F0602

D

Failure to Prevent and Address Misappropriation of Residents’ Money

Delta, Colorado Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from misappropriation and loss of personal money and belongings, as required by its own policy and abuse prevention strategy. The facility’s policy on identifying exploitation, theft, and misappropriation of resident property states that exploitation, theft, and misappropriation are strictly prohibited and that prevention requires staff education and training, with the QAPI committee responsible for reviewing and addressing quality deficiencies that may lead to such events. Despite this, multiple residents experienced missing cash from their rooms, and staff interviews revealed that direct care staff had not been trained on prevention of misappropriation of resident property.

One cognitively intact resident with chronic conditions including pressure ulcer, chronic kidney disease, and COPD reported withdrawing $200.00 from a bank, spending $50.00 on a food delivery requested through a nurse, and later being unable to locate the remaining $150.00 in his room. He reported the missing money to facility staff and filed a grievance, but he stated he did not receive restitution and refused to sign the grievance form for that reason. The facility’s investigation confirmed with the resident’s financial advisor that $200.00 had been withdrawn, documented that the resident believed the money might have been stolen or thrown away with his old wallet, and recorded the allegation of missing funds. The resident’s electronic medical record contained minimal documentation related to the missing money, and his safety and security care plan addressing storage of valuables was not initiated until 12 days after he reported the loss.

Another cognitively intact resident with diagnoses including muscle weakness, anxiety disorder, and insomnia reported that her daughter had given her $50.00, which she stored in an envelope in her dresser. After being out of her room, she returned to find the drawer open and $30.00 missing. The facility’s investigation documented that the resident’s wallet contained $28.00, that the resident and her daughter confirmed a total of $58.00 should have been present, and that $30.00 was unaccounted for. The investigation also noted a pattern of misappropriation incidents on the same hall involving other missing cash amounts. However, the resident’s care plan was not updated with interventions to prevent further misappropriation, and her progress notes and EMR did not contain documentation of the incident. The grievance form showed the matter was escalated and reported, but there was no documentation that restitution was made.

A third resident with severe cognitive impairment and multiple chronic conditions reported missing $64.00 that she stated had been given by a friend. The facility’s investigation included interviews and a search of the room, and it documented inconsistent information from the resident and her family about the amount of cash involved. The investigation could not determine whether the money was lost or stolen and did not identify an alleged assailant or pattern specific to this resident, though it occurred during a period when several misappropriation incidents were reported. The resident’s grievance form confirmed the allegation of missing money and a lower amount reported by the resident’s representative, and the EMR contained no additional information about the incident. The social services director stated she was unable to locate the missing property for the three residents and that they did not receive restitution, and the NHA and DON acknowledged that the incidents were confirmed by families or representatives, while also indicating that staff had not received training related to misappropriation prevention.