Health inspection·July 31, 2025

Amended 08/13/2025 42 CFR § 483.12 Freedom from abuse, neglect, and exploitation. (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph § 483.95. 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. 22 CCR § 72527 Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The California Department of Public Health (CDPH) received a facility reported incident on 7/7/2025 reporting Resident 1 gave his debit card with the pin number written on an envelope to "somebody" to withdraw money from his bank account. The report indicated more funds were withdrawn than requested and funds were missing On 7/8/2025, the CDPH conducted an unannounced onsite investigation at the facility. The facility failed to follow its Policy and Procedure (P&P), titled, "Abuse, Neglect, Exploitation and Misappropriation Prevention Program," which indicated residents had the right to be free from abuse, misappropriation of resident property and exploitation, when Dietary Aide (DA) 1 agreed to withdraw cash from Resident 1's debit card to purchase cigarettes 1) Resident 1 was free from financial abuse when Dietary Aide (DA) 1 agreed to withdraw cash from Resident 1's debit card to purchase cigarettes. As a result, $8,000 of unauthorized cash was withdrawn from Resident 1's bank account within a four-day span from 6/25-28/2025. This failure had a potential to result in further financial abuse to Resident 1 and other residents in the facility. Resident 1, was a 67-year-old male, admitted to the facility on 2/6/2025 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one entire side of the body) following a cerebral infarction (an interruption in blood flow to the brain), muscle weakness, and depression (persistent feeling of sadness). A review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 5/9/2025, indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making were intact. The MDS indicated Resident 1 required partial to moderate assistance (helper does less than half of the effort) for toileting hygiene, bathing, and required supervision when performing oral hygiene, dressing, and personal hygiene. A review of Resident 1's History and Physical (H&P), dated 5/29/2025, indicated Resident 1 had the capacity to understand and make decisions. A review of Licensed Vocational Nurse (LVN) 1's written statement, dated 7/9/2025, indicated on 6/28/2025, Resident 1 came out of his room yelling, "That motherf... stole my money!" The statement indicated LVN 1 followed Resident 1 to the kitchen and Resident 1 pointed at Dietary Aide (DA) 1 and stated, "It was that guy!" The statement indicated DA 1 stated, "It wasn't me, my car has been in the shop!" Resident 1 explained that he lent his debit card to DA 1 "about a week ago" so that DA 1 could buy cigarettes for him, and the card was supposed to be returned the same day. The statement indicated DA 1 repeatedly stated his car had been in the shop for a week. The statement indicated LVN 1 proceeded to assist Resident 1 to speak with a bank representative and LVN 1 hand wrote the amounts withdrawn from Resident 1's bank account (as dictated by the bank representative). The statement indicated RN 1 informed the Director of Nursing (DON) of the situation. The statement indicated Registered Nurse (RN) 1 informed LVN 1 that the DON would notify the Administrator (ADM). A review of Resident 1's Bank Statement, dated 7/16/2025, indicated a total of $8,000 ($2,000 each day) was withdrawn from Resident 1's bank account from 6/25/2025 through 6/30/2025. During an interview on 7/8/2025 at 10:30 a.m. with ADM, the ADM stated DA 1 was suspended on 7/7/2025, pending investigation for Resident 1's missing funds. During an interview on 7/8/2025 at 10:47 p.m., with Resident 1, Resident 1 stated on 6/25/2025, he provided DA 1 with his debit card and the pin number in an envelope. Resident 1 stated he asked DA 1 to withdraw $100 and buy him (Resident 1) a pack of cigarettes. Resident 1 stated DA 1 returned with two packs of cigarettes and $50. Resident 1 stated when he asked DA 1 for his card back, DA 1 replied that the card was in his vehicle. Resident 1 stated he did not report the incident on 6/25/2025 but attempted to speak with DA 1 (6/26/2025), but DA 1 was off duty. Resident 1 stated on 6/27/2025, DA 1 told the resident the debit card was inside of his vehicle. Resident 1 stated DA 1 finally returned the debit card on 6/28/2025 (four days later). Resident 1 stated he immediately called the bank with the help of LVN 1 to verify the funds in his account. Resident 1 stated he was surprised to learn that $2,000 was withdrawn each day from 6/25/2025 through 6/28/2025, which totaled $8,000. Resident 1 stated this made him so mad that he went to the kitchen, confronted DA 1, and yelled. Resident 1 stated DA 1 remained silent, refused to provide an explanation, and "wore a dumb look on his face." Resident 1 stated LVN 1 and RN 1 told him to address the matter on 6/30/2025. Resident 1 stated on 6/30/2025, he notified Social Services Director (SSD) 1 of the situation and SSD 1 helped Resident 1 file a claim with the bank. Resident 1 stated on 7/1/2025 SSD 1 helped call the police. During an interview on 7/8/2025 at 11:13 a.m., with SSD 1, SSD 1 stated on 6/30/2025, Resident 1 reported he provided his debit card and pin number to DA 1 and money was missing. SSD 1 stated she assisted Resident 1 file a claim for the "missing money". SSD 1 stated on 7/1/2025, she called the police. SSD 1 stated staff were not allowed to accept a resident's personal debit card to perform cash withdrawals or to purchase items without the presence of the resident. SSD 1 stated she expected staff to defer the request to her, and she would verify if the resident had a family member or a representative party that could perform the transaction or assist the resident. SSD 1 stated another option was to arrange a qualified staff member to accompany the resident to the bank or the automated teller machine (ATM). SSD 1 stated the incident was considered misappropriation or financial abuse. During a telephone interview on 7/8/2025 at 11:57 p.m., with DA 1, DA 1 stated Resident 1 provided him a "thick envelope" with Resident 1's debit card and pin number. DA 1 stated Resident 1 requested for him to withdraw $100 and purchase a pack of cigarettes. DA 1 stated he took the debit card and withdrew $100 from an ATM at Bank A but could not recall the specific ATM location. DA 1 stated he proceeded to purchase the cigarettes for Resident 1, drove back to the facility, and gave Resident 1 $100 and the cigarettes. DA 1 stated, "I thought I brought the debit card back to him". DA 1 stated shortly after the exchange with Resident 1, he (DA 1) was involved in a motor vehicle accident (MVA), and "might" have left the envelope with Resident 1's debit card and pin number in the vehicle. DA 1 stated he left his car at a mechanic after the MVA, and "I was not thinking about nothing and was not thinking about no card". DA 1 could not provide any more details regarding the whereabouts of Resident 1's debit card from 6/25/2025 through 6/28/2025. DA 1 could not provide details about how he retrieved Resident 1's debit card to return to the resident on 6/28/2025. During an interview on 7/8/2025 at 12:17 p.m. with LVN 1, LVN 1 stated on 6/28/2025, Resident 1 was angry and hurriedly made his way out of his room towards the kitchen. LVN 1 stated she followed Resident 1. LVN 1 stated DA 1 came out of the kitchen to explain Resident 1 gave him (DA 1), his personal debit card and pin number to buy him (Resident 1) cigarettes. LVN 1 stated Resident 1 alleged DA 1 kept his debit card for "about a week". LVN 1 stated DA 1 explained the debit card was inside his car which had been at the mechanic shop. LVN 1 stated at that point, RN 1 intervened and told Resident 1 and DA 1 to "stop". LVN 1 stated she assisted Resident 1 back to his room and called the bank. LVN 1 stated she transcribed the amount of money withdrawn from Resident 1's account from 6/25/2025 through 6/28/2025 (total of $8,000). LVN 1 stated staff were not allowed to accept resident's debit cards for any purpose because it had the potential to lead to financial abuse. LVN 1 stated DA 1's possession of Resident 1's debit card and the confirmation of missing funds from Resident 1's bank account constituted suspicion of financial abuse. During an interview on 7/8/2025 at 1:30 p.m. with the ADM, the ADM stated DA 1's actions did not align with the facility's policy because staff were not permitted to handle personal banking transactions with a resident's debit card. The ADM stated it was the facility's responsibility to ensure residents' property was not misplaced or stolen. The ADM stated staff were not permitted to take a resident's debit card to protect the resident from any form of financial abuse. During an interview on 7/9/2025 at 11:40 a.m. with a representative from Resident 1's bank (Bank Representative 1), Bank Representative 1 confirmed $2,000 was withdrawn each day from 6/25/2025 through 6/28/2025, totaling $8,000. A review of the facility's Policy and Procedure (P&P), titled, "Abuse, Neglect, Exploitation and Misappropriation Prevention Program", revised 4/2021, indicated residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. A review of the facility's P&P, titled, "Resident Rights", revised 2/2021, indicated the facility would ensure the resident would remain free from abuse, neglect, misappropriation of property and exploitation. The facility failed to: 1) Follow its P&P, titled, "Abuse, Neglect, Exploitation and Misappropriation Prevention Program," which indicated residents had the right to be free from abuse, misappropriation of resident property and exploitation, when Dietary Aide (DA) 1 agreed to withdraw cash with Resident 1's debit card to purchase cigarettes As a result, $8,000 unauthorized cash was withdrawn from Resident 1's bank account from 6/25-28/2025. This failure had a potential to result in further financial abuse to Resident 1 and other residents in the facility. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1 and all residents in the facility.