F0585

E

Failure to Implement Effective Grievance Process for Missing Personal Property

Bellflower, California Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement an effective grievance process to ensure resident concerns, specifically about missing personal property, were documented, investigated, and resolved in a timely manner. The facility’s own grievance logs from January to March 2026 showed no grievances related to missing personal property for three sampled residents, despite multiple reports of lost items. The facility’s policy stated that a Social Services designee serves as the Grievance Official, responsible for receiving, tracking, investigating, and resolving grievances, and that staff who receive a grievance must document it and forward it for follow-up. However, staff interviews and record reviews confirmed that these steps were not carried out for the missing property concerns.

One resident with Alzheimer’s disease, dementia, major depressive disorder, and impaired cognition, who required assistance with ADLs and was occasionally incontinent, had all personal property reported missing by a family member. The missing items included labeled clothing, a hamper, slippers, blankets, robes, tank tops, and underwear. The family member stated the facility laundered the items and did not return them, that the resident was wearing clothing that did not belong to her, and that the family had to purchase replacement items. The family member reported the issue to multiple staff, including the charge nurse and the Administrator, and stated the Administrator was condescending and lacked empathy. The family member reported that the missing items, valued at approximately $350.45, had not been reimbursed, and the issue remained unresolved.

Another resident with orthopedic aftercare following amputation, type 2 DM with hyperglycemia, and hypertensive heart disease, who had moderately impaired cognition and required maximal assistance for bathing and personal hygiene, reported that her purse and wallet had been missing for about three weeks. The missing items contained two checks. She stated she reported the loss to the facility, staff searched but did not locate the items, and she had not been reimbursed. She also stated she did not feel her property was safe and that social services did not assist her with the loss or with canceling the checks. A third resident with DM, bipolar disorder, and schizophrenia, who had intact cognition but was dependent or required maximal assistance for ADLs, reported that personal items such as hair clippers, styluses, and tweezers had been misplaced on multiple occasions over about five months, often after hospital transfers when belongings were packed. He stated he reported the missing items to staff, was told the issue would be reported to a supervisor, but received no follow-up and multiple items remained missing.

The Social Services Assistant stated that when items were reported missing, staff should search laundry and rooms, check inventory sheets, and reimburse residents if listed items could not be located, and that missing items should be documented in progress notes and reported to Administration. The SSA acknowledged discussing missing clothing with the family member of the first resident and being aware of missing money and items for the third resident, but did not indicate that grievances had been initiated and stated she was unaware of a missing purse or checks for the second resident. She further acknowledged that grievances should be initiated when residents or families report concerns, including missing property, and that if missing items had been reported, they should have been documented and a grievance filed. The SSA admitted she did not usually handle grievances, was unsure of the grievance process, and that grievances for these missing property concerns had not been documented, resulting in a lack of follow-up and unresolved concerns.

The DON stated that when a complaint cannot be resolved immediately, the grievance process should be followed and that missing personal property should have been handled as a grievance because it required investigation and follow-up. The DON acknowledged that no grievances were filed for the missing property complaints from the three residents and that the lack of a grievance process meant the issues were ignored and unresolved. The Administrator stated that when property is lost, Social Services should follow up and, if needed, replace or reimburse the resident, and that the grievance process should be used to ensure timely and efficient handling. The facility’s written grievance policy specified that residents and family members may voice grievances verbally or in writing regarding care, treatment, or other concerns, that staff receiving a grievance must document it and take immediate action as needed, and that the Grievance Official must investigate, follow up, keep the resident informed of progress, and provide a written decision with findings and corrective actions. Despite these requirements, the missing property concerns for the three residents were not entered into the grievance system, not documented as grievances, and not resolved through the required process.