Deficiency in Providing Functional Bed for Resident
Summary
The facility failed to provide functional furniture for a resident, specifically a bed with a working remote control, which resulted in the resident being unable to adjust the bed's position. This deficiency was observed during multiple instances where the resident was seen attempting to eat meals while lying flat in bed. The resident reported that the bed remote control was broken, and they had not been offered an alternative bed despite the availability of open rooms. The resident's clinical record indicated they had intact cognition and were admitted with diagnoses including pressure ulcer, adult failure to thrive, and major depressive disorder. The facility's Maintenance Director from a sister facility confirmed that a new remote was ordered but was unsure of its arrival date. Despite the availability of open rooms, there was no consideration to swap the bed for a functioning one. The Director of Nursing acknowledged the lack of a specific policy for positioning during meals but stated that residents should be positioned comfortably. The deficiency was communicated to the Director of Nursing, who was informed of the ongoing concerns regarding the resident's poor positioning due to the broken bed control.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to provide individual designated closet space for residents, affecting several individuals. A resident with bipolar disorder and schizophrenia reported that his roommate wore his clothes due to the lack of dividers in the shared closet. Another resident with major depression and anxiety confirmed wearing his roommate's clothing because he could not identify his own. A third resident with adjustment disorder and psychosis found the closet too small and lacking dividers. The facility's policy required private closet space, but this was not followed, as verified by the Administrator and Unit Manager/LPN.
A resident with morbid obesity was not provided with a bed of appropriate size or a comfortable mattress. Observations showed the resident's feet pressed against the footboard and the mattress compressed to the springs, causing discomfort. The resident reported the bed was uncomfortable, and there was no documentation of an assessment for proper fit or comfort.
The facility failed to provide private closet space for 46 residents, resulting in shared closets without separation for clothing. This issue was confirmed during a facility tour and interview with the MD, affecting numerous resident pairs across the facility.
Deficiency in Providing Designated Closet Space for Residents
Penalty
Summary
The facility failed to provide individual designated closet space for residents, affecting three residents directly and potentially impacting three additional residents. The deficiency was identified through record review, observation, and interviews. Resident #17, diagnosed with bipolar disorder, paranoid personality disorder, and schizophrenia, expressed dissatisfaction with his roommate wearing his clothes due to the lack of dividers in the shared closet. The closet was shared by three residents, and clothing was hung randomly without any indication of ownership, leading to confusion and mix-ups. Resident #18, with major depression, anxiety disorder, schizoaffective disorder, and bipolar disorder, confirmed that he sometimes wore his roommate's clothing as he could not identify his own due to the absence of dividers. Similarly, Resident #81, diagnosed with adjustment disorder, major depression, and psychosis, reported that the closet was too small and lacked dividers, making it difficult to store his clothes. The facility's policy required providing each resident with a private closet space, but this was not adhered to, as verified by the Administrator and Unit Manager/LPN during their interview.
Inadequate Bed and Mattress for Resident
Penalty
Summary
The facility failed to ensure that a resident was provided with a bed of appropriate size and a comfortable, intact mattress. The resident, who was admitted with a diagnosis of morbid obesity, was observed with both feet pressed against the footboard and the mattress compressed to the bed springs. The resident expressed discomfort, stating that the mattress and bed were not comfortable, and his buttock was pressing against the springs. There was no documentation indicating that the bed was assessed for proper size or comfort, and the Director of Nursing confirmed the lack of evidence for such an assessment.
Deficiency in Private Closet Space for Residents
Penalty
Summary
The facility failed to provide private closet space separate from roommates' clothing for 46 residents out of 103 rooms reviewed. During a facility tour, it was observed that several pairs of residents were sharing a single closet without separation for their clothing. This deficiency was confirmed through observations and an interview with the Maintenance Director. The affected residents were identified by room numbers, indicating a widespread issue across the facility.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
