Health inspection·February 19, 2025

Brookside Care Center Recert Survey: KZNX11 1/31/25 Representing the Department: Leigh Danipour 50161 State Citation B was written Code of Federal Regulations, Title 42, Section §483.12 483.12(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 1/31/25, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to conduct a recertification survey and investigate six Facility Reported Incidents. The Department determined the facility failed to ensure allegations of abuse were reported to the state survey agency after Resident 40 reported his suspicion that 2 facility staff members had stolen his money. This failure resulted in a delay of the state survey agency investigating the allegations of abuse, which had the potential to put residents' psychosocial and physical health and safety at risk. Resident 40 was admitted into the facility with diagnoses including but not limited to depression (affects how you feel, think and behave and can lead to a variety of emotional and physical problems) and anxiety (excessive fear or worry about a specific situation). Review of Resident 40's facility document titled, "Property Loss Report," dated 8/9/24, indicated, Resident 40 reported to the facility staff that two CNAs (Certified Nurse Assistants) took his $2400 cash kept in his zip-lock bag on 8/9/24. The report also indicated that the facility decided not to reimburse the missing cash as "Money that was Reported missing did not equal amount that was released to the Resident." During a concurrent observation and interview on 1/28/25, at 10:47 a.m., Resident 40 stated he was missing approximately $2600. Resident 40 stated his money was taken by two CNAs which he identified by name (name redacted, CNA 6 and CNA 7). Resident 40 explained the money was contained in an envelope and wrapped in a towel and stated he kept it tucked into his bedding. Resident 40 stated after the incident he told his nurse his money was gone. During a concurrent interview and record review on 1/31/25, at 1:18 p.m., the Social Services Director (SSD) 1 stated Resident 40 had cash in his possession in the amount of $1088.00 prior to his allegation of missing money in August (2024). SSD 1 provided and reviewed Resident 40's "Theft and Loss Report" dated 8/9/24, and stated at the time of the incident Resident 40 had called wanting to speak with him (SSD 1) and Resident 40 told him two CNAs took his money when they were changing his bed linens in his room. SSD 1 stated because Resident 40 signed a paper releasing Resident 40's money to him that the facility had held for him in the facility safe on 4/9/24, Resident 40 had assumed the risk and would not be reimbursed. During an interview and record review on 1/31/25, at 2:05 p.m., the Administrator (ADM) reviewed Resident 40's "Theft Loss Report" provided by SSD 1 and stated he was not aware Resident 40 had taken cash out of the safe earlier in the year. The ADM stated he did not think Resident 40 had any money in his possession and stated looking at the bigger picture he would have followed a different path knowing Resident 40 took out his money in April (2024). The ADM confirmed the incident should have been reported to the Department as abuse due to Resident 40's reporting of two specific CNA's taking his money. The ADM stated the facility was still supposed to help safeguard Resident 40's possessions and stated he would have done something sooner had he known Resident 40 had money in his possession. During a phone interview on 2/3/25, at 9:16 a.m., the Ombudsman (OMB, long term care ombudsman are advocates and can assist residents to obtain quality care) 2 stated she was familiar with Resident 40, and he came to the Resident Council Meeting (meeting held at long-term care centers for residents, as a group, to influence the quality of their care) held at the facility on 8/22/24. The OMB 2 stated Resident 40 brought up the issue with his money at the meeting and afterward she met with him privately. The OMB stated Resident 40 seemed very upset over the incident and spoke with the ADM regarding the issue. Review of a facility Policy and Procedure (P&P) titled, "Compliance with Reporting Allegations of Abuse/Neglect/Exploitation," dated 2024, indicated, "...It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator at the facility and to other appropriate agencies in accordance with current state and federal regulations with prescribed timeframe...The Administrator or designee will...Notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident..." Therefore, the department determined the facility failed to ensure allegations of abuse were reported to the state survey agency after Resident 40 reported his suspicion that 2 facility staff members had stolen his money. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.