Health inspection·September 16, 2022

The following reflects the findings of the California Department of Public Health during the investigation of: Entity Reported Incident # 742942 and Complaint # 743698. Abbreviated Survey: Event ID: Z46M11 Representing the Department: Health Facilities Evaluator Nurse 42910 State Citation B was written Regulation: F-Tag 602 CFR 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 (deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) 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. On 7/13/21 at 2:47 P.M., an unannounced visit was conducted at the facility to investigate an entity reported incident and a complaint investigation regarding an allegation of misappropriation of Resident 1's money. Resident 1's bank account was accessed by the facility's Social Services Director (SSD) without Resident 1's permission. As a result, Resident 1's money, amounting to almost $12,000.00, was used by SSD for her own personal use, without Resident 1's knowledge. The facility failed to ensure Resident 1 was free from financial abuse. Resident 1 was admitted to the facility on 3/14/19 with diagnoses which included unspecified dementia (loss of cognitive functioning) with behavioral disturbance, per the Resident Face Sheet. The Face Sheet indicated Resident 1 was under conservatorship (a court appoints a responsible person to care for another adult who cannot care for himself/herself or manage his/her finances). The Face Sheet also listed family members as emergency contacts. A review of Resident 1's conservatorship record, dated 3/3/20, indicated that Resident 1 was no longer under conservatorship effective 3/3/20. On 7/13/21 at 9:30 A.M., an interview with Resident 1's family member (FM) 1 was conducted. FM 1 stated, after Resident 1 died, FM 2 informed her (FM 1) on 5/20/20 that Resident 1 received a check amounting to $ 26,000 as an inheritance. FM 1 stated, $5,000 was deposited towards funeral cost through a conservator and the $21,000 was deposited to the bank. FM 1 stated, Resident 1 also had a trust fund with the facility. FM 1 stated she was not very close with Resident 1, and that FM 2 was designated as one of the emergency contacts for Resident 1. On 7/13/21 at 1:15 P.M., an interview with FM 2 was conducted. FM 2 stated, she grew up with Resident 1 and they had a close relationship. FM 2 stated, Resident 1's conservatorship ended in March 2020 and Resident 1 managed his own finances until his death. FM 2 stated, they (the family) provided Resident 1 cigarettes and other personal necessities whenever they visited. FM 2 stated, on 5/12/20, she was informed by the SSD through an email that Resident 1 had received a large amount of money. FM 2 stated, Resident 1 wanted her (FM 2) to keep the check, but she (FM 2) declined. FM 2 stated, during a visit with Resident 1 in June of 2021, Resident 1 mentioned to FM 2 that the SSD kept his debit card. FM 2 stated, she was not aware of the account Resident 1 mentioned. FM 2 stated she emailed the SSD for more information, but the SSD never replied to the e-mail. FM 2 stated, after Resident 1 died, she began to review Resident 1's bank account online and saw odd charges stemming from 9/15/20. FM 2 stated, on 7/6/21, she contacted law enforcement to report a possible fraud or financial abuse. FM 2 stated she knew it was the SSD who was using Resident 1's account because the SSD's personal cell phone number was listed as contact phone number in the account. A record review of Resident 1's trust fund in the facility titled, "Resident Statement Landscape" (RSL), indicated, on 6/11/20, a check amounting to $21,168.86, dated 12/11/19, was deposited to Resident 1's trust fund. On 9/2/20, the facility issued a check back to Resident 1 amounting to $18,603.18. On 8/6/21, Resident 1's trust fund had an ending balance of $4482.97. A record review of Resident 1's bank statement provided by FM 1, dated 9/14/20 to 6/7/21, was conducted. The bank statement indicated, on 9/14/20, Resident 1 had opened an account and deposited a check amounting to $18,603.18, minus a $25.00 bank fee. The bank statement indicated from 9/15/20 to 6/7/21, charges were made from Resident 1's bank account at different places such as a cigar house, popular big box stores, restaurants, convenient stores, and cash withdrawals. Resident 1's bank statement indicated, on 6/7/21, the ending balance was $6,621.54. On 7/13/21 at 2:47 P.M., an interview with administrator (Admin) 1 was conducted. Admin 1 stated, he started working at the facility in March 2021. Admin 1 stated the activities of the social services department was directly under the supervision of the administrator. Admin 1 stated, on 7/6/21, FM 1 presented Resident 1's bank statement which indicated suspicious fraudulent charges that Resident 1 could not have done because he was in the facility most of the time. Admin 1 stated during the investigation, the SSD initially denied knowing about the charges on Resident 1's bank account. Admin 1 stated, a few minutes into the interview, the SSD admitted to Admin 1 and to the Director of Clinical Operations that she had used Resident 1's debit card for her personal purchases, services and cash withdrawals. Admin 1 stated, the SSD stated on 9/14/20, the SSD took Resident 1 to the bank to open an account with the check issued by the facility amounting to $18.603.18. Admin 1 stated, the SSD felt Resident 1 authorized her to borrow his money and would pay Resident 1 back with her tax return. Admin 1 stated, the SSD admitted to the misappropriation of personal funds of Resident 1. Admin 1 stated the SSD was immediately terminated from her employment and was escorted out of the facility by the Sheriff Department. Admin 1 stated, the facility had a locked vault where resident's valuable items such as money, debit card and jewelries were deposited for safekeeping. Admin 1 stated only the administrator had access to the vault. Admin 1 stated, the SSD never surrendered Resident 1's debit card to the facility for safekeeping. On 7/14/21 at 1:15 P.M., a telephone interview with the SSD was attempted. The SSD was not available for an interview. A review of the Social Services progress notes, dated from 4/12/19 to 6/30/21 was conducted. The progress notes indicated no documentation related to the SSD and Resident 1 going to the bank and opening an account on 9/14/20. There was also no mention of Resident 1's account on all the IDT (Interdisciplinary Team) meetings. On 8/18/21 at 4:15 P.M., an interview with Nurse Practitioner (NP) 1 was conducted. NP 1 stated, Resident 1 had been under her care and knew Resident 1 very well since 6/11/19. NP 1 stated, she considered Resident 1 as a vulnerable adult. A review of NP 1's notes, dated from 6/11/19 to 5/26/21, was conducted. The notes indicated, Resident 1 had impaired insight/judgement, calculations, and abstraction. On 8/23/21 at 10 A.M., an interview with the former administrator (Admin) 2 was conducted. Admin 2 stated, she was the administrator at the facility until March 2021. Admin 2 stated the amount of money in Resident 1's trust account was too big to be handled by the facility. Admin 2 stated, a check amounting to $18,603.18 was issued back to Resident 1 from the trust fund. Admin 2 stated, Resident 1 was encouraged to open a personal bank account outside of the facility. Admin 2 stated, Resident 1 was not referred to the appropriate state agencies because he was determined competent enough to have financial decision making at that time. Admin 2 stated the debit card of Resident 1 was never surrendered to the facility for safekeeping. Admin 2 stated, she did not know the SSD was holding Resident 1's debit card. On 3/22/22 at 3:30 P.M., an interview with the current administrator (Admin) 3 was conducted. Admin 3 stated, the administrator had the responsibility of protecting the resident's funds and property specially if a resident had no capacity to decide on finances and medical management. Admin 3 stated, "If I were the administrator when the check was issued by the facility, I would not have allowed a personal bank account for Resident 1 to be opened because the resident had no capacity for financial or medical decisions and had no power of attorney (POA). Admin 3 stated, the facility should have filed for a new conservatorship to manage Resident 1's finances. Admin 3 further stated another way to manage the money was to deposit the money in Resident 1's trust and work with Medi-Cal for Resident 1's care and needs. Admin 3 stated, she expected the staff to be the first to advocate for the protection of residents against any kind of abuse and to not take advantage of all residents, especially vulnerable residents. Admin 3 stated, the importance of protecting all residents from any kind of abuse was to prevent significant harm, distress, and exploitation. A review of the facility's policies and procedure titled, "Abuse and neglect prohibition", dated 4/15/01, was conducted. The policy indicated, each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. The facility failed to ensure Resident 1 was free from financial abuse. As a result, Resident 1's bank account was accessed by the facility's Social Services Director (SSD) without Resident 1's permission. Resident 1's money, amounting to almost $12,000.00, was used by SSD for her own personal use, without Resident 1's knowledge. This violation had a direct or immediate relationship to the health, safety, or security of residents.