Health inspection·October 3, 2025

§483.12(c)(1)- Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §72523- Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. (c) Each facility shall establish and implement policies and procedures, including but not limited to: 2(A) Current nursing procedure manuals. Health and Safety Code- 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 8/21/25 at 9:44 A.M., an unannounced visit to the facility was conducted relative to a complaint from Resident 1 regarding his money that was stolen by an unknown certified nursing assistant (CNA), amounting to $4,700 and that the facility Administrator (ADM) told Resident 1 the facility was not responsible. The facility failed to: 1. Report to the Department within 24 hours as required which resulted in the delay of investigation. 2. Follow and implement their own policies and procedures related to reporting an alleged or suspected case of theft, exploitation or misappropriation of resident property. On 8/21/25 at 12 noon, an interview with Resident 1 was conducted. Resident 1 stated he took out his $ 3200 dollars total in large $100 bills from the business office on 5/30/25 and signed the document. Resident 1 stated it was his lifelong money from social security and that he wanted it back. Resident 1 stated he told the Administrator (ADM) on 8/7/25 that the money was missing from his room. Resident 1 stated he wondered why the investigation on the missing money was just started on 8/21/25 when Resident 1 had reported the money missing on 8/7/25. Resident 1 stated when he came back to his room, he found his bedding and everything on his bed, all tossed away. On 8/21/25, a review of Resident 1' records were conducted: The Facility's Admission Record (AR) indicated Resident 1 was admitted to the facility on 5/26/25 with diagnoses which included Aftercare following Joint Replacement. The Minimum Data Set (MDS - a federally mandated assessment tool) dated 6/2/25, indicated a brief interview for mental status (BIMS) score of 11, which indicated Resident 1's cognition (thought process) was mildly impaired. A cognitively intact has a score of 13-15. On 8/21/25 at 1:20 P.M., an interview with the Administrator (ADM) was conducted. The ADM stated, "I did not know that we had to report the incident since no one was accused of stealing the money" until the surveyor came to the facility and started to investigate, including interviewing Resident 1. The ADM could not provide evidence that the incident was reported to the Department. On 8/21/25 at 1:30 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the facility should have reported any forms of abuse, in a timely manner as required by state laws. On 8/21/25 at 2:18 P.M., a second interview with the DON was conducted. The DON confirmed that the facility reported the incident on 8/21/25. This was 14 days later after Resident 1 had informed the ADM of the allegation. On 8/22/25, A review of the facility's record titled, "Investigating Incidents of Theft and/ or Misappropriation of Resident Property" dated April 2021, indicated ...6. If an alleged or suspected case of theft, exploitation or misappropriation of resident property is reported, the facility administrator, or his designee, notifies the following person or agencies within twenty-four (24) hours of such incident as appropriate: a. State licensing & certification agency... A review of the facility's policy dated January 2011 indicated, ...2. within 5 working days of the alleged incident, the facility will give the resident, resident representative, the ombudsman, the state survey and certification agency... written report of the findings of the investigation and summary of corrective action... In violation of the above standards cited, the facility failed to report the allegation of missing money amounting $4,700 to the Department within 24 hours as required, which resulted in the delay of investigation. In addition, the facility failed follow and implement their own policies and procedures related to reporting an alleged or suspected case of theft, exploitation or misappropriation of resident property. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.