Health inspection·December 11, 2024

The following reflects the findings of the California Department of Public Health during the investigation of Facility Reported Incident number 920872. The inspection was limited to the specific facility reported incident investigated during an Abbreviated Standard Survey and does not represent the findings of a full inspection of the facility. Representing the Department: 38993, HFEN A deficiency was written for Facility Reported Incident #920872 at F-tag/S/S F600/D. F602 §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. INTENT §483.12 On 9/19/24, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding an alleged misappropriation of property to a long-term care resident. Resident 1 is a 73-year-old male who was admitted to the facility on 8/15/23 with diagnoses of personal history of transient ischemic attack (TIA-a temporary stroke that occurs when blood flow to the brain is cut off). . .cognitive communication deficit. . ." Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) personal funds were accounted for when they were kept secured in the nurse's medication cart. This failure resulted in Resident 1's personal funds being unaccounted for and the potential for emotional distress for Resident 1. Findings: During a review of the facility's "5-day report" (DR), dated 9/23/24, the DR indicated, "On 9/16, it was reported to Administrator, the resident (Resident 1) alleges staff of stealing his money. There was only 2 twenty-dollar bills and one ten dollar bill left in resident envelope." During a review of Resident 1's "Progress Notes" (PN), dated 4/30/24 (approximately 5 months prior to reporting) at 1:32 p.m., the PN indicated, "Resident came into writers office requesting to have a place to store his money. Writer informed resident that money could be counted in front of resident and two RNA's (Restorative Nursing Assistance) present in writer's office. Resident agreed to have money stored in nurses med (medication) cart and money was counted it was a total of $2600.00 that was placed in an envelope and placed in the nurses medication locked box." During a review of Resident 1's money envelope, that was kept in the nurse's medication cart, the envelope indicated on 4/30/24 Resident 1 had $2,600, and it was signed by LVN 1 (Licensed Vocational Nurse) and Resident 1. On 6/10/24 the envelope indicated Resident 1 had $1,000 remaining and it was signed by LVN 2. On 9/16/24, when the money was reported missing, the envelope contained $50 cash. During an interview on 9/19/24 at 11:06 a.m. with Director of Nursing (DON), DON stated on 9/16/24 when Resident 1 reported his money missing, Resident 1's envelope of money from the nurse's station was retrieved. DON stated Resident 1's envelope indicated there was $2,600 on 4/30/24, 6/10/24 the envelope indicated there was $1,000 left ($1,600 less) but the envelope only contained $50. There was no documentation indicating when or who removed the total of $2,550 from the envelope. DON stated all the nurses who had worked on the medication cart would have had access to Resident 1's money. During an interview on 9/19/24 at 11:30 a.m., with LVN 1, LVN 1 stated when money was removed from Resident 1's envelope, it should have been counted with the resident, the date and amount given to the resident should be documented on the envelope, and the nurse and resident should have signed the envelope with the remaining balance. During an interview on 9/25/24 at 3:04 p.m. with Administrator, Administrator stated when the money was in the nurse's medication cart, it was the responsibility of the nurse to document when the money was removed from the envelope. Administrator stated Resident 1's money should have always been accounted for. During a review of the facility's policy and procedure (P&P) titled, "Resident Personal Funds" dated 2024, the P&P indicated, "The facility will establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's person funds entrusted to the facility on the resident's behalf." During a review of the facility's policy and procedure (P&P) titled, "Abuse, Neglect and Exploitation" dated 2024, the P&P indicated, "The facility will implement policies and procedures to prevent and prohibit all type of abuse, neglect, misappropriation of resident property, and exploitation that achieves: Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur. . .Possible indicators of abuse include, but are not limited to. . .Resident reports of theft of property, or missing property. . ." In violation of the above cited, the facility failed to protect Resident 1's monies. This failure resulted in Resident 1 having financial loss. This violation had a direct or immediate relationship to the health, safety, or security of residents and constitutes a Class "B" citation.