Failure to Protect and Document Residents’ Personal Belongings
Penalty
Summary
The deficiency involves the facility’s failure to reasonably protect residents’ personal belongings from loss, as required by its personal property policy. The policy, last updated 8/15/23, states that staff will identify and record residents’ belongings upon admission on an Inventory of Personal Effects form, keep this in the clinical chart, and add any additional items brought in after admission. Any loss is to be documented on a property loss form and referred to the Administrator. For one resident (R26), who was documented as mentally intact on a quarterly MDS dated 6/4/25, an interview on 9/2/25 revealed that he reported several missing clothing items, including five sweatpants, one hoodie, two sweatshirts, and four T‑shirts. Review of his undated inventory list showed that all areas for documenting clothing were blank, with no record of his clothing. On 9/4/25, a CNA (E8) confirmed that the resident had reported missing clothing a few weeks earlier and that no property loss form had been created; instead, staff only checked the lost and found, where one pair of sweatpants labeled with the resident’s name was located. A second resident (R50), admitted on 3/7/19 and documented as cognitively intact with a BIMS of 15 on a quarterly MDS dated 7/24/25, also reported missing personal clothing. During an interview on 9/2/25, this resident stated that a shirt, pants, underwear, and a cowboy jersey were missing. An observation of the resident’s room shortly thereafter found no underwear and no cowboy jersey, and only one shirt, two pairs of pants, and a sweatshirt present. On 9/4/25, the Housekeeping Director (E4) confirmed he was going to buy the resident some clothes. The findings related to both residents’ missing belongings and the lack of proper documentation and protection of their property were reviewed with the Nursing Home Administrator (E1) and the Quality Manager (E3) during the exit conference on 9/9/25.
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