Health inspection·June 14, 2024

42 CFR §483.12 Freedom from abuse, neglect, and exploitation. (a) The facility must- (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. (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. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. 22 CCR § 72315 Nursing Service - Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. 22CCR §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. The California Department of Public Health (CDPH) received a complaint on 5/10/2024 regarding allegations of financial abuse (deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) and misuse of resident funds by a Social Services staff including suspicious transactions on Resident 9's online (computer-accessible) back account. On 5/16/2024 at 11:50 a.m., an unannounced visit was conducted at the facility to investigate the allegations. The facility failed to ensure Residents 1, 2, 3, 4, 5, and 6's personal properties (debit cards and cash) were safeguarded and protected from potential financial abuse, by failing to ensure: 1. Its undated policy and procedures (P&P) titled, "Abuse Prevention, Screening and Training Program," which indicated the facility should not condone (allow) any form of resident financial abuse and misappropriation (unlawful use) of resident property and wrongful use of resident's money without the resident's consent (permission) were implemented. 2. The Social Services Designee (SSD) did not have access to residents' financial documents including debit cards (a bank card linked to a checking account to access money) and cash for Residents 1, 2, 3, 4, 5, and 6. 3. All residents' (Residents 1, 2, 3, 4, 5, and 6) debit cards and cash were included in the residents' Clothing and Possessions list (document that contained the lists of all residents' belongings). 4. The responsible parties and residents were provided with receipts indicating how much money was withdrawn from their debit cards at any given time. 5. Residents' cash and debit cards (Residents 1, 2, 3, 4, 5, and 6) were securely kept in a facility's locked cabinet. 6. The SSD did not keep debit cards for Residents 5 and 6, who no longer reside in the facility. 7. The facility had a tracking system in place to identify which residents had debit cards and money in the facility's possession. As a result, the facility placed Residents 1, 2, 3, 4, 5, and 6 at risk for unauthorized use of residents' money and placed all 93 residents at risk for financial abuse. a). A review of Resident 1's Admission record, indicated Resident 1 was a 67-year-old female, originally admitted to the facility on 11/19/2018 and readmitted on 10/24/2023. Resident 1's diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and adult failure to thrive (poor appetite, weight loss, fatigue, and overall progressive decline in a person's ability to carry out everyday activities). A review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 1/5/2024, indicated Resident 1 understood and was able to make self-understood. The MDS indicated Resident 1 required set up for eating and substantial assistance (helper does more than half the effort) with oral hygiene and personal hygiene. The MDS indicated resident was dependent with toileting and showers. A review of Resident 1's History and Physical (H&P), dated 10/25/2023 indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Clothing and Possessions List, dated 10/24/2023, indicated Resident 1's belongings such as clothes, and shoes but did not indicate Resident 2 had a debit card/or money. During an interview on 5/23/2024 at 11:50 a.m., with Family member (FM) 1, FM 1 stated she was not aware the SSD had Resident 1's debit card. FM 1 stated she never received any bank statements, or receipts for any of Resident 1's transactions. b). A review of Resident 2's Admission record, indicated Resident 2 was an 81-year-old male, originally admitted to the facility on 2/1/2022, and readmitted on 1/17/2024. Resident 2's diagnoses included schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves) and bipolar disorder (serious mental illness that causes unusual shifts in mood). A review of Resident 2's MDS, dated 5/10/2024, indicated Resident 2 had the ability to understand and be understood. The MDS indicated Resident 2 required assistance with setup or clean up with eating and oral hygiene. The MDS indicated Resident 2 required supervision with toileting, showering, and bathing. The MDS indicated Resident 2 required supervision with personal hygiene. A review of Resident 2's H&P, dated 1/19/2024 indicated Resident 2 had fluctuating (changing) capacity to understand and make decisions. A review of Resident 2's Clothing and Possessions List, dated 1/17/2024, indicated Resident 2's belongings such as socks and one nightgown, but did not indicate Resident 2 had a debit card/or money. During interview on 5/17/2024 at 10:42 a.m., with Resident 2, Resident 2 stated the SSD took him to the bank every three months and withdrew $50.00 from his account to buy snacks. Resident 2 stated the SSD never gave him any of his bank statements. Resident 2 stated the SSD kept all bank statements each time they went to the bank to withdraw money from his account. c). A review of Resident 3's Admission record, indicated Resident 3 was an 83-year-old female, originally admitted to the facility on 3/13/2020, and readmitted on 2/3/2024 with diagnoses of adult failure to thrive and schizophrenia. A review of Resident 3's MDS, dated 5/12/2024, indicated Resident 3 had the ability to understand and be understood. MDS indicated Resident 3 was independent with eating. The MDS indicated Resident 3 required supervision with oral hygiene, and required moderate assistance with toileting hygiene, shower, and bathing. A review of Resident 3's H&P, dated 2/15/2024 indicated Resident 3 had fluctuating capacity to understand and make decisions. A review of Resident 3's Clothing and Possessions List, dated 2/5/2024, indicated Resident 3's belongings such as clothes and dentures, but did not indicate Resident 3 had a debit card/or money. During an interview on 5/17/2024 at 10:45 a.m., with Resident 3, Resident 3 stated he did not know anything about money. Resident 3 stated he could not answer any further questions because the SSD managed his money. d). A review of Resident 4's Admission record, indicated Resident 4 was a 75-year-old male, originally admitted to the facility on 10/27/2022, and readmitted on 5/3/2024 with diagnoses of adult failure to thrive and dysphagia (difficulty swallowing). A review of Resident 4's MDS, dated 5/12/2024, indicated Resident 4 had the ability to understand and be understood. The MDS indicated Resident 4 was dependent with eating, oral hygiene, toileting hygiene, shower, bathing, and personal hygiene. A review of Resident 4's Clothing and Possessions List, dated 2/5/2024, indicated Resident 4's belongings such as one hospital gown, but did not indicate Resident 4 had a debit card/or money. During an interview on 5/23/2024 at 12:10 p.m., with a Public Guardian (PG), the PG stated she was not aware the SSD was in possession of Resident 4's debit card. The PG stated she was never given any statements or receipts for any of Resident 4's transactions. e). A review of Resident 5's Admission record, indicated Resident 5 a 68-year-old female, admitted to the facility on 7/8/2022, with diagnoses of bipolar disorder, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 5's MDS, dated 4/26/2022, indicated Resident 5 had the ability to understand and be understood. The MDS indicated Resident 5 required a two person assist with bed mobility, transfer, locomotion (moving from place to place), dressing, eating, toilet use and personal hygiene. A review of Resident 5's's H&P, dated 7/10/2022 indicated Resident 5 had fluctuating capacity to understand and make decisions. A review of Resident 5's's Clothing and Possessions List, dated 4/26/2023, indicated Resident 5's belongings such as clothes and two sweaters but, did not indicate Resident 5 had a debit card and/or money. A review of facility's daily census dated 5/19/2024, did not indicate Resident 5 was a resident at the facility. During an interview on 5/17/2024 at 10:00 a.m., with the SSD, the SSD stated Resident 5 no longer resided in the facility. The SSD stated she forgot to return Resident 5's debit card to the resident or the responsible party at the time of discharge. f). A review of Resident 6's Admission record, indicated Resident 6 was a 75-year-old male, originally admitted to the facility on 8/3/2020, and readmitted on 3/17/2023. Resident 8's diagnoses included schizoaffective disorder, bipolar type (a mental condition marked by alternating periods of elation and depression) and muscle wasting (weakening, shrinking, and loss of muscle caused by disease or lack of use). A review of Resident 6's MDS, dated 4/3/2023, indicated Resident 6 had the ability to understand and be understood. The MDS indicated Resident 6 required set up assistance for bed mobility, transfer, locomotion, dressing, eating, toilet use and personal hygiene. A review of Resident 6's H&P, dated 3/9/2023 indicated Resident 6 had fluctuating capacity to understand and make decisions. A review of Resident 6's Clothing and possessions List, dated 3/17/2023, indicated Resident 6's belongings such as socks and one hospital gown but did not indicate Resident 6 had a debit card. A review of facility's daily census dated 5/19/2024, did not indicate Resident 6 was still a resident at the facility. During an interview on 5/16/2024 at 2:18 p.m., with CNA 1, CNA 1 stated residents' debit cards and money were kept by the SSD. CNA 1 stated CNAs did not list residents' debit cards and money in the Clothing and Possession List because the SSD was the one who took care of residents' debit cards and money. During an interview on 5/16/2024 at 2:40 p.m., with the SSD, the SSD stated she did not have any debit cards or cash for any residents in the facility. The SSD stated if the debit cards were not noted on the residents clothing and possession list, it meant the facility did not receive the items. During a concurrent observation and interview on 5/17/2024 at 10:00 a.m., with the SSD and the Social Services Assistant (SSDA), in the SSD's office, the SSD opened the unlocked right bottom drawer of her (SSD) desk. The drawer was observed to have an unlocked tin box with an unknown amount of cash. The drawer also contained the following items: 1. Four residents' (Residents 1, 5, 13 and 14) social security cards 2. Three residents' (Residents 15, 16 and 17) birth certificates 3. One debit card belonging to Resident 1 4. Two debit cards belonging to Resident 2 5. Three debit cards belonging to Resident 3 6. One debit card and a check book belonging to Resident 4 7. One debit card belonging to Resident 5 8. One debit card belonging to Resident 6 9. Two temporary debit cards with unidentified names The SSD stated the box also contained old cards belonging to residents including Residents 5 and 6, who no longer resided (lived) in the facility. The SSD stated the drawer used to have a lock, but it broke, and was never repaired so the drawer had been unlocked for over a year. The SSD stated she was the only one with access to the contents of the drawer. The SSA stated she only had access to the drawer when instructed by SSD to get her (the SSD's) purse. The SSD stated she had no means of tracking the items in the drawer because she did not have a log or binder to indicate what each resident had. The SSD stated she had been working in the facility for 16 years, kept residents' debit cards and money but never had any documentation or evidence of residents' items in her possession. The SSA stated the SSD always took residents to the bank to withdraw their money. The SSD stated she did not have any receipts of residents' funds withdrawn or amounts in her possession, because the residents kept their own receipts. During an interview on 5/17/2024 at 10:58 a.m., with Business Manager (BM), the BM stated the SSD was the one who always took residents to their banks. The BM stated she was not aware if SSD provided residents with receipts after each bank transaction. During a concurrent observation and interview on 5/17/2024 at 1:15 p.m., with the ADM, in the SSD's office, the office drawer was observed. The ADM opened the unlocked drawer and the tin box and stated the box contained residents' cash, debit cards, social security cards and birth certificates. The ADM stated the items should have been locked and no one should have access to residents' debit cards, cash, social security cards, identification cards, passport, and birth certificates. The ADM stated leaving residents' private documents in an unlocked drawer placed the residents at risk for misappropriation of property, identity theft and unauthorized access to their funds. The ADM stated the SSD was not supposed to manage any of residents' debit cards and cash. The ADM stated every day, she asked the SSD if she (the SSD) was in possession of any residents' debit cards or cash and the SSD denied every time. The ADM stated she was asking SSD daily about resident's debit cards and cash because she wanted to ensure the facility was compliant with a previous deficiency in which the SSD had residents debit cards and cash. The ADM stated all residents' possessions including debit cards, social security cards, cash, and identification cards should have been included in their clothing and possessions' list. The ADM stated staff had not been listing debit cards, social security cards, cash and identification cards in the residents' possession lists. A review of the facility's undated P&P titled, "Personal Property", indicated a resident's personal belonging and clothing shall be inventoried and documented upon admission. A review of the facility's undated P&P titled, "Management of Residents' Personal Funds," indicated, if the resident elects to have the facility manage his or her personal funds, it must be authorized in writing by the resident or the resident's representative, and a copy of such authorization must be documented in the resident's medical record. The P&P indicated; a copy of all financial transactions will be filed in the resident's permanent records. A review of the facility's undated P&P titled, "Abuse Prevention/Prohibition," indicated that the facility should not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation and/or mistreatment, and develops facility policies, procedures, training programs, and systems to promote an environment free from abuse and mistreatment. The facility failed to ensure Residents 1, 2, 3, 4, 5, and 6's personal properties were safeguarded and protected from potential financial abuse, by failing to ensure: 1. Its undated P&P titled, "Abuse Prevention, Screening and Training Program," which indicated the facility should not c