Health inspection·August 1, 2024

Amended 8/16/24 Originally sent on 8/1/24 (Rev. 208; Issued:10-21-22; Effective: 10-21-22; Implementation:10-24-22) §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. 72523(a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 6/13/2024 the California Department of Public Health (CDPH) received a complaint alleging Resident 1’s Power of Attorney ([POA] a legal document that allows someone else to act on your behalf) reported to the facility’s Social Services Director (SSD) that Resident 1’s bank debit card (a payment card that deducts money directly from a person’s checking account) was lost and/or stolen and continued to accrue fraudulent charges after Resident 1 no longer resided at the facility. On 6/14/2024, CDPH conducted an unannounced visit to the facility to investigate the allegation. Upon investigation, CDPH determined on 5/14/2024, the facility’s SSD was made aware that Resident 1’s bank debit card was lost/stolen and did not report the allegation to the facility’s Administrator (ADM), CDPH, the State Long Term Care Ombudsman (an agency that assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences), or the local police department (PD). The facility failed to: 1. Report Resident 1’s bank debit card was missing to CDPH, the State Long Term Care Ombudsman and the local PD within the regulated time frame of 24 hours. 2. Ensure staff followed the facility’s policy and procedure (P&P), titled, “Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment,” that indicated the facility will ensure that all alleged violations involving misappropriation of resident property, are reported immediately but not later than 24 hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury. As a result of these deficient practices, there was a delay in CDPH’s investigation of Resident 1’s missing bank debit card and 325 unauthorized debit card transactions, totaling approximately $11,254.00 from 12/21/2023 through 5/23/2024. This deficient practice had the potential for other residents’ missing or stolen property to go unreported. A review of Resident 1’s Admission Record (Face Sheet), indicated Resident 1, a 61 year-old male, was originally admitted to the facility on 9/4/2020 and readmitted on 1/3/2024 with diagnosis including schizoaffective disorder (combination of two mental illnesses which include schizophrenia [a mental health condition which causes hallucinations (when a person hears, sees, smells, tastes or feels things which appear to be real but only exist in the mind)], delusions [a belief which is clearly false and which indicates an abnormality in the affected person’s content of thought), a mood disorder, and depression (constant feeling of sadness and loss of interest which stops a person from doing their normal activities). A review of Resident 1’s History and Physical (H&P) dated 1/4/2024, indicated Resident 1 had a fluctuating capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 3/12/2024, indicated Resident 1’s cognitive (thinking process) skills for daily decision-making were modified (had some difficulty in new situations only). A review of Resident 1’s Nursing Home to Hospital Transfer Form dated 12/21/2023 and timed at 12:33 p.m., indicated Resident 1 was transferred to a General Acute Care Hospital (GACH) for behavioral issues (12/21/2023). A review of Resident 1’s Clinical Census Report, indicated Resident 1 was readmitted to the facility on 1/3/2024. A review of Resident 1’s Bank Statements dated 12/3/2023 to 1/3/2024, indicated 59 debit transactions were made, totaling approximately $1,914.00, during Resident 1’s stay at the GACH from 12/21/2023 to 1/3/2024. A review of Resident 1’s Nursing Home to Hospital Transfer Form, dated 3/12/2024 and timed at 9:40 p.m., indicated Resident 1 was transferred to a GACH for behavioral issues (3/12/2024). A review of Resident 1’s GACH Discharge Aftercare Plan, the GACH Discharge After care Plan indicated Resident 1 was discharged from the GACH and transferred to a different Skilled Nursing Facility (SNF) on 3/22/2024. A review of Resident 1’s Bank Statements dated 3/13/2024 to 5/23/2024, indicated 266 debit transactions were made totaling approximately $9,340.00, during Resident 1’s stay at the GACH from 3/12/2024 to 3/22/2024. A review of a text message dated 5/14/2024 and timed at 9:33 a.m., between the POA and the SSD, indicated the following: The POA texted, “Resident 1’s debit card was missing for several months and there are several thousands of dollars in gas, food, etc. near the facility and the purchases are still occurring.” The SSD texted, “O wow, I would immediately cancel the card and honestly I do not know who would have the card.” A review of a text message dated 5/28/2024 and timed at 9:49 a.m., (14 days after the POA initially reported Resident 1’s missing debit card to the SSD) between the POA and the SSD, indicated the following: The POA texted, “Who would you suggest I speak with about Resident 1’s missing debit card? I really think it’s important to make the Admin aware of this!!” The SSD texted, “Oh wow I will let him know. Is the card still being used? Did you file a police report, I am sorry this is happening, but I have no idea who would have it.” The POA texted, “As of last week, it is still being used all around the care center – and online orders for women’s clothing and marijuana shops nearby…thousands and thousands of dollars.” The SSD texted, “Wow I will report it.” A review of a text message dated 5/30/2024 and timed at 12:50 p.m., (16 days after the POA initially reported Resident 1’s missing debit card to the SSD) between the POA and the SSD, indicated the following: The POA texted, “Good afternoon, can you share the response/info from the administration regarding what they said about the missing debit card please?” The SSD texted, “Administration is off this week but when he comes back, I will share it, I do not have anything right now.” A review of a text message dated 6/3/2024 and timed at 2:34 p.m., (20 days after the POA initially reported Resident 1’s missing debit card to the SSD) between the POA and the SSD, indicated the following: The POA texted, “I really think it’s important that I speak with the director about Resident 1’s missing debit card. How do I reach the director please?” A review of a text message dated 6/3/2024 and timed at 4:42 p.m., between the SSD and the POA, indicated the following: The SSD texted, “I understand let me reach out to him.” A review of a text message dated 6/5/2024 and timed at 1:07 p.m., (22 days after the POA initially reported Resident 1’s missing debit card to the SSD) between the POA and the SSD, indicated the following: The POA texted, “I have all the bank statements showing all the fraud charges made to Resident 1’s account. I think the next step is to make an appointment with the director to discuss and show this information in person.” A review of a text message dated 6/7/2024 and timed at 11:17 a.m., (24 days after the POA initially reported Resident 1’s missing debit card to the SSD) between the POA and the SSD, indicated the following: The POA texted, “When you can send a quick update, please.” The SSD texted, “The admin will let me know when he’s available.” During a telephone interview on 6/14/2024 at 12:48 p.m., Resident 1’s POA stated on 5/14/2024 she informed the facility’s SSD that Resident 1’s debit card had been lost or stolen for several months. The POA stated she informed the SSD that Resident 1’s bank statements reflected the debit card had been used several times at places that were in close proximity to the facility, and she (the POA) requested a meeting with the facility’s administration, but she never heard from them. The POA stated there was no way Resident 1 could have used his debit card because he currently resided at a SNF which was not located in the same city where the debit card had been used. During an interview on 6/14/2024 at 2:12 p.m., the SSD stated Resident 1’s POA made her aware that Resident 1’s debit card was missing on 5/14/2024. The SSD stated she did not report that Resident 1’s debit card was missing to CDPH, the Ombudsman, or the local PD because Resident 1 no longer resided at the facility at the time she was informed of the missing debit card, and she did not notify the Administrator (ADM) that Resident 1’s debit card was missing until 5/28/2024 (14 days after she was made aware by the POA that Resident 1’s debit card was missing). The SSD stated in hindsight, she should have reported the missing debit card to the local PD, CDPH and the Ombudsman so an investigation could be conducted because there was a potential for other residents in the facility to be affected if someone in the facility was taking Residents’ debit cards and using Resident’s money without authorization. During an interview on 6/18/2024 at 4:33 p.m., the ADM stated he was not made aware of Resident 1’s missing debit card until 6/14/2024 (1 month after Resident 1’s POA reported to the SSD that Resident 1’s debit card was missing). The ADM stated he was not aware he needed to report Resident 1’s missing debit card to CDPH, the Ombudsman and the local PD because Resident 1 no longer resided at the facility. A review of the facility’s P&P titled, “Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment,” revised 10/2022, indicated it is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. The facility will 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 24 hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury. The facility failed to: 1. Report Resident 1’s bank debit card was missing to CDPH, the State Long Term Care Ombudsman and the local PD within the regulated time frame of 24 hours. 2. Ensure staff followed the facility’s policy and procedure (P&P), titled, “Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment,” that indicated the facility will ensure that all alleged violations involving misappropriation of resident property, are reported immediately but not later than 24 hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury. As a result of these deficient practices, there was a delay in CDPH’s investigation of Resident 1’s missing bank debit card and 325 unauthorized debit card transactions, totaling approximately $11,254.00 from 12/21/2023 through 5/23/2024. This deficient practice had the potential for other residents’ missing or stolen property to go unreported. These violations had the direct or immediate relationship to the health, safety, or security of patients and Resident 1.