Deficiencies in Infection Control and Personal Property Management
Summary
The facility was found to have deficiencies in infection control and management of residents' personal property. There was no evidence of infection control committee meetings after February 2024, indicating a lapse in ongoing infection control oversight. Additionally, a review of closed clinical records revealed that the facility failed to document the disposition of a resident's personal belongings following their discharge. Specifically, Resident 16, who was admitted on February 8, 2025, and passed away on March 5, 2025, had personal items such as prescription glasses, clothes, shoes, a cell phone, and a charger listed in their inventory. However, there was no documentation indicating what happened to these belongings after the resident's death. This was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Resident 16 personal belonging inventory disposition was completed and reviewed with the resident's representative. 2. A retrospective review of the last 3 months of discharges was reviewed for the presence of a personal belonging inventory disposition and completed as indicated. 3. The Director of Nursing and/or designee will educate RNs, LPNs, and Housekeeping to ensure that the personal belongings inventory disposition is completed and reviewed with the resident/resident representative as indicated. 4. The Director of Nursing and/or designee will audit all closed records to ensure that the personal belongings inventory disposition is completed and reviewed with the resident/resident representative as indicated. The audit will be completed for 3 months or until substantial compliance is achieved. Results will be reviewed at the quarterly QA meeting.
Penalty
A resident's personal belongings were not properly documented upon admission and discharge, as required. The inventory list lacked signatures from the resident or responsible party, and there was no record confirming the return of the resident's possessions at discharge. The DON confirmed that no further documentation was available to verify the release of these items.
The facility did not maintain documentation regarding the personal belongings of two residents at admission or at discharge, and the DON confirmed the absence of records accounting for these items.
A facility failed to document the disposition of a resident's personal property after their death. The deficiency was identified during a review of the resident's closed clinical record, which lacked documentation on the final disposition of their belongings. This oversight was confirmed in an interview with the Nursing Home Administrator and the DON.
A facility failed to maintain accurate records of a resident's personal possessions upon admission and discharge. The inventory list for a resident, who was admitted and later discharged, included sixteen personal items but lacked signatures from the resident or their representative and a staff member. This was confirmed by the DON, highlighting a deficiency in the facility's process to protect residents' personal and property rights.
A facility failed to document the disposition of a resident's personal belongings after discharge. A resident was admitted and later discharged home, but the personal belongings inventory form was not signed by the resident or responsible party, and there was no documentation indicating what happened to the belongings.
A facility failed to maintain a complete and accurate record of a resident's personal possessions upon admission and discharge. The resident's clinical record lacked an inventory of personal belongings, which should have been completed and signed by the resident or their representative. The ADON confirmed the absence of documented evidence for the inventory, resulting in a failure to ensure accurate accountability for the resident's belongings.
Failure to Document and Return Resident's Personal Belongings at Discharge
Penalty
Summary
The facility failed to maintain a complete and accurate record of a resident's personal possessions upon both admission and discharge. Specifically, for one resident, the inventory list documenting personal belongings at admission and discharge did not include a signature from either the resident or a responsible party. Additionally, there was no documentation in the resident's discharge information indicating that the belongings were returned to the resident upon discharge. An electronic observation detail report showed that the resident arrived with four belongings, but the facility was unable to provide further documentation confirming the release of these items at discharge. During an interview, the Director of Nursing confirmed that no additional records could be produced to verify the return of the resident's possessions.
Plan Of Correction
Resident #94 received all of his personal belongings upon discharge. To identify like residents that have the potential to be affected, the DON/designee completed a 2-week audit of new admissions to ensure that personal inventory sheets were completed upon admission and discharge of the residents. To prevent this from recurring, the DON/designee educated the nursing staff on the completion of the personal inventory sheet upon admission and discharge of the resident. To monitor and maintain ongoing compliance, the DON/designee will audit personal inventory sheets of new admissions and discharges weekly for 4 weeks, then monthly for 2 months, to ensure they are being completed and signed per the policy. Results will be reported to QAPI for recommendations and follow-up.
Failure to Document Disposition of Resident Personal Belongings at Discharge
Penalty
Summary
A deficiency was identified when, upon review of closed clinical records and staff interviews, it was found that the facility failed to document the disposition of personal belongings for two out of three discharged residents. Specifically, there was no evidence indicating what personal items were brought in by the residents at admission, nor was there documentation accounting for these belongings at the time of discharge. The Director of Nursing confirmed that there was no record of the personal property for these residents upon their discharge.
Plan Of Correction
A search of the storage areas in which resident belongings are secured until picked up by family members was conducted, and there was no evidence of any belongings of identified residents #82 or 83. The facility has implemented a new inventory of personal effects forms that will be completed by the nursing department upon admission. Education was provided to clinical staff on the proper documentation of the personal properties/belongings of newly admitted residents. Included in the education is the process for logging and updating the form as additional items are provided to the residents. An explanation of the appropriate actions to take upon discharge or death will be included in the education. Audits of newly admitted residents' inventory sheets will be completed on a weekly basis for one month and bi-weekly for three months. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, including an explanation of any identified variance infractions. P 1210
Failure to Document Resident's Property Disposition After Death
Penalty
Summary
The facility failed to protect the personal and property rights of a resident upon their death. A review of the closed clinical record for a resident who expired at the facility revealed a lack of documentation regarding the final disposition of the resident's personal property. This deficiency was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing, who acknowledged that the facility did not document the disposition of the resident's personal property after their death.
Plan Of Correction
Resident 306 passed away on 1/25/25 (survey 2/4/25). Belongings were returned. The facility cannot retroactively correct alleged deficient practice. Staff development/designee re-educated licensed staff on documenting notification to resident/family on retrieving belongings. Director of customer engagement/designee will audit personal property documentation for notification weekly x4, then monthly x2, and report findings to QAPI committee monthly.
Failure to Maintain Accurate Inventory Records
Penalty
Summary
The facility failed to maintain a complete and accurate record of a resident's personal possessions upon admission and discharge. This deficiency was identified for one resident out of three sampled, specifically Resident 187. Upon review of the clinical records, it was found that the inventory list for Resident 187, who was admitted on October 23, 2024, and discharged on November 24, 2024, included sixteen personal items. However, the inventory list lacked the necessary signatures from the resident or their responsible party, as well as from a staff member, both at the time of admission and discharge. An interview with the Director of Nursing on January 16, 2025, confirmed the absence of these signatures, indicating a failure in the facility's process to ensure the protection of personal and property rights of residents, as required by the regulation.
Plan Of Correction
1. Resident 187 has discharged from the facility. 2. A facility wide audit of Inventory Sheets was conducted to ensure accuracy and appropriate signatures. 3. Licensed Nurses were re-educated on completing a Resident Inventory Sheet with signature on admission and discharge. The Administrative Assistant will complete random chart checks to ensure completion. 4. The NHA or designee will complete a resident inventory sheet audit weekly x 4 weeks and monthly x 2 months of resident admissions and discharges to ensure accuracy and appropriate signatures. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
Failure to Document Disposition of Resident's Belongings Post-Discharge
Penalty
Summary
The facility failed to meet the regulation regarding the protection of personal and property rights of residents, specifically concerning the return of personal property after discharge. This deficiency was identified through a clinical record review and staff interview, which revealed that there was no evidence documenting the disposition of a resident's personal belongings following their discharge. Resident 108 was admitted to the facility on February 8, 2024, and discharged home on November 11, 2024. However, the personal belongings inventory form for Resident 108 was not signed by the resident or their responsible party upon discharge, and there was no documentation in the closed clinical record indicating what happened to the resident's personal belongings after they left the facility.
Plan Of Correction
P1210 1. A signed belonging sheet cannot be retroactively produced for resident 108. 2. Audit will be completed of residents who have discharged from facility from January 6, 2025, to January 13, 2025, to ensure that disposition of their personal property was completed. 3. Education will be provided to licensed nursing staff on ensuring disposition of residents' personal property is completed and documented at the time of discharge. 4. Random audits will be completed by the DON or designee weekly for 4 weeks, then monthly for 2 months, on residents who have discharged from the facility to ensure disposition of their personal property is completed. Results of audits will be presented at the Quality Assurance Performance Improvement Committee meeting for review and recommendations.
Failure to Document Resident's Personal Property Inventory
Penalty
Summary
The facility failed to maintain a complete and accurate record of a resident's personal possessions upon admission and discharge. This deficiency was identified through a review of clinical records and staff interviews, specifically concerning one resident, referred to as Resident 84. The resident was admitted to the facility on September 5, 2024, and discharged on September 24, 2024. However, the clinical record for Resident 84 did not include an inventory of personal belongings that should have been completed and signed by the resident or their representative upon both admission and discharge. An interview with the Assistant Director of Nursing (ADON) confirmed that the facility was unable to provide documented evidence of an inventory record for Resident 84's personal property, thus failing to ensure accurate accountability for the resident's belongings.
Plan Of Correction
Resident 84 discharged. To identify residents with the potential to be affected, medical records personnel will audit all current residents to ensure that a current inventory sheet is in the medical record. To prevent re-occurrence, the DON/designee will educate nursing staff on inventory sheet policy. To monitor and maintain compliance, medical records will audit new admissions weekly for 4 weeks and monthly for 2 months to ensure inventory sheets are complete. All results will be brought to the QAPI committee.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
