Employee 11 accompanied Resident 79 to a bank in August 2023 to cash a check worth $3,925.77. The aide offered to hold $2,000 of the proceeds for the resident, who agreed. She never returned the money.
The resident, who tested cognitively intact on facility assessments, reported the theft to Aventura at Terrace View's Director of Social Services on March 26, 2025. Police confirmed the next day that the resident had indeed cashed the check for the full amount at a local financial institution on August 1, 2023.
When questioned by law enforcement, the nursing aide admitted she took the money for safekeeping but did not return it. She told police she was scared and made no effort to correct the issue even after the resident confronted her about the missing funds.
The aide was arrested and charged with theft.
Federal inspectors found the incident occurred at a facility that had completely failed to implement required ethics training. All six employees whose files were reviewed during the March 28 inspection lacked any documentation of compliance or ethics training, including the aide who stole from the resident.
The facility's Corporate Compliance and Ethics Plan, last updated in July 2024, established written policies intended to promote compliance with legal and ethical standards. The plan specified that employees must receive training on the facility's Code of Conduct, including expectations related to ethical behavior and reporting of misconduct.
But during the inspection, administrators could not produce a copy of the facility's Code of Conduct or any policies related to the compliance and ethics program.
Five employees hired between February and March 2025 had no evidence of ethics or compliance training in their personnel files. The nursing aide who committed the theft was rehired in February 2025, and her file also lacked documentation of any such training.
Federal regulations require nursing homes to develop, implement and maintain an effective compliance and ethics program. The program must include standards, policies and procedures to prevent and detect criminal, civil and administrative violations. It must designate a compliance officer, provide effective training and education for all staff, and make a Code of Conduct available to all employees.
Interviews with facility leadership confirmed the compliance and ethics program was not part of orientation or ongoing training for staff. Documentation to support the program's implementation could not be produced.
The facility's own assessment, last reviewed on July 15, 2024, did not identify the Compliance and Ethics Program or related staff training as a component of risk or operations.
Resident 79 was admitted to Aventura at Terrace View with a diagnosis of multiple sclerosis. His most recent annual assessment revealed a BIMS cognitive score of 15, indicating he was cognitively intact and capable of making informed decisions about his finances.
The theft went undetected by facility management for nearly two years. Only when the resident himself reported it to social services did administrators become aware of the incident.
The nursing aide's admission to police that she was "scared" suggests she understood the wrongfulness of her actions but chose not to return the money or report the situation to supervisors. Her decision to keep the funds despite the resident's confrontations demonstrates a pattern of deliberate misconduct.
Federal inspectors determined the facility failed to prevent this ethical violation through the implementation of a functioning compliance program. They also found the facility failed to detect or respond to unethical conduct in a timely manner.
The lack of any ethics training documentation for newly hired staff indicates systemic failures in the facility's oversight of employee conduct. The rehiring of the nursing aide who committed theft without providing required compliance training represents a missed opportunity to prevent the violation.
The case illustrates how facilities without proper ethics programs leave vulnerable residents exposed to financial exploitation. Resident 79's cognitive integrity made him capable of managing his own finances, but the facility's failure to train staff on ethical boundaries created an environment where theft could occur.
The nursing aide's arrest on theft charges represents the criminal consequences of the facility's compliance failures. Her admission to police provides clear evidence of the intentional nature of her actions and the facility's inability to detect or prevent the misconduct.
Aventura at Terrace View's inability to produce basic compliance documentation during the federal inspection reveals deeper organizational problems beyond the individual theft. The facility had established written policies but failed to implement the training and oversight necessary to make them effective.
The resident's $2,000 remains missing, taken by someone he trusted to help him manage his financial affairs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aventura At Terrace View from 2025-03-28 including all violations, facility responses, and corrective action plans.