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F0584
D

Failure to Timely Investigate and Report Missing Resident Belongings

Torrance, California Survey Completed on 08-08-2025

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

The facility failed to investigate a claim of missing belongings for a resident with severe cognitive impairment, resulting in the resident missing a blanket for three months. The resident, who had diagnoses including muscle weakness and dementia, was dependent on the facility for daily living and support. The family member reported the missing blanket to multiple certified nursing assistants and charge nurses, but the information was not relayed to the social services director (SSD) as required by facility policy. The SSD only became aware of the missing item after a significant delay, despite the family providing photographic evidence that the blanket had been in the facility. Facility policy required that all inquiries regarding lost or stolen items be reported immediately to the administrator or designee, and that a search for the missing property begin right away. However, the nursing staff did not follow this procedure, resulting in a lack of timely investigation and action. Both the SSD and the director of nursing (DON) confirmed that missing items should be reported within a day or two, but this did not occur, leading to a prolonged period during which the resident was without her personal belonging.

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