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F0585
D

Failure to Investigate and Document Resident Grievance Regarding Missing Money

San Pablo, California Survey Completed on 07-25-2025

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 intact cognition, as indicated by a BIMS score of 15, reported that $500 was stolen from him a few months prior and that he had informed the Director of Nursing (DON) about the missing money. The resident stated that nothing had been done regarding his grievance. Upon review, there was no documentation in the resident's records regarding the missing money or any grievance filed about the incident. The DON confirmed being informed of the missing money but could not provide documentation of any grievance or investigation related to the incident. The facility's policy and procedure on misappropriation of resident property requires that reports of misappropriation be promptly and thoroughly investigated and documented either in the progress notes or through the grievance process. The Administrator stated that if a grievance had been filed, there should have been an investigation and documentation, but there was no record of such actions for this incident. As a result, the resident's grievance regarding the missing money went unresolved, and the facility failed to follow its own grievance policy.

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