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F0584
D

Failure to Safeguard Resident's Personal Property and Document Valuables

San Francisco, California Survey Completed on 12-04-2025

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 safeguard the personal property of a resident who reported a black pouch containing cash missing after being readmitted from the hospital. The resident, who had diagnoses including acute respiratory failure, recurrent major depressive disorder, generalized anxiety disorder, and hoarding disorder, stated that the pouch with $2,000 was left in his room prior to hospitalization. The resident had previously shown a CNA $1,000 in the pouch, and the CNA confirmed witnessing this amount. However, the pouch and cash were not documented in the resident's inventory of personal effects as required by facility policy. Upon the resident's return, he reported the missing pouch and cash, expressing significant emotional distress, including sadness, tearfulness, and feelings of distrust toward staff. Multiple staff interviews and record reviews confirmed that the CNA had seen the pouch and cash but failed to update the inventory or ensure the valuables were secured in the facility's safe, as per policy. The resident continued to experience emotional distress related to the loss, requiring ongoing support from the social worker and referral to a psychologist. The facility's investigation did not find evidence of wrongdoing by staff, residents, or visitors, and the missing items were not recovered. The CNA involved received in-service training on the proper process for documenting resident property and the facility's procedures for safeguarding valuables. Despite these measures, the initial failure to document and secure the resident's cash resulted in its loss and ongoing emotional impact on the resident.

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