Other·July 22, 2022

Country Villa Rehabilitation Center. Intake: CA00785411 and CA00785431 EVID: W0BQ11 Received on: 1/31/2022 Eulie Miller: 44523 Intent Issued: 6/14/2022 CMS 2567 Issued: 6/24/2022 Citation Due: 7/22/2022 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 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 policies shall be accessible to the public upon request. Patients shall have the right: (7) To be encouraged and assisted throughout the period of stay to exercise rights as a patient and as a citizen, and to this end to voice grievances and recommend changes in policies and services to facility staff and/or outside representatives of the patient's choice, free from restraint, interference, coercion, discrimination, or reprisal. On 6/1/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident (FRI) about resident abuse. The facility failed to ensure Residents 1 and 2 were free from financial abuse from former Activities Director 1 (AD 1) and former Activities Assistant 1 (AA 1), who withdrew money from their bank accounts and used their bank cards for purchases and cash back. Residents 1 and 2 did not authorize the money withdrawals, cash back, and / or purchases. As a result, Resident 1 had a total of $1,842.63 taken/charged from his bank account from 3/2022 to 5/2022, causing Resident 1 to be tearful and feeling hurt. Resident 2 had a total of $ 4,636.88 taken/charged to her bank account from 5/28/2021 thru 5/24/2022. 1. A review of Resident 1's Admission Record indicated the facility readmitted Resident 1 on 11/20/2020, with diagnoses including hemiplegia (partial or complete loss of strength or paralysis [inability to move] one side of the body), hemiparesis (mild or partial weakness or loss of strength on one side of the body), and stroke [damage to the brain from interruption of its blood supply). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 3/4/2022, indicated the resident had moderately impaired cognition (decisions poor, cues/supervision required), was able to make self-understood, and was able to understand others. Resident 1 was dependent on staff for dressing, bed mobility, personal hygiene, and toilet use. A review of the facility's billing statements from 3/2022 to 5/2022, indicated Resident 1 had a share of cost (the amount of money a resident is responsible to pay toward their care at the facility) of $588.00. Resident 1's debit card was used for purchase and / or cash back from Resident 1's bank account as follows: - 1/2022 to 2/2022, $10:00 withdrawn. All charges were from the vending machine in the facility. - 2/2022 to 3/2022, $12:00 was withdrawn. All charges were from the vending machine in the facility. - 3/2022 to 4/2022, $385.76 was withdrawn and a debit card purchase at a store. - 4/5/2022, $85.30 a debit card purchase ($45.30 was for items, and $40.00 cash back). - 4/2022 to 5/2022, $821.02 was withdrawn. This included four ATM (automated teller machine) cash withdrawals of $475.75, of which three cash withdrawals had an additional fee of $2.50 each because the withdrawals were not done at Resident 1's bank. A review of the facility's five-day investigation summary dated 5/20/2022, indicated the Administrator (ADM) received a report from AD 1 on 5/17/2022 about inappropriate use of Resident 1's funds by AA 1. The report indicated AA 1 admitted using Resident 1's debit card to withdraw funds from Resident 1's bank account. The report indicated AA 1 was suspended. On 6/2/2022 at 12:01 pm, during an interview, Resident 1 stated a staff told him about money missing from his account. Resident 1 stated, "I have been here for the past four years and have not been able to make any purchases myself. Every now and then I would ask for my favorite cookies and activity staff would bring me a pack. It just hurts and I am trying to hold it together. It hurts to know that the people who are supposed to take care of me let this happen. Resident 1 was tearful during the interview. On 6/2/2022 at 1:25 pm, during an interview, the Business Office Assistant (BOA) stated he checked the bank statements for Resident 1 every month per Resident 1's request and noticed unusual charges on the 4/9/2022 thru 5/9/2022 bank statement. The BOA stated the charges to Resident 1's account would usually amount to around $20.00, that is why he was concerned when noticing different withdrawals. The BOA stated he believed someone stole the resident's information. The BOA stated he contacted AD 1 on 5/17/2022 and told him someone stole Resident 1's information and "we need to contact the bank and change his (Resident 1's) bank card." The BOA stated AD 1 replied someone in the office was using Resident 1's card. On 6/2/2022 at 1:50 pm, during an interview with the BOA and concurrent review of Resident 1's bank statements, the BOA stated the bank statements from 1/2022 to 3/8/2022, indicated all charges over $10 looked suspicious. On 6/2/2022 at 2:14 pm, during an interview, the current Activities Director (AD 2) stated AD 1 had Resident 1's debit card on AD 1's desk. AD 2 stated she heard on 5/17/2022, AD 1 questioning former AA 1 about money withdrawals using Resident 1's card. AD 2 stated AA 1 started crying and acknowledged using Resident 1's debit card inappropriately. AD 2 also stated AD 1 stated he knew AA 1 used Resident 1's debit card because a charge was done at a store near AA 1's home. On 6/8/2022 at 2:44 pm, during an interview, the Assistant Administrator (AADM) stated she was not aware Activities Staff had Resident 1's debit card. The AADM stated AA 1 admitted she withdrew money from Resident 1's bank account to buy lunch and get other items for the office (activities). On 5/19/2022, the facility reported AA 1 to the police. On 6/13/2022 at 3:42 pm, during a telephone interview, AA 1 stated she used Resident 1's debit card to get cash, buy food for the office (activities), and for another resident, who she did not identify. 2. A review of Resident 2's Admission Record indicated the facility initially admitted Resident 2 on 10/1/2019, and was readmitted on 3/13/2020, with diagnoses that included heart disease, hemiplegia, hemiparesis, and osteoporosis (brittle and fragile bones). A review of Resident 2's MDS dated 3/9/2022, indicated Resident 2 had mildly impaired cognition (some difficulty in new situations) and required extensive staff assist with dressing, bed mobility, personal hygiene and toilet use. A review of Employee Disciplinary Action Form for AD 1, dated 5/17/2022, indicated AD 1 was under investigation related to possible financial abuse on a resident. A review of the facility's five-day investigation summary report, dated 5/20/2022, indicated on 5/17/2022 AA 1 reported to the ADM that AD 1 was using Resident 2's debit card to buy food and other items for the activities staff. AD 1 stated he took cash out and bought cigarettes for Resident 2. Resident 2 stated she only had bank statements from 2021. Resident 2's bank statements were found in AD 1's office. Resident 2 was missing several thousands of dollars taken from the bank account. AD 1 resigned from the facility on 5/19/2022. A review of Resident 2's bank statement(s) dated 5/20/2020 indicated a total $291.00 for five cash withdrawals. One cash withdrawal occurred in a city located 60 miles away from the facility. A review of Resident 2's bank statement dated 8/19/2021 indicated two purchases for $42.26 and $140.95 from a pizza restaurant. A review of AD 1's employee file, indicated AD 1 lived 60 miles away from the facility, the same city where the ATM withdrawals occurred as indicated in Resident 2's bank statement dated 5/20/2020. A review of all of Resident 2's bank statements from 5/28/2021 to 5/24/2022, indicated that more than 30 cash withdrawals from ATMs totaled $4,063.25. The cash withdrawals did not include any transactions fees incurred from the ATM withdrawals or other purchases at other businesses. Resident 2's bank statement, dated 3/23/2022, also indicated $99.42 purchase at a restaurant on 3/2/2022. On 6/2/2022 at 11:51 am, during an interview, Resident 2 stated she gave AD 1 her debit card in 2021 to buy her cigarettes and food because she could not leave the facility. Resident 2 stated she usually spent around $50 a month on food and cigarettes. Resident 2 stated AD 1 was not trustworthy and she was missing $6,000 from her bank account. On 6/2/2022 at 2:34 pm, during an interview, AD 2 (who was working as an AA before AD 1 resigned, stated Resident 2 would request the activities staff to buy her cigarettes, donuts, pizza, and snacks. AD 2 also stated AA 1 and AD 1 were the only two people who would buy the items for Resident 2. On 6/2/2022 at 3:14 pm, during an interview, Social Services Director (SSD) stated the ADM informed her Resident 2's moneys were misappropriated, and she reported the incident to the local law enforcement on 5/18/2022. On 6/8/2022 at 2:44 pm, during an interview, the AADM stated the facility will pay back Residents 1 and 2 all their money with interest once the facility completed the final calculation of misappropriated money. A review of the facility's policy and procedure (P&P) titled, "Abuse Prevention and Prohibition Program," revised 6/1/2021, indicated the facility does not tolerate, and the facility staff must not allow anyone to abuse, neglect or misappropriate the property of residents. The P&P further indicated that the facility was committed to protecting residents from abuse by facility staff. A review of the facility's P&P titled, "Resident Funds - Handling & Recording," revised 6/1/2021, indicated when a resident request non-covered service or item, the facility will inform the resident of the cost of such items or services and obtains the resident's written permission to withdraw money from his/her personal funds to pay for such services. The facility failed to ensure Residents 1 and 2 were free from financial abuse from AD 1 and AA 1, who withdrew money from their bank accounts and used their bank cards for purchases and cash back. Residents 1 and 2 did not authorize the money withdrawals, cash back, and / or purchases. As a result, Resident 1 had a total of $1,842.63 taken/charged from his bank account from 3/2022 to 5/2022, causing Resident 1 to be tearful and feeling hurt. Resident 2 had a total of $ 4,636.88 taken/charged to her bank account from 5/28/2021 thru 5/24/2022. The above violations had direct or immediate relationship to the health, safety, or security of Residents 1 and 2.