Other·September 11, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an Abbreviated Standard Survey for the investigation of facility reported incident number: CA00642815. Representing the California Department of Public Health: 16553, Health Facilities Evaluator Nurse (HFEN). The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for facility reported incident number-CA00642815.

F602 SS=D Free from Misappropriation/Exploitation CFR(s): 483.12

F602 09/09/2019 §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. This REQUIREMENT is not met as evidenced by: Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to prevent fiduciary abuse/misappropriation of Resident 1's property when Resident 1 reported approximately $450.00 was missing from his pocket book (a purse with multiple zippered LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8DCM11 Facility ID: CA010000372 If continuation sheet 1 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555095 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - YOUNTVILLE 100 California Dr Yountville, CA 94599 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE compartments and a long strap that Resident 1 wore around his neck). This failure had the potential for Resident 1 to suffer mental/psychological distress that could potentially impact Resident 1's level of functioning. Findings: Resident 1's record was reviewed on 6/18/19. Resident 1 was an 89-year-old individual with diagnoses that included, but were not limited to, diabetes and chronic kidney disease. Resident 1 scored 15 on the BIMS (Brief Interview for Mental Status /cognitive test) which indicated little to no cognitive impairment. Review of the "Social Service Quarterly Report," dated 6/12/19, indicated that Resident 1 was able to manage his own finances. According to facility documentation, dated 6/17/19, Resident 1 reported that he was missing approximately $450.00 since 6/16/19 and stated he lost the money while he was taking a shower. Documentation indicated that Resident 1 reported that the only time his pocket book was out of sight was when he got up from his electric scooter and sat on the shower chair, at which time he pulled the shower curtain. Resident 1 stated that CNA (Certified Nursing Assistant) B handed him his pocket book after his shower and told him it had fallen off the scooter so she picked it up. Documentation indicated Resident 1 "adamantly" insisted that his pocket book would not have fallen off of the arm of his electric scooter because it was securely wrapped around the arm of the scooter. Resident 1 was interviewed on 6/18/19 at 2 p.m. Resident 1 stated that it was Sunday, his FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8DCM11 Facility ID: CA010000372 If continuation sheet 2 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555095 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - YOUNTVILLE 100 California Dr Yountville, CA 94599 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE bath day, and before his shower, he tied his pocket book strap around the arm of his electric scooter. Resident 1 proceeded to demonstrate how he securely wrapped the long strap of the pocket book to the arm of the scooter and stated, "It can't drop." Resident 1 stated that CNA B told him that he dropped his purse. Resident 1 stated, "I didn't drop it, she took it off." Resident 1 reported, at the time of his shower, he had $500.00 in his pocket book and after his shower, reported the entire amount was missing. Resident 1 stated that four $100.00 dollar bills were in one zippered compartment and other smaller bills were in another separate zippered compartment. Resident 1 stated that he "felt empty" after he realized the money was missing and stated, "I didn't think it would happen, I trust people, I felt bad." During an interview with CNA B on 6/18/19 at 2:30 p.m., CNA B confirmed that on 6/16/19 she provided care to Resident 1 and gave him a shower at approximately 9 a.m. CNA B stated that Resident 1 had asked her to tie his pocket book to the arm of the scooter. CNA B further stated, "I did not tie it tight." CNA B stated that she helped Resident 1 shower and get dressed. She stated she was in a rush and did not want him to fall so she grabbed the scooter and the pocket book fell on the floor. She stated she placed the pocket book on the sink and then assisted Resident 1 to sit on the scooter. CNA B stated that she saw the money on the floor and said, "It's my fault, I did not return the money to him. There were four 100.00 bills, I didn't return it, I kept them, I'm sorry." The policy for "Elder Abuse, Prevention and Reporting," last reviewed 3/19/19, contained the following entry: Each resident has the right FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8DCM11 Facility ID: CA010000372 If continuation sheet 3 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555095 (X3) DATE SURVEY COMPLETED 08/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VETERANS HOME OF CALIFORNIA - YOUNTVILLE 100 California Dr Yountville, CA 94599 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to be free from abuse, exploitation, mistreatment, neglect, and misappropriation of property. Misappropriation of Resident property was defined as: "The deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a Resident's belongings or money without the Resident's consent." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8DCM11 Facility ID: CA010000372 If continuation sheet 4 of 4