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F0921
D

Failure to Maintain Secure Storage for Resident Belongings

Duarte, California Survey Completed on 07-24-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a cabinet in a shared resident room was found to be missing a dead bolt, leaving the cabinet unable to be securely closed. During an observation, the cabinet belonging to a resident was open, and it was confirmed that the locking mechanism was missing. The Infection Prevention Nurse (IPN) acknowledged that all cabinets should have functioning locks to provide residents with a secure space for their personal belongings. The IPN also stated that staff are responsible for reporting maintenance issues, but in this case, the issue had not been properly addressed. Further investigation revealed that a counselor had verbally reported the missing lock to the Maintenance Department several weeks prior, but the maintenance supervisor to whom it was reported was no longer employed at the facility. The counselor was unaware of the need to document maintenance issues in a log and had not followed up after the initial report. The facility's administrator stated that maintenance staff and department heads are expected to conduct daily checks of rooms to ensure safety and functionality, and that the lock should have been repaired when first reported. Review of facility policy confirmed that maintenance is responsible for keeping equipment in safe and operable condition at all times.

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