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F0584
D

Failure to Safeguard and Track Resident's Personal Belongings

Battle Creek, Michigan Survey Completed on 05-12-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with legal blindness, muscle weakness, and cognitive intactness was admitted to the facility and relied on personal items, including a DVD set gifted by his daughter, to support his daily living and comfort. The resident reported that the DVD set was stolen the same day it was brought into the facility, and both he and his family reported the missing item to facility staff by submitting a concern form. The DVD set was important to the resident as it allowed him to watch his favorite show using headphones, which was necessary due to his roommate's loud television use. Despite the family submitting a concern form to the receptionist, and the receptionist recalling turning the form in to the administrator, there was no documentation or follow-up regarding the missing DVD set. The facility was unable to produce any grievance or concern forms related to the missing item, and the assistant director of nursing indicated that paperwork that should have been in the previous administrator's office could not be located. As a result, the resident's personal belongings were not safeguarded or made available for his use, and the facility failed to ensure a safe, comfortable, and homelike environment as required.

Plan Of Correction

F584 - Safe/Clean/Comfortable/Homelike Environment Element #1: R38's missing DVD set was replaced and an inventory checklist was reissued to the resident and updated. Element #2: The Social Service Director conducted an audit of all resident grievances and personal belongings reports to ensure appropriate follow-up. Any open items were addressed and resolved. Element #3: The policy on Resident and Family Grievances was reviewed by the Administrator and updated as necessary. Community staff were re-educated on the grievance process, along with resident inventories. Element #4: The Administrator or designee will audit the concern log weekly for 12 weeks to confirm timely follow-up on any resident property issues. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025

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