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F0602
D

Failure to Protect Resident's Personal Belongings During Hospitalization

Stockton, California Survey Completed on 12-11-2025

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 deficiency occurred when a resident's personal belongings, including a cell phone and wallet containing cash and important identification cards, went missing while the resident was hospitalized. The resident, who had incomplete paraplegia and limited mobility, had requested that CNAs secure his wallet, cell phone, and other personal items prior to his transfer to the hospital. Upon his return, the resident discovered that his wallet, clothing, and cell phone were missing. Although the wallet was eventually found by a housekeeper, only the identification card was returned, and the cell phone and other items remained missing. The resident reported emotional distress due to the loss and was using a loaner phone from a friend. Facility staff interviews and record reviews revealed that the process for handling and storing residents' belongings during hospitalizations was inconsistent and lacked proper tracking. Staff described that belongings were typically bagged and placed in a former shower room or storage area, sometimes with a four-digit code accessible to all staff. Inventory sheets were supposed to be completed and signed by both a CNA and a licensed nurse, but there were discrepancies in documentation, and the missing cell phone was not consistently listed on inventory records. The Social Services Director and other staff acknowledged that valuable items were not always separated or securely stored, and the Administrator confirmed that there was no effective tracking or monitoring process for residents' belongings during absences. Facility policies required that all resident possessions be inventoried, treated with respect, and protected from loss or theft, with documentation retained in the medical record. However, the actual practices did not align with these policies, as belongings were stored in unsecured areas and not adequately tracked. This failure resulted in the loss of the resident's property and caused emotional distress, with the potential for similar incidents affecting other residents.

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