Health inspection·August 20, 2021

F571 §483.10(f)(11) The facility must not impose a charge against the personal funds of a resident for any item or service for which payment is made under Medicaid or Medicare (except for applicable deductible and coinsurance amounts). The facility may charge the resident for requested services that are more expensive than or in excess of covered services in accordance with §489.32 of this chapter. (This does not affect the prohibition on facility charges for items and services for which Medicaid has paid. See §447.15 of this chapter, which limits participation in the Medicaid program to providers who accept, as payment in full, Medicaid payment plus any deductible, coinsurance, or copayment required by the plan to be paid by the individual.) (i) Services included in Medicare or Medicaid payment. During the course of a covered Medicare or Medicaid stay, facilities must not charge a resident for the following categories of items and services: (A) Nursing services as required at §483.35. (B) Food and Nutrition services as required at §483.60. (C) An activities program as required at §483.24(c). (D) Room/bed maintenance services. (E) Routine personal hygiene items and services as required to meet the needs of residents, including, but not limited to, hair hygiene supplies, comb, brush, bath soap, disinfecting soaps or specialized cleansing agents when indicated to treat special skin problems or to fight infection, razor, shaving cream, toothbrush, toothpaste, denture adhesive, denture cleaner, dental floss, moisturizing lotion, tissues, cotton balls, cotton swabs, deodorant, incontinence care and supplies, sanitary napkins and related supplies, towels, washcloths, hospital gowns, over the counter drugs, hair and nail hygiene services, bathing assistance, and basic personal laundry. (F) Medically-related social services as required at §483.40(d). (G) Hospice services elected by the resident and paid for under the Medicare Hospice Benefit or paid for by Medicaid under a state plan. (ii) Items and services that may be charged to residents’ funds. Paragraphs (f)(11)(ii)(A) through (L) of this section are general categories and examples of items and services that the facility may charge to residents’ funds if they are requested by a resident, if they are not required to achieve the goals stated in the resident’s care plan, if the facility informs the resident that there will be a charge, and if payment is not made by Medicare or Medicaid: (A) Telephone, including a cellular phone. (B) Television/radio, personal computer or other electronic device for personal use. (C) Personal comfort items, including smoking materials, notions and novelties, and confections. (D) Cosmetic and grooming items and services in excess of those for which payment is made under Medicaid or Medicare. (E) Personal clothing. (F) Personal reading matter. (F) Gifts purchased on behalf of a resident. (H) Flowers and plants. (I) Cost to participate in social events and entertainment outside the scope of the activities program, provided under §483.24(c). (J) Non-covered special care services such as privately hired nurses or aides. (K) Private room, except when therapeutically required (for example, isolation for infection control). (L) Except as provided in (e)(11)(ii)(L)(1) and (2) of this section, specially prepared or alternative food requested instead of the food and meals generally prepared by the facility, as required by §483.60. (1) The facility may not charge for special foods and meals, including medically prescribed dietary supplements, ordered by the resident’s physician, physician assistant, nurse practitioner, or clinical nurse specialist, as these are included per §483.60. (2) In accordance with §483.60(c) through (f), when preparing foods and meals, a facility must take into consideration residents’ needs and preferences and the overall cultural and religious make-up of the facility’s population. (iii) Requests for items and services. (A) The facility can only charge a resident for any non-covered item or service if such item or service is specifically requested by the resident. (B) The facility must not require a resident to request any item or service as a condition of admission or continued stay. (C) The facility must inform, orally and in writing, the resident requesting an item or service for which a charge will be made that there will be a charge for the item or service and what the charge will be. T22 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 facility failed to limit charges on the personal funds for Residents 1, 2, 3, and 4 and failed to ensure the residents were free from misappropriation of property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent, includes all residents’ possessions, regardless of their apparent value to others since they may hold essential value to the resident) by failing to: 1. Ensure Residents 1, 2, 3, and 4 who were unable to independently make medical and financial decisions were not charged an excessive amount of money for items the residents did not request or consent to purchase such as: puzzles, art supplies, iPads, televisions, exercise wrist watch, wireless headphones, and pet supplies. 2. Inform Residents 1, 2, 3, 4, and/or their responsible parties orally and in writing before purchasing any items that were not requested by the residents so the responsible parties would be able to make a decision on the residents’ behalf. 3. Involve an advocate for Residents 2 and 3 who did not have a responsible party or family in the decision making prior to the facility staff purchasing items from the resident’s funds that the residents did not request. 4. Assess Residents 1, 2, 3, and 4’s personal needs and determine reasonable costs prior to facility staff purchasing items from the resident’s funds. 5. Ensure Residents 1, 2, 3, and 4, were not charged for items that were not part of the residents’ care plans and were not required to achieve the residents’ goals. 6. Misuse the personal funds of Residents 1, 2, 3, and 4 who were unable to independently make medical and financial decisions by using residents’ money to purchase items not being used by the residents such as pet supplies, exercise wristwatch, and computer tablet. 7. Protect residents’ personal funds by charging Residents 1, 2, 3, and 4 an excessive amount of money for items not requested by the residents or their responsible parties such as puzzles, art supplies, computer tablet, television, exercise wristwatch, wireless headphones, and pet supplies. These deficient practices violated the residents’ rights by the facility using residents’ personal funds without the requests and wishes from the residents or their responsible parties which caused the misuse of the residents’ personal funds and had the potential to result in the residents’ failure to exercise their rights to be free from financial abuse, theft, and loss of personal property, and personal funds. A review of Resident 1’s Admission Record, indicated the facility admitted a ninety-five-year-old resident on 8/8/2006 and readmitted the resident on 5/6/2018 with diagnoses of dementia (a brain disorder that impairs memory, personality changes and cognition [ability to think and reason]). A review of Resident 1’s Minimum Data Set (MDS, a resident assessment and care screening tool), dated 11/2/2020, indicated Resident 1 was assessed with severe impairment in memory and cognition, needing total assistance with one person to assist with activities of daily living (ADL). A review of Resident 1’s "Resident Statement Landscape," indicated Resident 1’s personal funds were debited (monies deducted) with the following: 1. On 9/14/2020, $ 1,886.00 was debited for “personal needs items,” (unidentified items). 2. On 9/28/2020, $384.73 was debited for “personal needs items,” (unidentified items). 3. On 10/23/2020, $848.36 was debited for “personal needs items,” (unidentified items). 4. On 10/26/2020, $ 156.50 was debited for “personal needs items,” (unidentified items). 5. On 11/19/2020, $662.78 was debited for “personal needs items,” (unidentified items). 6. On 11/27/2020, $606.02 was debited for “personal needs items,” (unidentified items). 7. On 11/27/2020, $936.02, was debited for “personal needs items,” (unidentified items). 8. On 11/27/2020, $261.00 was debited for “personal needs items,” (unidentified items). 9. A total of $1,348.96 was debited for “clothing,” (unspecified clothing items) from 12/24/2019 to 7/21/2020. A review of Resident 1’s “Resident Essentials,” with an ordered date of 9/30/2020, indicated an order for a 32-inch television for the amount of $395.00, pet supplies for the amount of $95.00, and wireless headphones for the amount of $190.00. The form included other multiple orders for various clothing items and musical products. During an interview 7/8/21 at 10:17 am, the Business Office Manager (BOM) verified there was no documentation in Resident 1’s records to indicate the resident or the resident’s responsible party requested for the facility or facility staff to make purchases on the resident’s behalf for any personal needs items with the residents’ personal funds. The BOM stated Resident 1 had enough funds and needed to "spend down," to continue to receive Medi-cal benefits (a state medical insurance). b. A review of Resident 2’s Admission Record indicated the facility admitted a fifty-seven-year-old resident on 7/25/2018 and readmitted the resident on 1/21/2020 with diagnoses of cognitive communication deficit (inability to communicate effectively, understand and reason) and paranoid schizophrenia (a mental disorder that affects mood and behavior). A review of Resident 2’s MDS, dated 3/20/2020, indicated Resident 2 was assessed as being moderately impaired in cognitive skills and poor decision-making. A review of Resident 2’s “Resident Statement Landscape,” indicated Resident 2 received a Social Security check in the amount of $3,4801.00 on 2/7/2019 and $1,244.00 on 3/7/2019. The statement indicated the following were deducted from Resident 2’s personal funds: 1. On 3/27/2019, $564.59 was debited for “personal needs items,” (unidentified items). 2. On 3/27/2019, $433.00 was debited for “TV/Antenna.” 3. On 4/2/2019, $1034.74 was debited for “IPad with insurance” (portable computer tablet with insurance coverage). 4. On 4/2/2019, $888.38 was debited for “personal needs items,” (unidentified items). 5. On 4/2/2019, $280.00 was debited for a “cash withdrawal.” 6. 4/9/2019, $220.00 was debited for “cash personal.” During an interview and concurrent record review on 7/9/2021 at 9:21 am, the AD verified there was no documented evidence Resident 2 or the resident’s family and/or responsible party approved of the purchases or requested the facility or facility staff to make purchases on the resident’s behalf for any personal needs items with the residents’ personal funds for the items listed above. c. A review of Resident 3’s Admission Record, indicated the facility admitted an eighty-seven-year-old resident on 9/25/2019 and readmitted the resident on 11/2/2020 with diagnosis of Alzheimer's disease (a progressive brain disorder that affects memory and cognition). A review of Resident’s Interdisciplinary Team Conference (Bioethics) dated 9/26/2019, indicated Resident 3 did not have the capacity to make decisions and did not have a family member or a next of kin with legal authority to make healthcare or financial decisions for the resident. A review of Resident 3’s MDS, dated 5/31/2021, indicated Resident 3 was assessed with moderate impairment in memory and cognition (ability to think and reason) that required limited ( resident involved in activity) with one person assistance on activities of daily living (ADL). A review of Resident 3’s "Resident Statement Landscape," indicated the following were deducted from Resident 3’s personal funds: 1. On 6/25/2020, $352.79 was debited for “personal needs items,” (unidentified items). 2. On 6/25/2020, $329.55 was debited for “personal needs items,” (unidentified items). 3. On 12/4/2020, $551.13 was debited for “personal needs items,” (unidentified items). 4. On 12/4/2020, $296.94 was debited for “personal needs items,” (unidentified items). 5. On 2/18/2021, $768.56 was debited for “personal needs items,” (unidentified items). 6. On 5/21/2021, $ 1,835.64 was debited for “personal needs items,” (unidentified items). 7. On 6/17/2021, $42.14 was debited for “personal needs items,” (unidentified items). 8. On 7/17/2020, $413.20 “clothing.” 9. From 11/6/2020 to 6/24/2021, $79.00 for “snack bar.” A review of Resident 3’s Original Invoice, dated 5/7/2021, indicated some of the items that were purchased by the facility for Resident 3 were: 1. Storage Caddy in the amount of $55.00 2. Puzzles in the amount of $23.38 3. Pattern Play blocks in the amount of $32.95 4. Set Swirly mats in the amount of $67.95 5. Tempera Stick Flour in the amount of $119.85 6. Brush Bright Canister Collection in the amount of $107.30 7. Art Start in the amount of 32.35 8. Slot Machine in the amount of $22.49 During an observation inside the facility’s activity room on 7/8/2021 at 10:10 am, the AD stated the items listed above and other items listed in the resident’s inventory list dated 5/7/2021, were observed in the activity room marked with Resident 3's name. The AD stated she purchased the items for Resident 3 but did not have a written request from the resident or any family or resident’s representative prior to purchasing the items with the resident’s personal funds. During an interview on 7/8/21 at 11:52 am, the Business Office Regional Manager (BORM) stated, Residents 1, 2, 3, 4 were supposed to have less than two thousand dollars in the residents’ personal funds to ensure the residents did not lose their Medi-cal Benefits. During a facility tour on 7/8/2021 at 1:30 pm, Resident 3 was observed sitting in the wheelchair near the nursing station. An attempt was made to interview the resident, however, the resident was unable to state the date and place of residence. During an observation on 7/8/2021 at 1:57 pm inside Resident 3’s room, no television was observed. During an observation conducted with Certified Nursing Assistant 1 (CNA 1) on 7/9/2021 at 2:42 pm, inside Resident 3’s room, Resident 3 was observed lying in bed. With the permission of Resident 3, the resident's closet was observed with wireless headphones, one exercise wrist watch, and two pairs of workout pants (resident 3’s inventory indicated 10 workout pants), and a large flat screen television mounted on a mobile television mount at the foot of resident's bed (was not observed at the bedside on 7/8/2021). During an interview with 7/9/21 at 2:51 pm, Licensed Vocational Nurse 1(LVN 1) stated Resident 3 was confused. LVN 1 stated, he had not seen Resident 3 use the computer tablet and she would not be able to use the computer tablet without help. LVN 1 stated he had not seen Resident 3 use the Beats headphones, or the exercise wristwatch, he stated that the resident preferred to be outside of the room. d. A review of Resident 4’s Admission Record indicated the facility admitted a seventy-six-year-old female the on 11/28/2003 and readmitted the resident on 11/9/2018 with diagnosis of dementia and difficulty with speech and language following Cerebrovascular Accident (CVA, a stroke or interruption of blood flow to the brain). A review of Resident 4’s MDS dated 5/4/2021, indicated Resident 4 had moderately impaired memory and cognition that required total assistance with one person assistance with the activities of daily living. A review of Resident 4’s “Resident Statement Landscape,” indicated the following were deducted from Resident 4’s personal funds: 1. Clothing in the amount of $324.90 2. Personal need item in the amount of $34.00 During an interview on 7/9/21 at 3:30 pm the BOM st