Health inspection·January 6, 2025

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect one of four sampled residents (Resident 1) from misappropriation (the unauthorized, improper, or unlawful use of funds or other property for purposes other than that for which intended) of property and personal belongings when a Certified Nursing Assistant (CNA) 1 used Resident 1's debit card without his consent or permission and charged $376.38. Residents Affected - Few This failure resulted in Resident 1 loss of $376.38 from his bank account. Findings: During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], Resident 1's MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 15 out of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 1 had no cognitive impairment. During an interview on 1/6/25 at 1:30 p.m., with the Director of Nurses (DON), DON stated Certified Nursing Assistant (CNA) 1 was using Resident 1's debit card without his permission or consent to order food on the phone delivery application for herself, stepmother and sister. The sum of 12 delivery transactions charged to Resident 1's debit card was $376.38. The DON stated CNA 1 had saved Resident 1's debit card number on her personal phone and used it for the 12 transactions. The DON stated the facility expectation was that the Activity Director (ACTDIR) is allowed to make approved purchases for residents with permission of their responsible parties (RP-person who is responsible for paying the patient's account). The DON stated no other staff are allowed to make purchases, handle resident cash or resident debit cards. The DON stated the facility did not have a protocol in place prior to this incident to reinforce that the ACTDIR was the only one to make purchases on behalf of residents. The DON stated no formal education or training was provided to staff regarding using residents personal funds. The DON stated she considered CNA 1s unauthorized use of Resident 1's debit card as stealing. The DON stated CNA 1 was terminated due to financial elder abuse and law enforcement was notified. During an interview on 1/6/25 at 2:30 p.m., with the Activity Director (ACTDIR), ACTDIR stated Resident 1 approached her for some assistance regarding money missing from his account. The ACTDIR stated while reviewing Resident 1's financial records, it was identified that unauthorized purchases were made on the food delivery application under the name of CNA 1 in the sum of $376.38 the transactions were verified with Resident 1, and 12 out of of the 13 purchases made were not approved by Page 1 of 2 055028 055028 01/06/2025 Los Banos Post Acute 931 Idaho Ave. Los Banos, CA 93635

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1. The ACTDIR stated she is in charge of making purchases for residents in the facility. The ACTDIR stated Resident 1 had asked CNA 1 to make a purchase of food on the food delivery application, CNA 1 made the purchase through her own account and had saved Resident 1's debit card number and continued to make unauthorized purchases. The ACTDIR stated when CNA 1 made additional purchases and used Resdent 1's debit card number without his permission it was stealing. The ACTDIR stated CNA 1 also failed to notify leadership prior to making a purchase for Resident 1. During an interview on 1/6/25 at 3:02 p.m., with the Social Service Director (SSD), the SSD stated the facility did not have policy or procedure in writing to educate staff on proper protocols or guidelines concerning purchasing items on behalf of the residents. SSD stated It wasn't until after CNA 1 made unauthorized purchases for Resident 1 that staff received education regarding purchases for residents. During an interview on 1/7/25 at 10 a.m., with Resident 1, Resident 1 stated he initially asked CNA 1 to assist him with making a phone delivery application order online but since he didn't have a phone CNA 1 used her phone and her food delivery account to assist him. Resident 1 stated he provided her with his debit card number and the order was completed. Resident 1 stated it wasn't until a few weeks later he noticed his bank funds decreasing without making any purchases, he requested the assistance of ACTDIR and that's when he found out that CNA 1 was stealing from him by using his card to make unauthorized purchases for herself. Resident 1 stated the total sum of money spent was close to $400 dollars. Resident 1 stated he was reimbursed his money by the facility once the investigation was completed. During a review of facility's policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021, indicated, .Facility-wide commitment and resource allocation to support .develop and implement policies and protocols to prevent .theft, exploitation or misappropriation of resident property . During a review of facility's policy and procedure titled, Investigating Incident of Theft and/or Misappropriation of Resident Property dated April 2021, indicated, .Residents have the right to be free from exploitation, theft and/or misappropriation of person property .implementing policies that strictly prohibit . staff or employee theft or misappropriation of resident property .providing measures to safeguard resident valuables . 055028 Page 2 of 2