Sequoia Vista

Based on interview and record review, the facility failed to follow its policy and procedure for one of three sampled residents (Resident 1) when an alleged misappropriation of resident property was not reported to Department of Public Health, Ombudsman, Adult Protective Services and Law Enforcement Officials within 24 hours.

This failure resulted in a delay of the investigation.Findings:During a review of the Theft & Loss Form (TLF) dated 8/10/25, the TLF indicated Date & Time of Report.8/10/25.Description of missing items.money 600 dollars.During a review of Resident 1's Progress Notes (PN) dated 8/10/25 at 2:32 p.m., the PN indicated, CNA (Certified Nursing Assistant) approached writer and stated that the resident said she was missing personal belongings.

Upon arrival RN (registered nurse) supervisor was in residents' room helping look for belongings.

Writer called daughter (daughter name) and notified.

Inventory sheet was reviewed.

Resident filled out theft and loss form and turned into SS (Social Services). SS aware.During a review of the Report of Suspected Dependent Adult/Elder Abuse (SOC341) dated 8/18/25 (seven days after the facility was aware), the SOC341 indicated, Resident report of alleged allegation of missing money.

Resident has BIMS (Brief Interview for Mental Status-used to assess cognitive function) 15/15 (indicating Resident 1 was cognitively intact).

During an interview on 8/18/25 at 3:46 p.m. with Social Service Director (SSD), SSD stated when the $600 was reported missing the daughter did not want to call the police. SSD stated the incident should have been reported to the Department of Public Health, Ombudsman, Adult Protective Services and Law Enforcement Officials per facility policy.

During an interview on 8/18/25 at 4:12 p.m. with Ombudsman, Ombudsman stated the facility did not report the missing money to their office.

During an interview on 8/18/25 at 4:41 p.m. with Administrator, Administrator stated on 8/10/25, Resident 1 had reported she was missing $600, and an investigation was started.

Administrator stated the missing $600 was not reported to Department of Public Health, Ombudsman, Adult Protective Services and Law Enforcement Officials because the amount of money missing was not adding up during the investigation.

Administrator stated it should have been reported within 24 hours.During a review of the facility policy and procedure (P&P) titled, Theft/Loss Prevention dated 8/2020, the P&P indicated, When an alleged or suspected case of misappropriation of resident property is reported, the Administrator, or designee, notifies the following persons or agencies within twenty-four (24) hours of such incident.Department of Public Health/Aging.Ombudsman.Adult Protective Services.Law Enforcement Official.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

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