Resident Sleeps in Wheelchair Due to Uncomfortable Bed
Summary
The facility failed to provide functional furniture appropriate to the resident's needs, specifically a comfortable mattress for a resident identified as R609. R609, who has multiple diagnoses including Amyotrophic Lateral Sclerosis (ALS) and is at high risk for pressure injuries, reported discomfort with her current bed and requested a new mattress. Despite filing a grievance and expressing her discomfort, the facility did not provide a new mattress or alternative sleeping arrangement, leading R609 to sleep in her wheelchair. The resident's grievance, filed on 9/3/24, indicated that the bed was uncomfortable, and she requested a recliner to sleep in. The facility's response was that no other mattress options were available, and an air mattress was not provided because R609 did not have any wounds. The Assistant Nursing Home Administrator (ANHA) acknowledged the resident's complaint but stated that the facility's mattresses were all the same and that the resident did not qualify for an air mattress. The grievance was considered resolved by the facility, despite the resident's continued discomfort and lack of a suitable sleeping arrangement. The facility's communication with the Board of Aging & Long Term Care (BOALTC) revealed that the resident's bed was not broken, but the footboard was out of its bracket. The facility maintained that the resident was sleeping in her wheelchair due to breathing issues and discomfort in her bed. Despite the resident's ongoing complaints and the BOALTC's involvement, the facility did not provide a new bed or mattress, resulting in the resident continuing to sleep in her wheelchair, which was not documented in her care plan.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident was found to be sleeping on a low air flow therapeutic mattress with a dark brown circular stain. An LVN reported that the stain did not look appealing and that the mattress should have been changed. The DON and DOH later reviewed a photograph of the mattress and confirmed the dark brown stain, acknowledging it should have been removed and replaced. This situation occurred despite a facility policy stating that residents are to be provided with a safe, clean, comfortable, and homelike environment.
Surveyors found that all 46 semi-private rooms had only one shared closet without partitions, causing roommates’ clothing and personal items to touch and become intermingled on shelves and floors. A tour confirmed that no semi-private room closets had partitions to separate belongings, and the DON acknowledged that none of the closets provided private closet space for individual residents.
A resident experienced ongoing discomfort due to an inadequate mattress and reported the issue to multiple staff members over several months. Despite these reports, no documentation or maintenance work order was submitted, and the mattress was not replaced, even though other mattress replacements were processed for different residents during the same period.
A resident was provided with a makeshift closet area consisting of a PVC pipe and a portable metal rack, without any shelving or a proper wardrobe. The family had to add a curtain to make the space more homelike, as the facility did not meet its policy of providing sufficient individual closet space.
Multiple rooms on one unit were found to be missing bed frames, mattresses, and functional furniture, with some rooms also being used for storage instead of resident accommodation. The NHA confirmed these rooms were not available for resident use and lacked required furnishings as mandated by regulations.
A resident in a four-person room was required to share a wardrobe with another individual due to insufficient private closet space, after the room's occupancy was increased from three to four. Observations revealed that this issue affected multiple rooms on the unit, with inadequate storage provided for residents' personal clothing.
Failure to Provide a Clean Therapeutic Mattress
Penalty
Summary
Surveyors identified that the facility failed to provide a clean mattress for one of six sampled residents. On 2/8/26, a Licensed Vocational Nurse (LVN) observed that this resident’s low air flow therapeutic mattress had a dark brown circular stain and stated the stain did not look appealing and the mattress should have been changed. During a subsequent interview, the Director of Nursing (DON) and Director of Housekeeping (DOH) reviewed a photograph of the mattress taken on 2/8/26 and confirmed the presence of the dark brown stain, agreeing that the mattress should have been removed and replaced. As a result of this inaction, the resident slept on a stained mattress, with the report noting potential for skin irritation and respiratory issues. Review of the facility’s “Homelike Environment” policy dated 2001 indicated residents are to be provided with a safe, clean, comfortable, and homelike environment, which was not met in this instance. The deficiency centers on the facility’s failure to ensure the resident’s mattress was clean and appropriately maintained in accordance with its own policy and procedure for providing a safe and clean environment.
Failure to Provide Private Closet Space in Semi-Private Rooms
Penalty
Summary
The facility failed to provide private closet space for residents in all 46 semi-private rooms, resulting in roommates’ clothing and personal items being intermingled. Observation of semi-private room closets on January 5, 2026, showed that each room had only one shared closet without any partition, causing roommates’ clothing to touch and personal items on the shelf and floor to be mixed together. A tour of all semi-private rooms confirmed that none of the closets contained a partition to separate residents’ belongings. In an interview on December 5, 2026, at 2:30 PM, the DON confirmed that no closets in the semi-private rooms had partitions to provide private closet space for individual residents. These findings demonstrate noncompliance with the requirement to ensure adequate and private closet space for each resident, as required under 28 Pa. Code 201.18(b)(2) Management.
Failure to Timely Replace Uncomfortable Mattress After Resident Complaints
Penalty
Summary
A deficiency was identified when a resident reported having an uncomfortable mattress that felt as though it had a hole and caused them to feel the bed frame. The resident stated this issue had persisted since their admission approximately six months prior and that they had informed various staff members about the problem during this time. Despite these reports, the mattress was not replaced, and the resident continued to experience discomfort. Observations confirmed the mattress had a visible wrinkle and a compressed, softer center, supporting the resident's complaint. Interviews with staff, including a CNA and an LPN, confirmed that the resident had repeatedly voiced concerns about the mattress over several months. However, there was no documentation in the resident's progress notes regarding these complaints, and a review of the facility's maintenance reporting system (TELS) showed no work order had been submitted for a mattress replacement for this resident. Administrative staff confirmed that all staff are trained to enter work orders into TELS, and other mattress replacements had been processed for different residents during the same period. Maintenance staff also indicated that no work order had been received for this issue.
Failure to Provide Adequate Closet Space and Shelving
Penalty
Summary
The facility failed to provide adequate closet space with shelving for one resident. According to a family member, the resident's room was located at the end of the hall and did not contain an actual closet or a portable wardrobe. Instead, the facility had installed a PVC pipe from the ceiling, forming a box-like structure intended for hanging clothes, but there were no shelves available. The family had to purchase a curtain and tension rod to make the space more homelike, as the original setup was not considered homelike. Observation of the room confirmed the absence of a built-in wardrobe or closet. The only available storage was a portable metal clothes rack and the PVC pipe structure, with no shelving present. The facility administrator acknowledged that the wardrobe had been removed from the room and that maintenance had installed the PVC pipe, but no shelves were provided. The facility's own policy requires sufficient individual closet space for each resident, which was not met in this case.
Missing Beds, Mattresses, and Furniture in Resident Rooms
Penalty
Summary
Surveyors observed that multiple resident rooms on the third floor were missing essential furnishings, including bed frames, mattresses, and functional furniture. Both single and dual occupancy rooms were affected, with some rooms lacking one or two bed frames and mattresses, as well as necessary furniture. Additionally, one double occupancy room was found to have a key lock on the doorknob and was being used for storage rather than for resident accommodation. These findings were based on direct observation during the survey. During an interview, the Nursing Home Administrator confirmed that the rooms in question were not readily available for resident use as required. The absence of proper beds, mattresses, and furniture was acknowledged, and it was stated that these items were on order. The deficiency was cited under federal and state regulations requiring that each resident be provided with a separate bed of proper size and height, a clean and comfortable mattress, appropriate bedding, and functional furniture suitable to the resident's needs.
Lack of Private Closet Space for Residents
Penalty
Summary
During an extended recertification survey, it was observed that a four-person resident room on the North Two Unit lacked adequate private closet space for each resident. Specifically, there were only three freestanding wardrobes available for four residents, resulting in one wardrobe being shared between two individuals. One resident reported that the room was originally designed for three people, but an additional person was added after staff took measurements, leading to the need to share closet space. The survey further identified a total of six four-person occupancy rooms on the unit, raising concerns about the adequacy of private storage for residents' clothing. These findings indicate that the facility did not ensure each resident had private closet space to keep their clothing separate from that of their roommates, as required by regulations.
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.
