Deficiency in Providing Beds and Furniture on First Floor
Summary
The facility failed to provide essential furniture, including beds and mattresses, in resident rooms on the first floor. During a tour, it was observed that 13 out of 13 rooms on the first floor were missing beds and mattresses, with some rooms also lacking chairs. This deficiency was confirmed by both the Nursing Home Administrator (NHA) and the Director of Nursing during interviews and tours of the unit. The NHA explained that the beds from the second and third floors had been sent back to the rental company and replaced with those intended for the first floor. However, since the first floor was closed, the facility decided to purchase new beds for that floor, which had not yet arrived. As a result, there were no available beds in the building to use on the first floor if needed, leading to the deficiency in providing a homelike environment as per the facility's policy.
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.
