F0584

E

Systemic Failure to Inventory, Label, and Track Residents’ Personal Clothing and Belongings

Maumee, Ohio Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement effective procedures to safeguard residents’ personal belongings, particularly clothing, as required by its own policies. Multiple residents with varying cognitive statuses reported missing clothing and personal items, and surveyors found that inventory forms were incomplete, inaccurate, undated, and often unsigned. For one resident with Alzheimer’s disease and impaired cognition, the admission inventory listed general categories of clothing and photographs but no quantities and did not include a recliner chair that remained in the facility after discharge. A concern form documented that this resident’s representative reported missing slippers, pajamas, and a shirt; some items were later found among unlabeled clothing, and one pair of slippers remained missing. The Administrator confirmed the recliner was not on the inventory sheet.

Another resident with Huntington’s disease and moderately impaired cognition reported missing underwear, stating she had informed staff but received no follow-up. Her inventory form was undated and unsigned, listing only a few clothing items and a cell phone with charger. When surveyors and the ADON later checked her belongings, they found more clothing items than were documented, and several items were unlabeled. A resident with hemiplegia, schizoaffective disorder, and intact cognition reported missing shoes, leggings, jogging pants, a sentimental t‑shirt, and a hoodie, and stated she had reported these losses without staff follow-up. Her inventory form, completed by a social worker, listed only broad categories of clothing and a few specific items, with almost no quantities recorded. Observation showed she had numerous clothing items not accurately reflected on the inventory form, and some items were unlabeled.

A resident admitted with a femur fracture and intact cognition reported missing three pairs of pajamas and said he had notified laundry staff, who did not follow up. His undated, unsigned inventory form listed only a small number of clothing items and dentures, while observation later revealed multiple additional clothing items, most of which were unlabeled and not on the inventory. Another resident with cerebral infarction, bipolar disorder, and intact cognition reported missing pajama pants, undershorts, dress pants, and shirts, and said staff told him he would need to sort through bags of clothes himself, which he refused. His inventory form, signed by therapy staff, listed general clothing and personal items without quantities. Subsequent observation showed numerous clothing items, including unlabeled pants the resident said he received as gifts, and the inventory remained inaccurate. Surveyors later observed racks of unlabeled clothing in the social worker’s office, including pajama pants matching this resident’s description.

Staff interviews and laundry observations showed systemic failures in the processes for inventorying, labeling, and tracking clothing. The Laundry Account Manager stated that about 90% of inventory sheets had not been completed and clothing was not being labeled, with CNAs sending bags of unlabeled clothing to laundry. Laundry staff reported the tracking process was “broken,” that they lacked descriptions and sizes on inventory sheets, and that they had not received missing item forms for months. Surveyors observed large quantities of unlabeled clothing in the laundry room and on racks in the social worker’s office. CNAs and the DON gave inconsistent descriptions of who completes inventories, what details should be documented, and who is responsible for labeling clothing. The receptionist, who had labeling equipment, was unsure of her responsibility. The DON and ADON acknowledged that inventory sheets were not consistently completed, updated, or reviewed after admission, that many items were unlabeled, and that new items brought in by families were not routinely added to inventories. Despite facility policies requiring inventory of belongings, prompt investigation of complaints, and maintenance of lost-and-found records, there were no documented concern forms or nurse notes for the missing items reported by several residents, and the Resident Council President reported ongoing issues with clothing not being returned from laundry.