Health inspection·May 22, 2025

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §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. §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. § 483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Title 22 CCR § 72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 4/7/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct its annual recertification survey and investigate a Facility-Reported Incident (FRI) regarding misappropriation of resident property (wrongful, deliberate, and unauthorized use of a resident's belongings or money without their consent, including misplacement, exploitation, or permanent use). The facility failed to implement its policy and procedure (P&P) titled, “Investigating Incidents of Theft and Loss,” by: 1. Not reporting to CDPH, the local Ombudsman (an advocate who supports residents by resolving issues related to their health, safety and well-being) and the Local Law Enforcement (LLE) an allegation of misappropriation of resident property Resident 38 made on 10/11/2024 to Social Services Assistant 1 (SSA 1). 2. Not thoroughly investigating an allegation of misappropriation of resident property Resident 38 made of 10/11/2024 to SSA 1. 3. Not reporting to CDPH the results of the investigation of the alleged misappropriation of resident property Resident 38 reported on 10/11/2024, within five working days. As a result, Resident 38 was placed at an increased risk of financial abuse in the facility. A review of Resident 38's Admission Record indicated that the facility initially admitted Resident 38 on 9/30/2015 and readmitted the resident on 2/19/2022 with diagnoses including acute kidney failure (a condition in which the kidneys are damaged and cannot filter blood well), diabetes type 2 (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), and atherosclerotic heart disease (buildup of fats, cholesterol and other substances (plaque) in and on the artery walls [refers to the layers of tissue that make up the structure of an artery - a blood vessel responsible for carrying oxygen-rich blood from the heart to the body]). A review of Resident 38's Minimum Data Set (MDS – a resident assessment tool), dated 2/6/2025, indicated that the resident had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience and the senses). The MDS further indicated that Resident 38 required setup assistance for eating, moderate-to -maximal assistance with bed mobility, upper body dressing and personal hygiene and was totally dependent on two or more helpers for toileting hygiene, shower and bed- to-chair transfer. A review of Resident 38 's Transfer Form, dated 10/7/2024, indicated Resident 38 was transferred to General Acute Care Hospital 1 (GACH 1) for congestion (an abnormal or excessive accumulation of body fluid) and desaturation (a decrease in the amount of oxygen in the blood). A review of Resident 38's Nursing Documentation Evaluation, dated 10/10/2024, indicated Resident 38 was readmitted to the facility from GACH 1 on 10/10/2024. A review of Resident 38's Theft/Loss Report dated 10/11/2024, indicated Resident 38 reported that he (Resident 38) was missing some money but was not able to recall the exact amount (approximately $20 to $50). The Theft/Loss Report further indicated that after the facility conducted its investigation (which involved staff interviews and searches of the resident room and laundry area), no money was found, and the LLE was not notified. During a concurrent observation and interview on 4/7/2025 at 10:45 a.m., with Resident 38, observed Resident 38 in bed. Resident 38 stated that following his (Resident 38) admission to the hospital (referring to GACH 1) in 10/2024, he (Resident 38) noticed that $400 was missing. Resident 38 stated that he (Resident 38) keeps his money in the drawers of his bedside table and usually takes his wallet with him when hospitalized, but did not do so during this hospitalization. Resident 38 stated that he (Resident 38) informed the Administrator about the missing money and was assured it would be returned; however, he has not received it. During a concurrent interview and record review on 4/10/2025 at 4:16 p.m., with the Director of Social Services (DSS), the DSS reviewed Resident 38's electronic health record (a digital version of a resident’s medical history). The DSS stated that she (DSS) did not find any notes indicating that a social services staff member followed up with Resident 38 after he reported missing money. The DSS stated that Resident 38 was offered the option to keep his money in the safe located at the social services office, but Resident 38 refused. The DSS stated that a new inventory completed on 4/9/2025 indicated Resident 38 has $357 in his wallet, but Resident 38 refused to place the money in the safe and chose instead to keep it in his wallet, which he stores in a drawer of his bedside table. During a concurrent interview and record review on 4/10/2025 at 4:29 p.m., with Social Service Assistant 1 (SSA 1), SSA 1 reviewed the Theft/Loss Report. SSA 1 stated that she (SSA 1) initiated the Theft/Loss Report in 10/2024 regarding Resident 38's missing money. During an interview on 4/11/2025 at 10:14 a.m., with Restorative Nursing Assistant 1 (RNA 1), RNA1 stated that she (RNA 1) was changing Resident 38's bed after he was transferred to GACH 1 last 10/2024 (unable to recall specific date). RNA 1 stated she (RNA 1) noticed a wallet inside the bedside table drawer. RNA 1 stated that there was about $30 in the wallet, and she (RNA 1) left the wallet inside the bedside table drawer. RNA 1 stated she did not give the wallet to the social services office for safekeeping until Resident 38 returned from the hospital (GACH 1). During an interview on 4/11/2025 at 11:10 a.m., with the Director of Staff Development (DSD), the DSD stated that she interviewed staff in 10/2024 (unable to recall specific date) regarding Resident 38's report of missing money. The DSD stated that the staff (unable to recall) she interviewed did not see any money in Resident 38's room or in the laundry. The DSD stated she did not interview RNA 1 in 10/2024. During an interview on 4/11/2025 at 1:15 p.m., with the Director of Nursing (DON), the DON stated that staff should hand over any resident valuables to the social services office if a resident is transferred to hospital. The DON stated a social services staff should have followed up with Resident 38 after Resident 38 reported missing money in 10/2024 to monitor for any possible psychosocial effects resulting from missing money. The DON stated that the facility should have interviewed all staff involved in Resident 38's care to ensure a thorough investigation. The DON stated that this deficient practice had the potential to result in a failure to protect Resident 38 from misappropriation of property, as the missing money was not thoroughly investigated. During a concurrent interview and record review on 4/11/2025 at 4:11 p.m., with the Administrator, the Administrator reviewed the Theft/Loss Report dated 10/11/2024. The Administrator stated that Resident 38’s allegation of missing money (referring to 10/2024 report) was investigated, found to be unsubstantiated, and no money was returned to Resident 38. The Administrator stated he did not report the allegation of misappropriation of Resident 38's money to CDPH, the local Ombudsman, and the LLE. The Administrator stated that he was not informed until today (4/11/2025) that RNA 1 had observed a wallet containing $30 inside Resident 38’s bedside table drawer. A review of the facility's P&P titled "Investigating Incidents of Theft and Loss" last reviewed on 1/16/2025 indicated "Should an alleged or suspected case of staff misappropriation of resident property be reported, the facility Administrator, or his/her designee, will notify the following persons or agencies within twenty-four (24) of such incidents, as appropriate: a. State Licensing and Certification Agency (CDPH). b. Ombudsman. c. Resident Representative. d. Adult Protective Services. e. Law Enforcement Officials ... The administrator or his or her designee will report the result of the investigation to the local police department, the ombudsman, and to the state survey and certification agency within five (5) working days of the incident." All reports of theft or misappropriation of resident property shall be promptly investigated. Residents have the right to be free from theft and loss." The facility failed to implement its P&P titled, “Investigating Incidents of Theft and Loss,” by: 1. Not reporting to CDPH, the local Ombudsman and the LLE an allegation of misappropriation of resident property Resident 38 made on 10/11/2024 to SSA 1. 2. Not thoroughly investigating an allegation of misappropriation of resident property Resident 38 made of 10/11/2024 to SSA 1. 3. Not reporting to CDPH the results of the investigation of the alleged misappropriation of resident property Resident 38 reported on 10/11/2024, within five working days. As a result, Resident 38 was placed at an increased risk of financial abuse in the facility. The above violations had a direct relationship to the health, safety, or security of Resident 38.