Health inspection·October 10, 2024

Guardian Care and Rehabilitation Center The following reflects the findings of the California Department of Public Health during the investigation of: Complaint # CA00908274, CA00911015 Survey Event ID: VWEZ11 State Citation B was written. Code of Federal Regulations, Title 42, Section §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. Code of Federal Regulations, Title 42, Section §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. California 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 5/29/24 at 1:52 p.m., the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding abuse. The Department determined the facility failed to report an allegation of stolen property to the facility Administrator and the Department within twenty-four hours and the facility failed to protect patients from misappropriation (the unauthorized use of funds or other property for purposes other than that for which intended) of property and personal belongings for 2 of 25 sampled patients (Patient 1 and Patient 2) when: 1. Patient 2 reported to staff her suspicion that staff stole 200 dollars during the first week of July 2024, and the facility reported the incident to the Department on 7/19/24; and 2. Certified Nursing Assistant (CNA) 6 took Patient 1's wallet containing money, Automated Teller Machine (ATM) card, health insurance card, and ID (Identity Document) without Patient 1's consent. This failure resulted in a delay of the state survey agency and the facility in investigating an allegation of misappropriation of property, which had the potential for continued loss and/or theft of other patients' property/money. This failure also caused emotional distress to Patient 1 and Patient 2. 1. A review of Patient 1's "Admission Record," indicated Patient 1 was admitted to the facility in early 2024 with multiple diagnoses. A review of Patient 1's Minimum Data Set (MDS, an assessment and care screening tool) dated 5/26/24, indicated Patient 1 had the ability to understand and be understood by others with a Brief Interview for Mental Status (BIMS) score of 15 (a score of 13 to 15 suggests memory is intact). During an interview on 7/16/24, at 11:10 a.m., Patient 1 stated CNA 6 came to her and pulled Patient 1's wallet out. Patient 1 stated her wallet had $160.00, an ATM card/debit card, health insurance card, and an ID. Patient 1 stated she was very scared. During a concurrent interview and record review on 7/17/24, at 9:29 a.m., with the Director of Staff Development (DSD), the DSD stated CNA 6 was responsible for taking Patient 1's wallet and verified Patient 1's wallet contained $160.00, ATM/debit card, insurance card and ID. The DSD stated she confirmed the stolen items with Patient 1's family member. CNA 6's personnel record was reviewed with the DSD. CNA 6 had orientation to the facility on 6/18/24 at which time CNA 6 received and signed an in-service for "Theft and Loss." The DSD stated CNA 6 was terminated from work on 7/7/24. During an interview on 7/17/24 at 12:16 p.m. with Licensed Nurse (LN) 10, LN 10 stated he heard Patient 1 screaming for help. LN 10 stated he observed CNA 6 at the facility entrance leaving the facility. LN 10 stated he went to Patient 1's room and Patient 1 informed him CNA 6 stole her wallet. LN 10 further stated one of the housekeeping staff saw CNA 6 outside Patient 1's room when Patient 1 was screaming for help. During a concurrent interview and record review, on 7/17/24, at 2:23 P.M., with the Social Services Director (SSD), the SSD stated Patient 1's money was reimbursed. During a review of Patient 1's care plan initiated on 7/16/24, indicated, "...[Patient 1] has a potential for trauma r/t [related to] theft and lost incident on 7-7-24..." Review of the facility's policy and procedure titled, "Identifying Exploitation, Theft and Misappropriation of Resident Property," indicated, "...Exploitation, theft and misappropriation of resident property are strictly prohibited..."Misappropriation of resident property" means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without resident's consent...Examples of misappropriation of resident property include...theft of money...theft of personal belongings..." 2. During an interview on 7/18/24, at 12:20 p.m., Patient 2 stated that she took 200 dollars out of the bank at the end of June and kept the money in her wallet. Patient 2 further stated a certified nursing assistant (CNA) came in about a week later and asked if she had change for twenty dollars. Patient 2 stated when she pulled her purse out, she noticed her 200 dollars was gone, and she told Licensed Nurse (LN) 10. Patient 2 further stated this occurred shortly after 7/4/24. Patient 2 stated she asked LN 10 several times for information regarding a follow-up, but LN 10 never got back to her. During an interview on 7/18/24, at 2:36 p.m., Patient 2 stated having someone come into her room and go through her personal belongings made her feel terrible and very upset. Patient 2 further stated she liked to have her own money because sometimes she wanted to purchase things or go out for a pedicure. During a telephone interview on 7/18/24, at 4:22 p.m., LN 10 stated Patient 2 told him someone took money from her purse on either 7/1/24 or 7/4/24. LN 10 further stated Patient 2 told him she suspected a specific CNA because that person came into her room earlier that day and knew where her money was in her purse. LN 10 stated he notified the charge nurse and wrote a note to the social worker and left it under the social worker's office door. LN 10 further stated that he also told the night nurse to follow up with the social worker the next day. LN 10 stated that he had not followed up with the social worker regarding Patient 2. During an interview on 7/19/24, at 11:17 a.m., the Social Services Director (SSD) stated she had not received notification regarding a theft or loss for Patient 2. During a subsequent interview on 7/19/24, at 11:49 a.m., the SSD stated she was not aware Patient 2 had missing money. The SSD stated if she had known, she would have made a police report and followed up with the patient to monitor for psychosocial distress. During an interview on 7/19/24, at 3:56 p.m., the Administrator (ADM) stated staff should have gone to social services as soon as they received the allegation or complaint. The ADM further stated that he was not aware of Patient 2 missing money. The ADM confirmed Patient 2's report of missing money in the amount of 200 dollars was considered abuse, and due to this it should have been reported to the police, to the Department, and ombudsman (advocate for seniors) within 24 hours. Review of the facility's undated policy and procedure titled, "ABUSE PROHIBITION AND PREVENTION POLICY AND PROCEDURE AND REPORTING REASONABLE SUSPICION OF A CRIME IN THE FACILIY POLICY AND PROCEDURE," indicated, "...facility staff are...Mandated Reporters [people required by law to report suspected or known instances of abuse]...all mandated reporters will report reasonable suspicion of a crime against a resident...examples of crimes that need to be reported include...theft...the Facility will report allegations of abuse...misappropriation of resident property...No later than 24 hours (actual, alleged...misappropriation of property)...To Whom...Facility Administrator, State Survey Agency, Law Enforcement, Ombudsman..." Therefore, the Department determined the facility failed to report an allegation of stolen property to the facility Administrator and the Department within twenty-four hours and the facility failed to protect patients from misappropriation (the unauthorized use of funds or other property for purposes other than that for which intended) of property and personal belongings. This violation had a direct or immediate relationship to the health, safety, or security of Patient 1 and Patient 2.