Based on observation, interview, and record review, the facility failed to implement one of six sampled residents' (Resident 1) care plan (personalized plan of care outlining a person's needs and how they will be addressed) when the facility did not ensure Resident 1's room was well-lit and Resident 1 was wearing footwear (item of clothing that covers and protects the foot, including the soles of the feet) when walking. These failures resulted in Resident 1 sustaining a nondisplaced fracture (broken bone that did not move out of alignment) of the neck of the right femur (thigh bone) requiring open reduction and internal fixation (surgical procedure that treats severe bone fracture or dislocation by realigning the bones and stabilizing them with internal hardware [tools or devices used in medical procedures]). Findings: During a review of Resident 1's admission Record (AR), dated 11/15/24, the AR indicated, Diagnosis. Spondylosis (age-related breakdown in the spine [backbone]) . Muscle Weakness (Generalized). Anemia (condition in which the body does not have enough healthy red blood cells that provide oxygen throughout the body) . Unsteadiness on Feet (difficulty walking or maintaining balance). During a review of Resident 1's admission Minimum Data Set (MDS - an assessment tool), dated 9/24/24, the MDS indicated under Section GG (Functional Abilities and Goals) Resident 1's admission performance required substantial or maximal assistance (helper does more than half the effort) with putting on or taking off footwear. The MDS indicated walking was not attempted due to safety concerns (Resident 1 was not walking at the time of assessment). During a review of Resident 1's Care Plan (CP), dated 9/23/24, the CP indicated, (Resident 1) is high risk for falls related to generalized weakness, balance problems, decreased strength. Interventions. Footwear to prevent slipping when ambulating (walking). Keep environment well-lit. During a review of Resident 1's Clinical Health Status with Baseline Care Plan (CHSBCP), dated 9/23/24, the CHSBCP indicated Resident 1 had a score of 13 indicating he was high risk for falls. During a review of Resident 1's SBAR (Situation Background Appearance Review), dated 11/3/24, the SBAR indicated, Res (Resident 1) had a witnessed fall (someone had seen the fall) when attempting to sit on the edge of his bed; abrasion (scrape) to top of head, skin tear (cut) to R (right) elbow, and c/o (complained of) pain with AROM (assisted range of motion - assistance provided to move a part of the body through its full range of movement) to RLE (right lower extremity). During a review of Resident 1's Medication Administration Record (MAR), dated November 2024, the MAR indicated Resident 1 had a pain level of 3/10 (mild pain) on 11/3/24 at 3:05 a.m. (time of fall). During a review of Resident 1's RISK MANAGEMENT IDT (Interdisciplinary Team - group of professionals who assess, coordinate, and manage each resident's comprehensive needs [RMI]), dated 11/3/24, the RMI indicated, (Resident 1) is high risk for falls. He is alert and able to make needs known. Resident interviewed and stated, I (Resident 1) was getting out of the restroom and when I got out, I turned around (to sit on his bed) and my feet slipped. Xray (medical imaging technique that uses radiation to create a picture of the inside of the body) was completed. MD (Medical Director) orders to send out to ER (Emergency Room) for further eval (evaluation) and tx (treatment). During a review of Resident 1's Core Analytics Lab & Radiology Patient Report (CALRPR), dated 11/3/24, the CALRPR indicated, There appears to be an acute (severe and sudden in onset) nondisplaced right femoral (part of the thigh bone) neck fracture. During a review of Resident 1's SBAR Post Fall (SBARPF), dated 11/3/24, the SBARPF indicated, Prior to fall resident was: a. Ambulating (walking). Bare Feet. Environment. Dim lighting. Injury. Skin tear. VISION STATUS. Poor (with or without glasses) During a review of Resident 1's Nurses Note (NN), dated 11/6/24, the NN indicated, Recently sent out to (acute hospital) due to hip fracture to right side with admitting diagnosis of fracture of femoral neck (right), s/p (status post [condition after]) open reduction internal fixation. During a review of Resident 1's Documentation Survey Report (DSR - activities of daily living [basic personal tasks that people perform in their everyday lives] flowsheet), dated November 2024, the DSR indicated on 11/3/24 night shift, CNA 1 provided Resident 1 partial or moderate assist (helper does less than half the effort) with putting on or taking off footwear. During a concurrent observation and interview on 11/15/24 at 12:56 p.m. with Resident 1 in Resident 1's room, Resident 1 was not wearing footwear. Resident 1 stated he needed assistance when getting up and walking. Resident 1 stated, I couldn't do (walking) it myself. I'm scared of falling again. Resident 1 stated, I don't think I was (wearing footwear at the time of fall). During an interview on 11/18/24 at 4:13 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 11/3/24 she was guiding Resident 1 to the restroom at 2:40 in the morning. CNA 1 stated Resident 1 slipped and fell when she was assisting him back to bed. CNA 1 stated every time a staff would assist a resident to walk, the staff must make sure the resident wears a nonskid (designed to prevent slipping or skidding) footwear for safety. During an interview on 11/19/14 at 10:00 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, He (Resident 1) told me (11/3/24) when he was about to sit on the bed, when he turned, his legs flew under him. He was barefoot. LVN 1 stated it was dim in Resident 1's room and the overhead light was the only light on. LVN 1 stated Resident 1 was supposed to wear nonskid footwear whenever walking to prevent slipping. LVN 1 stated CNA 1 could not find Resident 1's nonskid footwear when Resident 1 was going to the restroom, but LVN 1 found Resident 1's nonskid footwear in Resident 1's room after the fall on 11/3/24. During an interview on 11/19/24 at 2:07 p.m. with Physical Therapy Assistant Rehabilitation Coordinator (PTARC - treats residents through exercise, massage, gait and balance training, and coordinates rehabilitation services for residents), PTARC stated Resident 1 was supposed to wear nonskid socks or nonskid footwear when walking to prevent slipping. During an interview on 11/19/24 at 2:33 p.m. with Director of Nursing (DON), DON stated Resident 1's cause of fall on 11/3/24 was Resident 1's feet slipped. DON stated Resident 1 was barefoot when he fell. During a review of the facility's policy and procedure (P&P) titled, Care Planning, dated 11/1/17, the P&P indicated, Purpose To ensure that a comprehensive person-center Care Plan is developed for each resident based on their individual assessed needs. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from financial abuse when: 1. The facility did not have a policy & procedure in place to protect vulnerable residents who do not have the mental capacity to manage their own financial matters. 2. The Social Services Director (SSD), as the perpetrator (culprit/wrongdoer), used Resident 1 ' s credit card (a plastic card you can use to buy goods and services and pay for them later) and debit card (a payment card that can be used in place of cash to make purchases or withdraw cash) without Resident 1 ' s consent when more than $6,500 in unauthorized purchases were made by her (SSD). These failures resulted in Resident 1 being a victim of financial abuse and resulting in over $6,500 in financial loss for Resident 1. Findings: 1. During a concurrent interview and observation on 9/17/24 at 11:48 a.m. with Resident 1, Resident 1 was sitting in a chair at the dining room table, with large white purse closed and hanging on a chair. Resident 1 stated she has been in the facility for two years and does not really ask anyone to help her call her bank (sic). Resident 1 stated she does not go out with her friends. Resident 1 stated she would give her (credit) card to someone (staff) if they needed it (sic). Resident 1 stated she is unaware of any issues regarding her credit card or debit card. During a review of Resident 1 ' s Minimum Data Set (MDS-assessment tool), dated 6/7/24, the MDS indicated Resident 1 had a BIMS (Brief Interview for Mental Status-assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 6 (score of 0-7 means severe cognitive impairment). The MDS indicated Resident 1 required supervision (needs touch assistance and verbal cues) with activities of daily living. During a review of Resident 1 ' s Inventory List (list of items resident possess), dated 2/28/23 (admission date), the Inventory List indicated Resident 1 had a Visa (credit/debit card), Mastercard (credit card), Costco card (membership card) and $30 cash. During a review of Resident 1 ' s admission Record (AR), dated 9/17/24, the AR indicated Resident 1 is a [AGE] year-old female resident. Resident 1 had diagnoses of Dementia (memory loss), Psychotic Disturbance (a severe mental disorder that causes people to lose touch with reality and experience abnormal thinking and perceptions), Mood Disturbance (a change in a person's emotional state that can involve feelings of distress, sadness, depression, or anxiety), Cognitive Communication Deficit (communication issues), Bipolar Disorder (a mental illness that causes extreme shifts in mood, energy, and activity levels). During an interview on 9/17/24, at 11:08 a.m. with Business Office Manager (BOM), BOM stated, Resident ' s [1] BIMS is a 6, in my personal opinion, she [Resident 1] does not have [mental] capacity. BOM stated the facility do not have a policy on financial protection for vulnerable residents having no capacity to manage their finances. 2. During an interview on 9/12/24 at 9:53 a.m. with Complainant, Complainant stated he is from the fraud (wrongful or criminal deception intended to result in financial gain) department at a bank. Complainant stated, A woman named [SSD] that works at [the facility] has been calling in and impersonating [pretending to be] [Resident 1] to gain access to her [Resident 1 ' s] accounts. Complainant stated, Reviewing all recorded phone calls in the past, [SSD] has called in with [Resident 1] present and has identified herself as the Social Services, a facility representative, however now, she is not, she is changing her voice and calling in stating her name is [Resident 1 ' s name]. Complainant stated, We locked resident ' s [1] debit card, however her credit card was not locked and has concerning charges such as from gas stations, shoe store with $200 charges, clothing store with $300 charges. There are several gas station charges. During an interview on 9/17/24 at 11:18 a.m. with SSD, SSD stated she did call the bank and stated her (SSD) name was Resident 1 ' s name because she (SSD) was trying to help her (Resident 1) get access to her (Resident 1) pin number because Resident 1 was asking for assistance to get a new pin number. SSD stated, [Resident 1] goes out shopping on the weekends with friends. During an interview 9/17/24 at 11:48 a.m. with Resident 1, Resident 1 stated she does not really ask anyone to help her call her bank, and she stated she does not go out with her friends. Resident 1 stated she would give her (credit) card to someone (staff) if they needed it [sic]. During a review of Resident 1 ' s (Name of Bank) Visa Signature Credit Card Statement, dated 4/3/24-5/2/24, the (Name of Bank) Visa Signature Credit Card Statement, indicated a charge on 4/11/24 at a grocery store for $132.13. During a review of the facility ' s Resident Sign in and out Sheets (record of residents going out of the facility), dated April 2024, the Resident Sign in and out Sheets indicated Resident 1 did not leave the facility in April 2024 to go to a grocery store to make purchases. During a review of Resident 1 ' s (Name of Bank) Visa Signature Credit Card Statement, dated 5/3/24-6/2/24, the (Name of Bank) Visa Signature Credit Card Statement, indicated the following charges: a) On 5/3/24, there was a charge at a gas station for $114.99. b) On 5/8/24, there was a charge at a grocery store for $225.30 and a grocery store for $37.38. c) On 5/22/24, there was a charge at a pizza place for $10.70. d) On 5/23/24, there was a charge at a gas station for $202.00. The total charges for May 2024 were $590.37. During a review of Resident 1 ' s Inventory List (list of items resident possess), dated 2/28/23, the Inventory List indicated Resident 1 did not have a vehicle to get gas at a gas station. During a review of the facility ' s Resident Sign in and out Sheets, dated May 2024, the Resident Sign in and out Sheets indicated Resident 1 did not leave the facility on 5/3/24, 5/8/24, 5/22/24, and 5/23/24 to make the purchases indicated in the above credit card statement. During a review of Resident 1 ' s (Name of Bank) Credit Card statement, dated 6/3/24-7/2/24, the (Name of Bank) Credit Card statement, indicated on 6/3/24 there was a charge at a dollar store for $40.86, another dollar store for $43.62, and a gas station for $303.00. During a review of the facility ' s Resident Sign in and out Sheets, dated June 2024, the Resident Sign in and out Sheets indicated Resident 1 did not leave the facility on 6/3/24 to go to a dollar store and to the gas station. During a review of Resident 1 ' s Statement of Accounts (Name of Bank) Member Advantage Checking (debit card), dated 6/17/24-7/16/24, the Statement of Accounts (Name of Bank) Member Advantage checking, indicated a cash back (a debit card transaction in which cardholders receive cash when they make a purchase) withdrawal on 7/16/24 of $35.00 at a dollar store. During a review of the facility ' s Resident Sign in and out Sheets, dated May 2024, the Resident Sign in and out Sheets indicated Resident 1 did not leave the facility on 6/3/24 and 7/16/24 to go to the dollar store and a gas station. During a review of Resident 1 ' s (Name of Bank) Visa Signature Credit Card Statement, dated 7/3/24-8/2/24 the (Name of Bank) Visa Signature Credit Card Statement, indicated the following charges: a) On 7/5/24, there was a charge at a dollar store for $ 59.19, another dollar store for $32.49, and a gas station for $422.59. b) On 7/13/24, there was a charge at a dollar store for $137.47, pharmacy for $37.53, and a gas station for $1,035.57. c) On 7/15/24, there was a charge at a dollar store for $57.86 and a gas station for $1,048.97. d) On 7/26/24, there was a charge at a dollar store for $ 151.99, dollar store for $55.33, and a gas station for $65.00. e) On 7/27/24, there was a charge at a grocery store for $12.56. f) On 7/29/24, there was a charge at a gas station for $69.78 and gas station for $1.99. g) On 7/30/24, there was a charge at a dollar store for $150.80. h) On 7/31/24, there was a charge at a gas station for $76.79, gas station for $29.85 and fast food for $42.19. The total charges for July 2024 were $3,487.95. During a review of the facility Resident Sign in and out Sheets, dated July 2024, the Resident Sign in and out Sheet indicated Resident [1] left the faciity on 7/10/24 for facility activity outing to a cinema. There was no documentation of Resident 1 going to a dollar store, grocery store, or a gas station in July 2024. During a review of Resident 1 ' s Statement of Accounts (Name of Bank) Member Advantage Checking, dated 7/17/24-8/16/24, the Statement of Accounts (Name of Bank) Member Advantage checking, indicated: a) On 8/5/24, there were cash back withdrawals and charges of $315.64 at a grocery store, $58.77 at a gas station, $284.00 at a clothing store, and $194.79 at a shoe store. b) On 8/6/24, there was a charge of $72.05 at a gas station During a review of Resident 1 ' s (Name of Bank) Visa Signature Credit Card Statement, dated 8/3/24-9/2/24, the (Name of Bank) Credit Card Statement, indicated the following charges: a) On 8/1/24, there was a charge at a gas station for $78.78 and clothing store for $179.54. b) On 8/2/24, there was a charge at a grocery store for $128.15 and a makeup store for $314.80. c) On 8/6/24, there was a charge at a dollar store for $91.99. d) On 8/11/24, there was a charge at a gas station for $70.00. e) On 8/14/24, there was a charge at a grocery store for $10.65. f) On 8/15/24, there was a charge at a gas station for $151.52, shoe store for $406.90, and shoe store for $200.25. g) On 8/17/24, there was a charge at gas station for $60.00. h) On 8/21/24, there was a charge at a Dollar store for $79.63 and dollar store for $182.32 and gas station for $74.74. The total charges for August 2024 were $2,029.27. During a review of Resident 1 ' s Statement of Accounts (Name of Bank) Member Advantage Checking, dated 8/17/24-9/16/24, the Statement of Accounts (Name of Bank) Member Advantage Checking, indicated on 8/19/24, there was a withdrawal $6,287.99 to transfer (payment) to Resident 1 ' s credit card. During an interview on 9/19/24 at 11:39 a.m. with AD, AD stated there were no outings in August due to the facility vehicle being broken down. During a review of the facility Resident Sign in and out Sheets, dated August 2024, the Resident Sign in and out Sheets indicated there were no documentation of Resident [1] left the facility in August 2024. During an interview on 9/17/24 at 12:23 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she works on the weekends on a rotating schedule and has not seen Resident 1 go out of the facility with anyone during her (day) shifts. During an interview on 9/17/24 at 12:27 p.m. with CNA 2, CNA 2 stated she has not seen Resident 1 go out of facility on the weekends or with anyone during her shifts. During a concurrent interview and record review on 9/17/24 at 12:45 p.m. with SSD, Resident 1 ' s Inventory List dated February 2023 was reviewed. The Inventory List indicated there was no documentation of additional items purchased since admission. SSD stated, The inventory list is supposed to be updated frequently anytime a resident gets something new, the item should be labeled with resident ' s name also. During an interview on 9/18/24 at 10:33 a.m. with Family Member (FM) 1, FM 1 stated, I received a call yesterday from [SSD] at 2:22 p.m., she [SSD] said there was an ongoing investigation regarding financial abuse, the cops came in, [SSD] was very defensive in our conversation, and it did not sit right. [SSD] also stated, ' your mother [Resident 1] likes to go shopping a lot and go out. ' That statement didn ' t sit right with me because I know my mother [Resident 1] and she [Resident 1] does not in fact like to go shopping, every time I talk with her [Resident 1] she asks me to send her [Resident 1] clothes and toiletries. So, I was thinking why she [Resident 1] is asking for these things if she [Resident 1] is going out all the time. FM 1 stated, My mother [Resident 1] does not know anyone at all in that area [facility location]. My brother and I live out of state we know no one there, and her [Resident 1] friends from [out of state] do not go down there to see her. I became suspicious a few months ago when I started getting alerts about her [Resident 1] credit card bill not being paid and her [Resident 1] regular recurrent charges for other bills not being paid and the balance jumping to $4,655. I tried to call the bank, but I was not a user anymore, but somehow, I still got the alerts. I was trying to get Power of Attorney [POA-a legal document that gives someone permission to act on behalf of another person] and had a conversation with [SSD] where she told me I could not get POA while my mom was at nursing home, so I stopped that process but I am really concerned and have a lot of red flags [something that indicates or draws attention to a problem, danger, or irregularity]. I have reached out to an attorney to assist. During an interview on 9/18/24 at 10:59 a.m. with Complainant, Complainant stated, I can verbally give you a list of transactions that stand out to me that are recent. Going back to April 2024 there is a [grocery store] for $132, May 2024 a [gas station] charge one transaction for $105 another for $202. A [grocery store] for over $300, June 4 2024 a [gas station] for $300, July 5 2024 a [dollar store], a [gas station] again for $422, July 13 2024 a [gas station] for $1035, July 13 2024 a [dollar store] for $113, August 1 2024 a [gas station], [clothing store] on August 2 2024 and [Makeup store] $315, August 6 2024 [dollar store], August 11 2024 [gas station], August 14 2024 [grocery store], August 15 2024 a [gas station] $151. There are more charges I can continue to compile a list. During an interview on 9/18/24 at 2:27 p.m. with SSD, SSD stated Resident 1 goes out shopping with her [SSD] and Activities Director (AD). SSD stated she got confused about Resident 1 going out on weekends, and SSD and AD take her shopping [clothing stores], [dollar store], [grocery store] and there is a shopping center with clothes and a couple shoe stores. SSD stated, I spoke with the daughter about the financial abuse allegation on Monday and yesterday morning before you guys [California Department of Public Health surveyors] got here. SSD stated she does not sign Resident [1] in and out even though she was supposed to. SSD stated Resident 1 did not give her the receipts (proof of purchase from the shopping expenses). During an interview on 9/19/24 at 11:39 a.m. with AD, AD stated she does take Resident 1 out on activity outings but there were no outings in August due to facility vehicle being broken down. AD stated she did not start signing Resident [1] in and out on the log until July (2024) when it was enforced. Resident [1] did attend outing in February to Walmart, May to Picnic in the park, June to Dewars [NAME] store and July to Cinema. AD stated she reported using personal vehicle one time with SSD to take Resident 1 to a dollar store. AD stated she does not recall the date when it took place, but it was a couple months ago, and she stated she did not obtain a receipt as the business office was not handling Resident 1 ' s funds. AD stated she has never taken Resident 1 to a gas station, and the only place outside of town they go to is Walmart in [out of town], she has never taken Resident 1 anywhere in [out of town] besides an approved activity outing. During an interview on 9/26/24 at 4:11 p.m. with Administrator, Administrator stated he was able to obtain bank records from Resident 1 ' s daughter and compare the records against Resident 1 ' s sign in and out logs which indicated Resident [1] had not been leaving the facility when the credit card was being used, and notified Police Department (PD) when they did not match and gave the PD the records. Administrator stated he suspended the SSD, visited local gas stations where the Resident 1 ' s credit card was used with photo of the SSD. Administrator stated he notified the PD on 9/19/24 or 9/20/24 who have begun an investigation. During an interview on 9/30/24 at 9:40 a.m. with Administrator, Administrator stated SSD was suspended on 9/18/24. Administrator stated they reviewed Resident 1 ' s inventory sheet from admission and looked at Resident [1 ' s] belongings she has in her room. Administrator stated Resident [1] does have a few clothing items but nothing they can identify with the amount of purchases on her credit card statements. Administrator stated they reviewed the statements and there are several concerning charges they cannot confirm Resident [1] authorized. Administrator stated they re-interviewed Resident 1 and Resident 1 does not recall going shopping or giving her credit card or debit card to anyone. Administrator stated Resident 1 ' s memory varies from day to day; Resident 1 cannot recall what she did the previous days. During an interview on 10/1/24, at 2:10 p.m. with Administrator in Training (AIT), AIT stated, We actually terminated [SSD] last Friday, 9/27/2024. Based on the evidence we collected and our investigation on our end we are confident that she was in fact the perpetrator based on the bank records of where the credit card was being used, there could have been no one else. During a review of the facility ' s policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, dated 2020, the P&P indicated, Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and or misappropriation of resident property. The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial wellbeing. During a review of the facility ' s Job Description-Social Services (JDSS), dated 2/21/22, the JDSS indicated, Essential Job Duties: Understand, comply with and promote all rules regarding resident rights, promote positive relationships with residents, visitors and regulators.