Health inspection·October 17, 2024

F607 Freedom from Abuse, Neglect, and Exploitation §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations T22 Section 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 9/5/2024, the California Department of Public Health (CDPH) conducted an unannounced visit for a facility reported incident regarding resident abuse. As a result of the investigation, the CDPH determined the facility failed to include in its written Policy and Procedure (P&P) titled "Abuse Prevention" specific information and guideline on how the facility staff would identify, intervene, and manage resident's property including handling of resident's money for Resident 1. As a result, Certified Nursing Assistant 1 (CNA 1) and Activity Aide 1 (AA 1) received and cashed multiple personal checks from Resident 1. This violation violated Resident 1’s right and placed Resident 1 at risk for financial abuse (withholding, stealing, or restricting money). A review of Resident 1's Admission Record indicated the facility admitted a 77-year-old male on 4/11/18 and readmitted the resident on 1/27/23, with diagnoses including chronic obstructive pulmonary disease, chronic pain syndrome and major depressive disorder. A review of Resident 1's Minimum Data Set dated 3/11/23 indicated Resident 1 was cognitively intact. During a phone interview on 9/5/24 at 12:48 p.m., with Resident 1's Family Member 1 (FM1- Resident 1's daughter), FM 1 stated Resident 1 signed Resident 1's checks, but staff should not take/receive money whether Resident 1 signed them or not. FM 1 stated checks were written to CNA 1 and Activity Aide 1 (AA1). FM 1 stated, Resident 1 was not that type of person to "throw this kind of money". A review of the photocopies of Resident 1's personal bank checks provided by FM 1 indicated the checks were written to CNA 1 and endorsed by CNA 1, as indicated: 1. Check Date: 3/1/22. Check Amount: $9,500.00 2. Check Date: 6/2/22. Check Amount: $9,000.00 3. Check Date: 7/11/22. Check Amount: $9,500.00 4. Check Date: 8/13/22. Check Amount: $6,000.00 5. Check Date: 10/14/22. Check Amount: $9,500.00 6. Check Date: 12/7/22. Check Amount: $9,500.00 7. Check Date: 1/4/23. Check Amount: $9,500.00 A review of the photocopies of Resident 1's personal bank checks provided by FM 1 indicated the checks were written to AA 1 and endorsed by AA 1, as indicated: 1. Check Date: 2/15/22. Check Amount: $2,000.00 2. Check Date: 3/4/22. Check Amount: $2,000.00 3. Check Date: 3/17/22. Check Amount: $700.00 4. Check Date: 3/19/22. Check Amount: $700.00 5. Check Date: 4/1/22. Check Amount: $5,000.00 6. Check Date: 4/29/22. Check Amount: $3,000.00 A review of the facility's investigation summary titled, "5 Day Follow Up Report," dated 8/26/24 indicated on 8/19/24, it was reported to the facility's Administrator (ADM) by FM 1 that throughout the years of 2021- 2023, there were staff at the facility receiving checks from Resident 1. Resident 1 was a long-term resident at the facility. The investigation summary indicated, based on evidence from Resident 1's personal bank account, checks were being handed out to certain staff (CNA 1 and AA 1) though none of them work for the company anymore besides CNA 1 who was placed on suspension pending investigation. The investigation summary further indicated after the ADM spoke and interviewed CNA 1, Resident 1 willingly gave checks out to staff to have the staff hold Resident 1's money in the event Resident 1 wanted lunch or dinner and lump sum of money brought from outside for Resident 1 and Resident 1's wife. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 9/5/24 at 2:20 p.m., LVN 1 stated LVN 1 was taught not to accept any money from residents. LVN 1 stated staff do not handle any kind of money from residents. LVN 1 stated if money needed to be held for a resident, it was done by the resident’s family members or Social Services. LVN 1 stated, staff were not allowed to hold the resident's money or utilize any of the resident's money. LVN 1 stated holding resident's money was not an acceptable practice. LVN 1 stated there was no reason for a staff to handle money directly with the resident or have a check written to them. LVN 1 stated, facility staff were educated not to accept any money or gifts from residents and if staff was offered money or gifts from any resident, it should be reported to the Supervisor. During an interview with LVN 2 on 9/5/24 at 2:43 p.m., LVN 2 stated, an example of financial abuse was getting money from a resident or receiving any gifts from the resident. LVN 2 stated under no circumstance should a staff request or accept money or gifts from a resident. LVN 2 stated, there was no reason that a staff would hold money for a resident because money matters needed to be handled by Social Services. LVN 2 stated, staff should not accept any money or monetary benefits from a resident. LVN 2 stated, staff should not solicit (ask for) money from a resident. During an interview on 9/5/24 at 3:37 p.m. with LVN 3, LVN 3 stated the facility policy does not allow staff to accept money, check or gifts from a resident. LVN 3 stated it was not appropriate for staff to hold money for a resident. During an interview on 9/5/24 at 3:43 p.m. with CNA 2, CNA 2 stated staff should not accept money from residents and accepting money was inappropriate. CNA 2 stated there was no reason to accept money or gift of money from a resident. During an interview on 9/5/24 at 3:48 p.m. with Social Services Director (SSD), SSD stated staff should not hold money for a resident. The SSD stated it was inappropriate for staff to ask or request money from a resident. During three attempted phone calls to CNA 1 on 9/5/24 at 1:52 p.m., 9/15/24 at 4:47 p.m., and 9/15/24 at 5:02 p.m., CNA 1 did not answer the phone calls. During a phone interview on 9/5/24 at 2:59 p.m., with the facility's ADM, the ADM stated AA 1 left the facility for some type of absence and never returned to the facility. The ADM stated CNA 1 stated Resident 1 offered to give CNA 1 money to hold the money so that Resident 1 would be given dinner at Resident 1's request and if Resident 1 wanted something, CNA 1 would get it for Resident 1. The ADM stated when CNA 1 was asked where the money was, CNA 1 stated CNA 1 does not have the money and CNA 1 could not state where the money was. The ADM stated CNA 1 stated CNA 1 was told by Resident 1 it was okay to receive the money. The ADM stated CNA 1 did not tell anyone regarding receiving money from Resident 1. The ADM stated, CNA 1 stated CNA 1 felt uncomfortable taking the money from Resident 1 because CNA 1 felt it would be financial abuse. The ADM stated it was not appropriate to receive money from the residents. The ADM stated, "It was not a malicious intent, but the perception of the act was financial abuse." The ADM stated CNA 1 knew what CNA 1 needed to do but CNA 1 did not do it. The ADM stated staff should not accept money or gifts from residents and if offered money or gifts from residents, staff needed to report it to the Abuse Coordinator. A review of the facility's P&P titled "Abuse Prevention" revised 12/2018, indicated the facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment and develops facility policies, procedures, training programs and screening and prevention systems to promote an environment free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. The P&P indicated the facility identifies, corrects, and intervenes in situations in which abuse, neglect, exploitation, misappropriation of resident property and/or mistreatment is more likely to occur. The P&P further indicated the facility conducts mandatory staff training programs during orientation, annually and as needed on prohibiting and preventing abuse, neglect, exploitation, misappropriation of resident property or mistreatment. A review of the above facility's P&P titled "Abuse Prevention" revised 12/2018, in its entirety did not indicate any specific action regarding how the facility staff would address/handle resident's money to prevent potential financial abuse. The facility failed to include in its written P&P titled "Abuse Prevention" specific information and guideline on how the facility staff would identify, intervene, and manage resident's property including handling of resident's money for one Resident 1. As a result, CNA 1 and AA 1 received and cashed multiple personal checks from Resident 1. This violation violated Resident 1’s right and placed Resident 1 at risk for financial abuse. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.