Health inspection·August 19, 2025

F609 §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. On 7/15/25 at 10:15 am, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding the misappropriation of resident property. The facility had reasonable suspicion that a Certified Nursing Assistant (CNA) had stolen Resident 2 and 3’s wedding rings and posted them for sale on social media. This resulted in emotional distress and mental anguish for Resident 2 and 3. The facility failed to ensure that when a reasonable suspicion of crime against Resident 2 and 3 was suspected that they: 1. Reported the misappropriation of the resident’s property to the California Department of Public Health (CDPH), in accordance with State law. 2. Adhered to the policy and procedures for reporting and investigating abuse, neglect, exploitation, and misappropriation. A review of the “Admission Record,” dated, 5/1/24, indicated, Resident 2 was admitted to the facility on 3/28/22 with the diagnoses of unspecified dementia (memory loss) with behavioral disturbance and major depression (a sad mood). Resident 2 was not his own responsible party (RP, decision maker). A review of the Annual Minimum Data Set (MDS, a resident assessment tool), dated 4/24/25, indicated Resident 2 had scored 6 out of 15 during a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident), which indicated severe cognitive (thinking or remembering) impairment. A review of the “Admissions Record,” dated 4/18/25, indicated, Resident 3 was admitted to the facility on 4/18/25 with the diagnoses of depression, anxiety, and difficulty with walking. Resident 2 was not her own RP. A review of the Admission MDS, dated 4/27/28, indicated Resident 3 had severe hearing and vision loss. The MDS indicated Resident 3 had a BIMS score of 15 out of 15, which indicated intact cognition. During an interview on 7/15/25 at 11:11 am, CNA F stated, “CNA D was arrested for stealing from residents.” CNA E was present during the interview and confirmed, CNA D was arrested for stealing resident property and stated, “the police department came to the facility to arrest CNA D.” A review of the document titled, “Grievance Complaint Form,” dated 6/23/25, indicated, FM H, reported to the facility that Resident 3’s wedding ring was missing. A review of the document titled, “Grievance Complaint Form,” dated 7/7/25, indicated, FM J, reported to the facility that Resident 2’s wedding ring was missing. During an interview on 7/16/25, at 1:30 pm, Administrator (ADMIN) stated, “a few weeks ago, I got a call from Resident 3’s FM, stating Resident 3’s wedding ring was missing.” Admin stated, “we followed the facility’s protocols for lost and missing items and was not able to find the ring.” ADMIN stated, on the evening of 7/7/25, ADMIN “noticed an online post from CNA D with jewelry for sale and on 7/8/25, I was informed Resident 2’s wife alleged Resident 2’s ring was missing.” ADMIN stated, “CNA D was assigned to Resident 2 and 3 when the missing rings were reported” and confirmed, on 7/8/25, there were suspicions that CNA D had stolen Resident 2 and 3’s wedding rings. A review of the facility’s policy and procedure titled, “Abuse, Neglect, Exploitation and Misappropriation-Reporting and Investigating,” revised 9/1/22, indicated, all allegations of suspected or actual abuse, including misappropriation (taken without permission) of resident property, would be reported to the local police department, the Ombudsman’s (outside person who advocated for resident rights) office, and CDPH within two hours. ADMIN stated, “the police department was notified immediately” and confirmed, that suspicions of a crime were not reported to CDPH or the Ombudsman’s office, as indicated in their Abuse Policy. In violation of the above cited standards, the facility failed to report the misappropriation of Resident 2 and 3’s property to the California Department of Public Health (CDPH), in accordance with State law and adhere to the policy and procedures for reporting and investigating abuse, neglect, exploitation, and misappropriation. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.