Health inspection·March 15, 2024

The following reflects the findings of the California department of Public Health during the investigation of a complaint #871548 and 878046, and facility reported incident #873414. Health & 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 12/5/23, an announced visit was conducted at the facility to investigate a complaint regarding alleged abuse towards one long-term care resident (Resident 1). Resident 1 was a 75-year-old male, admitted to the facility on 5/17/18. Resident 1's diagnoses included malignant neoplasm of the bladder (bladder cancer- cancer that begins in the cells of the bladder. The bladder is a hollow muscular organ in your lower abdomen that stores urine.), anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), and pain related to cancer. Based on interview and record review, the facility failed to ensure suspected financial abuse was reported timely for one of two sampled residents (Resident 1). This failure resulted in a delay of investigation and had the potential for Resident 1 to be at risk for further abuse. Findings: During an interview on 12/5/23 at 11:47 a.m. with Accounts Payable (AP), AP stated License Vocational Nurse (LVN 1) made her aware Resident 1 used to have money, but recently LVN 1 was buying his cigarettes. AP stated LVN 1 asked her to investigate it. AP stated, she took Resident 1 to the bank. Resident 1 had his old debit card, the bank would not give him any information, due to not having an identification card (ID). AP stated Resident 1 was the only account holder for the bank account and he could not recall the last time he used his debit card. AP stated, she took Resident 1 to the department of motor vehicle to get an ID. AP stated on 11/2/23 the bank gave Resident 1 a printed document of the last 30 days activities, and there were withdrawals for thousands of dollars. AP stated Resident 1 told her "He has no idea who would have done that." AP stated, "I did not document in [Resident 1's] medical record but reported it in the stand up [meeting]." During an interview on 12/5/23 at 12:21 p.m. with LVN 1, LVN 1 stated, "[Resident 1] is my smoking buddy he was asking me for cigarettes, [LVN 1] did not mind it but I was concerned because he used to have money to buy cigarettes." LVN 1 stated she spoke to AP about a month ago so AP could look into Resident 1's financial situation. During an interview on 12/5/23 at 12:50 p.m. with Administrator, Administrator confirmed AP informed him about Resident 1's financial situation about two weeks ago. Administrator stated, "[AP] told me, 'There was something funky going on' and [AP] wanted to take Resident 1 to the bank. Administrator stated [AP] had mentioned "There was something fishy going on." Administrator stated he was not aware there was an actual financial abuse going on, he was just aware there was an issue with Resident 1's financial situation. Administrator stated when APS (adult protective services) came, he was not aware it was for Resident 1. Administrator stated, "Once APS is involved, I thought ok, it was probably already taken care of." Administrator stated his responsibility is to report to California Department of Public Health (CDPH), local law enforcement, Ombudsman, and APS. Administrator stated reporting timeline was two hours for abuse. Administrator confirmed the suspected financial abuse was not reported to CDPH or other agencies. During an interview on 12/5/23 at 12:59 p.m. with Social Services Director (SSD), SSD stated Resident 1's bank informed her Resident 1's account was receiving monthly deposit, and someone was withdrawing it. SSD stated she was "concerned" but "I thought the girl (staff from the bank) had taken care of it. I assumed it was taken care of because APS was out. I thought the APS was out because we called them, but I was informed this morning that it was not the case it was the bank." During an interview on 12/5/23 3:30 p.m. with the Director of Nursing (DON) and Administrator, DON stated the facility reported Resident 1's financial Abuse today (12/5/23, approximately 33 days after financial abuse was suspected). Administrator stated, "Recently we have had a lot to report, it [Resident 1's suspected financial abuse] fell through the cracks." Administrator stated, "Half of us were assuming it was us that called APS." Administrator stated the situation should have been drilled down more. During a review of the facility's policy and procedure (P&P) titled, "Abuse Prevention and Prohibition Program," revised 1/31/20, the P&P indicated, "IX. A. Facility Staff are mandatory reporters . . . C. All mandated reporters will report reasonable suspicion of a crime against a resident when it is objectively reasonable for a person to entertain a suspicion of conduct that appears to be financial abuse . . . resulting in . . . the deprivation of goods . . . D. The Facility will report allegations of abuse, . . . misappropriation of resident property, or other incidents that qualify as a crime. i. Immediately, but no later than 2 hours if the alleged violation involves abuse . . . to the state survey agency, law enforcement, and the Ombudsman. ii. No later than 24 hours - If the alleged violation (e.g., misappropriation of property, neglect) does not involve abuse and does not result in serious bodily injury to the state survey agency, law enforcement, and the Ombudsman." The facility failed to ensure suspicion/allegation of financial abuse was reported timely. This failure resulted in violation of health and safety code and had a direct or immediate relationship to the health, safety, or security of Resident 1 and constitutes a class "B" citation.