Health inspection·March 6, 2025

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: Residents Affected - Few 1. Thoroughly investigate an allegation of misappropriation of property per policy, 2. Implement the plan to protect other residents from theft, 3. Maintain a theft and loss log, and 4. Incorporate reported incidents of misappropriation of property into the facility quality assurance and performance improvement (QAPI) program for two of two residents (Resident 1 and Resident 2) with reports of missing debit cards and money missing from their bank accounts. These failures put vulnerable residents at risk of misappropriation of property. Findings: 1. On 1/22/25, the Department received a report from the facility that the police had informed the facility staff that Resident 1's family had reported Resident 1 had lost some money and an investigation was started. During a record review and concurrent interview on 2/6/25 at 12:20 p.m., Administrator verified an untitled, undated document kept in the investigation file for Resident 1's reported lost money was the five-day investigation summary sent to the Department. The investigation summary indicated Resident 1 was admitted to the facility on [DATE] and indicated an interview with Resident 1's daughter revealed Resident 1's ATM (automated teller machine) card had been used between 12/25/24 and 1/10/25 for payment to a gas station, for purchases from an online department store, and to withdraw up to $1000 in cash. Administrator verified she had personally investigated Resident 1's reported lost money. The investigation summary indicated Social Services Director (SSD) A was the alleged perpetrator. The investigation summary did not include documentation of an interview with SSD A. Administrator verified she did not attempt an interview SSD A during her investigation. During a phone interview on 3/5/25 at 1:30 p.m., Administrator verified the investigation summary for Resident 1's reported lost money indicated one staff interview, with Licensed Nurse B, and no other facility staff interviews. When queried, Administrator could not be sure if any other staff were interviewed for this investigation. Page 1 of 3 056430 056430 03/06/2025 Northgate Postacute Care 40 Professional Center Parkway San Rafael, CA 94903

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 3/6/25 at 9:55 a.m., Director of Staff Development (DSD) stated that since theft and loss could be considered financial abuse, staff were expected to adhere to the theft and loss policy and the abuse prevention policy together. Review of facility policy and procedure, Theft and Loss, dated 4/2018, indicated, The Administrator or designee investigates all reports of stolen items and documents the investigation: a. The investigation may consist of the following: . An interview with any witnesses that may have knowledge of the missing items. An interview with the person (if any) accused of taking the resident's property . Interviews with Facility staff (on all shifts) having contact with the resident during the past 48 hours . Facility policy and procedure, Abuse and Neglect Prohibition Policy, dated 6/2022, indicated, It is the facility's policy to prohibit abuse . and misappropriation of property for all residents through the following: . Investigation of incidents and allegations . The investigation will be thoroughly documented on the facility's investigation form and log. Ensure that documentation of witnessed interviews is included. 2. On 11/5/24, the Department received a report from the facility that Resident 2's palliative care nurse had called to report that Resident 2's ATM card was missing and there had been fraudulent charges. During a record review on 2/6/25 at 9:58 a.m., Resident 1's document titled Inventory of Personal Effects, dated 12/13/24 (date of his admission), indicated he had one wallet on admit. Resident 1's inventory did not include an itemized list of the contents of the wallet. During a record review and concurrent interview on 3/4/25 at 2:40 p.m. with Director of Nursing (DON) and Administrator, Resident 2's untitled document indicating an inventory of his personal effects, dated 8/22/24, revealed he had a black wallet containing $107. DON verified Resident 2 was admitted to the facility on [DATE]. Administrator verified both Resident 1's and Resident 2's admission inventories did not have the entire wallet contents itemized. Administrator stated it was her expectation that when residents were admitted , the staff should document the contents of wallets. Administrator verified the reason wallet contents should be inventoried was so that if a resident found later during their stay that something was missing from the wallet, they have documented what was in the wallet on admission. When queried, Administrator stated that after Resident 1 and Resident 2 had their ATM cards reported missing, she decided the nurses should be in-serviced regarding filling out the inventory sheets. During an interview on 3/4/25 at 2:45 p.m., SSD C stated she recently gave the staff an in-service on filling out the inventory sheet. SSD C verified that during the in-service she told the staff that they needed to itemize the contents of residents' wallets. During a record review and concurrent interview on 3/5/25 at 12:05 p.m., the inventory of personal effects for Resident 3, dated 2/28/25, indicated he had a wallet on admission, but the contents of the wallet were not itemized on the inventory. SSD C verified the wallet contents were not itemized and verified it was her expectation that staff itemized the contents of the wallet when filling out the inventory. Review of the sign-in sheet for SSD C's in-service regarding Resident Inventory/Preventing Theft and Loss revealed the date of the in-service was 2/25/25 and 12 staff had attended. 056430 Page 2 of 3 056430 03/06/2025 Northgate Postacute Care 40 Professional Center Parkway San Rafael, CA 94903

F 0610 Level of Harm - Minimal harm or potential for actual harm Facility policy and procedure, Theft and Loss, dated 4/2018, indicated, Purpose: To assure that residents [sic] properties and belongings are safeguarding [sic] and replaced in case of loss or theft. Procedure: . 2. Upon admission and on discharge, a resident inventory will be taken and recorded. a. A written inventory system for clothing and other valuables will be completed and acknowledge [sic] by the resident and/or resident's representative. Residents Affected - Few Facility policy and procedure, Abuse and Neglect Prohibition Policy, dated 6/2022, indicated, Purpose: To ensure that facility staff are doing all that is within their control to prevent occurrences of abuse . and misappropriation of property for all residents. 3. During a record review and concurrent interview on 3/5/25 at 2:50 p.m., the log of theft and loss for the past 12 months was requested from SSD C. SSD C brought a binder that contained a log for January 2025. SSD C stated she did not know what the previous system was for logging reports of theft and loss, but this was the system she started last month when she was hired. During an interview on 3/6/25 at 9:55 a.m., SSD C stated she had not been able to locate a theft and loss log for the previous 12 months as requested. SSD C stated the facility was supposed to maintain a theft and loss log for every year. Facility policy and procedure, Theft and Loss, dated 4/2018, indicated, Document reports of lost and stolen resident property and stolen property log for items with a value of twenty-five ($25) dollars or more or of particular value to the resident. a. The written theft and loss record for the past year is available to the Department of Public Health, law enforcement agencies and to the office of the Long-Term Care Ombudsman. 4. During an interview on 3/6/25 at 10:30 a.m., DON and DSD stated they were both in attendance at the QAPI committee meeting last month (February 2025) and the incidents involving Residents 1 and 2 that were reported to the Department were not discussed at the meeting. DSD stated they had recently discussed working on improving their inventory process, but this had not been discussed or developed at a QAPI committee meeting. During a record review and concurrent interview on 3/6/25 at 10:41 a.m., DSD provided the agenda for the 2/27/25 QAPI committee meeting. DSD pointed out the agenda items did not include theft and loss, but stated he would discuss with Administrator adding it to the list of items to review at every meeting. DSD verified the facility Theft and Loss policy and procedure indicated theft and loss trends will be reported to the QAPI committee. Review of QAPI committee meeting agendas for November 2024, December 2024, and January 2025 revealed theft and loss was not included. Facility policy and procedure, Theft and Loss, dated 4/2018, indicated, Trends are reported to the Quality Assurance and Performance Improvement Committee, as indicated. 056430 Page 3 of 3