F0689

D

Unlocked Personal Items Cart with Hazardous Contents Left Unattended in Hallway

Sacramento, California Survey Completed on 03-27-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency related to accident hazards and inadequate supervision when a personal items cart containing resident belongings was left unlocked and unattended in a hallway. During an observation near a resident room, three nursing staff were present at the personal items cart and then left it unlocked. A subsequent observation showed the cart still unlocked while three residents walked by it. The cart contained items such as a pair of broken glasses, resident dentures, and resident hearing aids, and was easily accessible to residents in the hallway.

In a concurrent observation and interview, a CNA stated she had checked out resident dentures from the cart, confirmed that three nursing staff had been present when she left, and acknowledged that the cart remained unlocked with no staff present. The CNA stated the cart should be locked at all times and that residents could harm themselves with items such as the broken glasses or dentures if not supervised. An LN confirmed that all medication and personal item carts should be locked to prevent resident access and that accessing the personal items cart could result in an accident for residents who wander. The DON stated the expectation is for all carts in the facility to be locked, confirmed that resident access to the cart items could have led to an accident and missing resident items, and acknowledged that there were missing pages and dates in the personal item log binder, indicating items were not monitored accurately. Review of the facility’s Safety/Supervision policy showed it required making the environment as free from hazards as possible and targeting interventions to reduce risks related to environmental hazards, including adequate supervision of assistive devices.