A resident with severe cognitive impairment, on hospice and dependent for all ADLs, reported that someone entered the room with their face covered, turned off the lights, and removed a wedding ring from her finger. An activities assistant relayed this allegation to an LPN, who searched the room and contacted the resident’s daughter to ask about the ring but did not disclose the resident’s report of theft or immediately notify the Abuse Coordinator. When the daughter arrived, the resident again reported that someone had stolen the ring, which the nurse overheard, but no prompt follow-up occurred, leading the daughter to call police. Law enforcement later advised that the ring had been pawned and that the ID used matched a CNA who had worked that day, while clinical notes documented bruising to the resident’s left ring finger and hospice records referenced an incident causing bruising and swelling. The facility had a policy prohibiting misappropriation of resident property and defining misappropriation as the deliberate wrongful use of a resident’s belongings without consent.
A resident with a neurocognitive disorder had a pre‑loaded credit card, managed by his guardian, whose image was sent to the business office and then forwarded to an AIT so it could be formatted and printed for billing. The AIT thereby gained access to the card information and, according to the guardian and facility records, used it to make an unauthorized phone purchase of a motorcycle battery that was billed under the facility’s name and shipped to the facility’s address, later reimbursing the guardian in cash without reporting the incident internally. The facility’s routine Advocate Rounds tool, used by concierge staff, did not include questions about the safety or security of belongings or personal funds, and staff interviews confirmed that only the business office and the AIT should have had access to the card image, establishing that the facility failed to adequately safeguard the resident’s financial information, resulting in misappropriation.
Misappropriation of resident property: A resident with intact cognition and diagnoses including difficulty walking and partial intestinal obstruction reported that a CNA entered his room while he was asleep, removed his phone from its charger, and plugged in the CNA’s personal iPhone at his bedside. A UM stated staff should not charge personal cellphones in resident rooms using residents’ property.
A resident with intact cognition and multiple medical conditions reported a returned check despite believing they had sufficient funds. When the BOM assisted with reviewing finances, the resident’s wallet was found in a social service employee’s desk and the bank card was missing. Speakerphone calls with the bank, overheard by the BOM and an LPN, revealed a large credit card payment from the resident’s account that caused an overdraft and numerous disputed transactions at various retailers, gas stations, and an airline. Bank staff indicated they had been tracking the involved employee for a cash advance with invalid data, and the resident’s report of missing property and unauthorized charges met the facility’s own definition and indicators of misappropriation of resident property.
A cognitively severely impaired resident with colon cancer had an order for scheduled Hydrocodone-Acetaminophen, but during a routine med pass staff discovered the narcotic supply was missing. Pharmacy records indicated 120 tablets should have been on hand, yet review of proof-of-use sheets and shift counts showed no documentation of administration, destruction, or waste. Staff interviews revealed that pharmacy medications were delivered in unsecured cardboard boxes left among other packages in the front office, without consistent signing or verification, and that the entire inventory sheet, narcotic count sheets, and four 30-tablet packages of the drug were missing. The facility’s abuse, neglect, and exploitation policy referenced preventing misappropriation of resident property but did not include specific protocol for misappropriation under F602.
A resident with a leg fracture, who was cognitively intact, reported that four hydrocodone/acetaminophen tablets she had brought from home in her purse were missing when she attempted to use them for pain, and the admission inventory did not list any medications. The DON acknowledged uncertainty about whether nurses routinely asked about or inventoried medications at admission. Around the same time, staff described an RN as appearing under the influence, not passing meds as expected, wobbling, falling asleep at the med cart, and prompting concerns that residents were not receiving correct pain meds. The administrator later found an empty hydrocodone bottle and other medications in the resident’s purse, and a room search revealed marijuana gummies, cigarettes, and a lighter, demonstrating a failure to safeguard and properly account for the resident’s personal narcotic medication.
The facility failed to prevent and monitor misappropriation of medications for two residents when an RN accepted and retained a GLP-1 (Ozempic) from the pharmacy that later could not be located, and only one LPN dispensed all PRN Norco doses to a cognitively intact resident whose pain was controlled with scheduled Tylenol and who reported not requesting the narcotic. Controlled drug records showed a missing Norco tablet that could not be accounted for, and the DON acknowledged that a single nurse exclusively dispensing a narcotic over time appeared suspicious for diversion.
Two residents' narcotic medications were misappropriated due to failures in medication tracking, incomplete shift-to-shift controlled substance counts, and lack of proper documentation by nursing staff. Pharmacy and administration records did not account for all received doses, and required signatures and explanations for missing medications were absent, resulting in unaccounted controlled substances.
A resident under full guardianship and legal incapacity experienced financial exploitation when a Business Office Manager facilitated unauthorized transfers of trust funds without guardian approval, resulting in unaccounted funds and psychological distress. The resident, with a history of mental health disorders, suffered increased anxiety and self-harm following the incident, and interviews confirmed violations of professional boundaries and facility policy.
Multiple instances of misappropriation of controlled substances occurred, including altered documentation, unaccounted-for doses, and administration of medications outside of prescribed times. An LPN was identified as altering narcotic counts and dispensing medications without proper documentation, affecting several residents. Additional deficiencies included dispensing medications without active orders and lack of required signatures for wastage, with staff failing to follow established procedures for controlled substance management.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
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.
Get More From Your Search Results
Create an account to access advanced search filters, save your searches, and get unlimited access to detailed Plan of Corrections.
Create an Account