Health inspection·July 17, 2023

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their Inventory List, Resident's Personal policy for one of three residents (R1) reviewed for theft. This failure resulted in money and credit cards being stolen from R1's purse. Residents Affected - Few Findings include: Facility's incident report of 5/8/2023 documents in part, CNA (Certified Nurse Assistant) notified Executive Director (V1 Administrator) that patient (R1) requested to meet. (V1) met with (R1) at approximately 8:45 AM on 5/1/2023. (R1) told (V1) that she realized on Sunday evening (4/30/2023) that some cash ($24.00) and her five credit cards were missing from her wallet and purse. (R1) does not remember looking in her wallet since Wednesday, 4/26 at about 12 noon. (R1's) wallet was in her purse-and the purse (was) hanging on the chair next to her bed. Investigation included a questionnaire being completed by department staff. No significant findings surfaced to help us identify the person that took the money and credit cards. (V1) also met with (R1's) roommate. Other resident interviews were conducted. No useful information was obtained from these interviews. We identified an Inventory List of Resident Personal Belongings upon admission that did not get completed for (R1) by the CNA or Nurse. This is required per policy to protect the resident('s) personal property and valuable items during their stay at the community. Investigation found evidence of financial exploitation. This was due to our non-compliance related to not completing the resident's Inventory of Personal Belongings-and then securely storing those valuable items. On 7/15/2023 at 2:00 PM, V1 (Administrator) said he was informed on 5/1/2023 by a CNA that R1 wanted to speak with him but did not offer any other information. V1 said he spoke with resident, who informed him that she was missing $24 and five credit cards from her purse which she kept at her bedside hanging on a chair. V1 said R1 told him that she realized on 4/30/2023 that the cash and credit cards were missing from her purse; the last time she had looked in her purse was four days earlier. V1 said R1 was reimbursed $24. On 7/17/2023 at 9:58 AM via telephone, R1 said she discovered money and credit cards missing from her wallet on 4/30/2023. R1 said she reported this to the V1 (Administrator). R1 said she was re-imbursed $24 by V1. R1 also said when she was admitted to the facility, no one asked her about her valuables or inventoried her belongings. Page 1 of 2 145748 145748 07/17/2023 Montgomery Place 5550 South Shore Drive Chicago, IL 60637

F 0602 Level of Harm - Minimal harm or potential for actual harm R1's medical record (Face Sheet) documents R1 is an [AGE] year-old admitted to the facility on [DATE] with diagnoses including but not limited to: Encounter for Surgical Aftercare Following Surgery on the Digestive System, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus Without Complications, and Essential (Primary) Hypertension. R1's MDS (Minimum Data Set, 4/28/2023) documents R1's BIMS (Brief Interview for Mental Status) as 13 or cognitively intact. Residents Affected - Few On 7/17/2023 at 11:50 AM, V1 said V11 (Agency Licensed Practical Nurse/LPN) and V12 (CNA) were staff responsible for completing R1's inventory list upon admission. On 7/17/2023 at 11:54 AM, V11 (Agency LPN) said, I did not receive any orientation related to admissions. So, I did what I was instructed to do at other facilities, I gave the inventory list to the CNA (to complete). V12 (CNA) was not available for interview. On 7/17/2023 at 1:59 PM, V19 (Registered Nurse) said, the nurse and CNA should complete resident inventory list upon resident's admission. Concern dated 5/1/2023 documents (R1) voiced concerns of missing funds/wallet. (R1) stated someone had taken her funds $24.00 and credit cards. Inventory List, Resident's Personal policy (undated) documents in part: Basic Responsibility-Licensed Nurse Certified Nursing Assistant, Social Service Personnel, Other Procedure 1. Record all items on the resident's inventory list. 3. Review list of items with resident and/or representative. Ask resident or representative to sign acknowledgement of inventoried items. 4. The individual completing the inventory list is to witness the signature by signing complete name and title. 5. Give a copy of the inventory list to the resident or resident's representative. 10. Document money and valuables left with the resident and/or who accepted responsibility for these items. Facility's abuse policy and procedure (Page 2, undated) states: Misappropriation of property is the deliberate misplacement, exploitation or wrongful, temporary or permanent, use of a resident's belongings or money without resident's consent. 145748 Page 2 of 2