resident 1 was asked if CNA 1 gave her $200 this month, she replied, "yes". When asked what other items were purchased, Resident 1 stated, "she buys me a carton of cigarettes" and "gummy bears". Resident 1 stated no one else has access to this account. Review of the facility document dated 10/12/18 included, "[Name of CNA 1] is aware of abuse of the policy and procedures and resident's rights", "the CNA refused to provide [sic] statement", and, "the CNA [name] notified the Administrator that she would not be returning to [facility name]". In an interview with the Administrator on 10/26/18 at 12:00 p.m., he stated Resident 1's stolen money would be replaced, "especially if a staff member stole it". The Administrator stated staff "all know" it is "against company policy" to accept money or use a resident's money. The facility policy titled, "Abuse Prevention Program", revised December 2016, included, "Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation... As part of the resident abuse prevention, the administration will: 1. Protect our resident from abuse by anyone including... facility staff." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H00R11 Facility ID: CA030000105 If continuation sheet 6 of 6