F0602

D

Failure to Prevent Staff–Resident Boundary Violations and Financial Exploitation

Los Angeles, California Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from exploitation and misappropriation of funds by allowing CNAs to develop inappropriate personal relationships with residents, accept gifts, and share personal contact information and photos. For one resident with atrial fibrillation and end stage renal disease, admitted with a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment, the resident reported that a CNA knelt in front of him in a common area and asked him to marry her. The resident stated he agreed, that a wedding date of December 29 was discussed, and that the CNA offered to move him into her home so he could help pay rent and living expenses with money he would save by not living at the facility. The resident also reported giving this CNA fifty dollars around Thanksgiving to buy a turkey, mashed potatoes, and sweet potatoes.

The facility’s social worker documented that the resident told her he was going to get married on December 29 to a nurse who had proposed to him and that he stated the proposal was serious when she asked if it might be a joke. The social worker later stated that the relationship between the CNA and the resident was “getting weird,” that the CNA had given the resident her personal phone number, and that she was sending pictures of herself to the resident, which the social worker said was not appropriate and against facility policy. The social worker also stated that although the resident was oriented to person, place, and time, he was “not great at knowing the situation,” as he wanted to move into the CNA’s house. The DON acknowledged that the resident had given the CNA fifty dollars, and the administrator stated that staff cannot receive gifts as individuals, while the facility’s Professional Boundaries and Ethics policy prohibited staff from accepting any gifts, including money or meals, from residents, from sharing personal contact information, and from engaging in sexual, romantic, or emotional relationships with residents.

A second resident, admitted with diabetes mellitus with other specified complication and mild cognitive impairment, was also involved in boundary violations with another CNA. This CNA reported she had known the resident for about ten years and had previously invited him to dinner at her house, which he attended. She stated that the resident bought her a burger and fries on one occasion, which she accepted, and that she was unaware she could not accept this meal. The social worker documented that the resident admitted buying the CNA a twenty-dollar lunch and later reported that the resident’s daughter said the CNA was speaking with the resident on his personal cell phone and “talking a lot about money,” after which the resident changed his phone number. The DON stated that CNA 2 denied any prior personal relationship with the resident, while also acknowledging a gift from the resident to the CNA involving approximately twenty dollars in cash or food. These actions occurred despite facility policies on Professional Boundaries and Ethics and Elder Abuse Prevention and Response, which define financial abuse and prohibit staff from accepting anything of value from residents, sharing personal contact information, or engaging in romantic or emotional relationships with residents.

Across both cases, the facility’s own policies clearly stated that employees must maintain professional relationships, set and maintain boundaries, not accept gifts or money from residents, not share personal phone numbers or other personal information, and not engage in sexual, romantic, or emotional relationships with residents, even if consensual. The documented interactions between the CNAs and the two residents—acceptance of money and meals, sharing of personal phone numbers, sending personal photos, discussion of marriage, and discussion of moving a resident into a staff member’s home—directly conflicted with these written policies. The facility’s failure to prevent or promptly address these boundary violations resulted in residents not being protected from potential financial abuse, misappropriation of property, and exploitation as defined in the facility’s Elder Abuse Prevention and Response policy.