§483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.
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Observations:
Based on review of policy, review of facility documentation, review of clinical record, and interview with staff, it was determined that facility failed to ensure a resident was free from misappropriation of resident property and/or exploitation for one of three residents reviewed (Resident R3).
Findings include:
Review of facility policy 'Prevention of Misappropriation and Exploitation of Resident Property,' indicates that the facility shall protect each resident's property, funds, personal information, credit cards, bank cards, and financial resources from misappropriation, exploitation, unauthorized use, coercion, manipulation, or theft. The facility prohibits misappropriation of resident property and exploitation of residents by any employee, contracted staff member, volunteer, visitor, resident, or other individual.
Further review of policy states that the purchase must be for the residents personal use or benefit only and the original receipt and any change, unused funds, or remaining balance information shall be returned to the resident immediately and documented. The transaction shall be reviewed for accuracy, and documentation shall be maintained in accordance with facility policy.
Review of Resident R3 clinical record revealed the resident is awake, alert and oriented to person place and time (x 3), with medical history of vertebra fractures, sleep disorder, embolism and thrombosis (formulation of blood clots), diabetes (when the body cannot properly regulate blood sugar cause high blood sugar levels), neuromuscular bladder dysfunction (loss of bladder control), anemia (deficiency of healthy red blood cells), and falls.
Review of information submitted to the state survey agency on July 8, 2026, revealed on July 6, 2026, Resident R3 reported accusations of Receptionist, Employee E3, stealing his/her money.
Review of facility documentation revealed a typed interview with Resident R3 dated July 6, 2026. When asked what happened with the credit card, Resident R3 reported "I asked the receptionist [Employee E3] to buy me cigarettes from across the street. She came back with the cigarettes but something this morning told me check my online banking. When I did, I saw an ATM transaction for 80$. Well $82.99. I assume the $2.99 the ATM fee".
Per the documented interview, Resident R3 admitted to giving the receptionist the PIN number for the credit card in case she needed it to make the purchase of cigarettes. Resident R3 stated that the Front Desk Receptionist, Employee E3, gave the card back but did not give a receipt. Resident R3 also reported he/she did not give permission to use the debit card at an ATM and only gave permission to use the card to purchase cigarettes. The purchase of the cigarettes was also noted to be a separate charge from the $80 ATM withdrawal.
Review of facility documentation revealed a statement dated July 7, 2026, by Resident R3, states"on Sunday, July 5, 2026, around 6:15 pm I gave front desk receptionist (Employee E3) my debit card to go to the gas station to get two packs of cigarettes for me. I offered her something, but she stated she didn't want anything, but in the midst of conversation she told me she gets off at 8:00 p.m. so meet her in the hallway. I came out by 8:00 p.m. and I've seen her coming up the hill. She gave me two packs of cigarettes. She also told me she won't be back to work until Wednesday I didn't think she was going to steal anything because she made me think she was trustworthy, but she took $80 out of my bank account without my permission, and I looked at my statements online Monday morning, and I had to report it "
Further review of facility documentation revealed resident/family concern form completed on July 6, 2026, by Resident R3 with the following concern: needed cigarettes asked the front desk staff to go to the store. Resident did say E3 went at 8:02 pm; R3 did give pin. E3 came back at 8:11 pm 8:17 pm with the cigarettes. When resident checked bank account saw an atm withdrawal for $80.
Further review of grievance form revealed that R3 confirmed that he/she did not receive receipt from Receptionist, Employee E3.
Further review of facility provided documentation revealed the facility returned Resident R3's funds in the amount of $82.99 was completed on July 6, 2025.
28 Pa. Code 201.14 (a) Responsibility of licensee.
28 Pa. Code 211.12 (d)(5) Nursing services.
| | Plan of Correction - To be completed: 09/04/2026
1. Funds were returned to resident R3 at the time of the incident.
2. All residents have the potential to be affected.
Audit completed of all residents to identify risk of misappropriation with resident questionnaire.
3. Education was initiated by NHA/designee for staff on the prevention of resident abuse including misappropriation.
4. NHA/designee will complete random audits of three residents to identify misappropriation risk and address as required. The audits will be weekly for four weeks and monthly for two months. Results of the audit will be taken through the facility's monthly Quality Assurance and Performance Improvement meeting. Based on the results of these audits a decision will be made regarding the need for continued submissions and reporting.
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