Inadequate Bed Size Leads to Resident Harm
Summary
The facility failed to provide a resident with a bed of proper size and height, which was necessary for the resident's safety and comfort. The resident, who was 80 inches tall, had been admitted with diagnoses including end-stage renal disease and chronic diabetic ulcers on both feet. Upon admission, the resident informed the staff that the bed was too small and uncomfortable, as his feet pressed against the footboard. Despite this, the facility did not initially provide a suitable bed, leading to the resident's feet hanging over the edge of the mattress and resting on a mattress extension. Interviews with staff revealed that the resident's bed was indeed too small, and the footboard had been removed after the resident developed diabetic ulcers on his feet. The Licensed Vocational Nurse (LVN) reported the issue to the Administrator (ADM), Director of Nursing (DON), and Assistant Director of Nursing (ADON), but was told that the bed was the largest available. The DON acknowledged that a mattress extension had been ordered upon the resident's admission but was misplaced, necessitating a reorder. The ADM confirmed the bed's length was measured and deemed sufficient, but the resident's mobility caused him to slide down, exacerbating the issue. The facility's policy on bed safety required the interdisciplinary team to assess the resident's sleeping environment, considering factors such as safety, medical conditions, and comfort. However, the failure to provide a bed of appropriate size resulted in harm to the resident, as evidenced by the development of diabetic ulcers on January 9, 2025. The facility's actions and inactions in addressing the resident's needs led to this deficiency, as the resident's comfort and safety were compromised due to inadequate bed accommodations.
Penalty
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Surveyors found that furniture in multiple resident rooms was not functional or accessible, with dresser drawers hanging open off the tracks or unable to be easily opened. The issue affected 13 of 28 rooms observed on the second floor, and the NHA later identified the same concern in multiple rooms on unit 2.
Missing Fitted Sheets on Bariatric Beds: Two residents with bariatric beds were observed lying on blankets with large areas of bare mattress exposed because fitted sheets were not on their beds. Staff stated the facility did not have enough bariatric sheets, and one resident said the sheets never fit properly. The DON stated all residents should have sheets on their beds, and the facility policy listed sheets as required bedding supplies.
Worn and Stained Mattress Not Replaced: A resident was found with a stained top sheet and a mattress that was worn, dipped in the center, ripped on one side, and discolored in multiple areas. CNA, housekeeping, DON, and LNHA interviews confirmed the mattress was in poor condition and needed replacement, and the resident’s cognition was severely impaired.
Broken Dresser Not Maintained in Safe Condition: A resident’s dresser drawer fell apart while in use, leaving belongings on the floor and striking the resident’s knee. The resident said she had asked several times for the dresser to be replaced because multiple drawer facings came off when opened. The maintenance director said he had assumed she wanted an additional dresser and had not checked the unit, and the dresser was not maintained in safe and functional condition before the surveyor observed it.
A resident with stroke, epilepsy, and dysphagia was dependent on staff for ADLs and had capacity to make medical decisions, but his assigned closet was being used to store facility pillows. During observation, his backpack was on the floor and clothing was piled on a chair because the pillows took up most of the closet space. Staff and the DON acknowledged that residents have a right to private closet space and that resident belongings were supposed to be stored in the resident’s own closet or alternative storage furniture.
Failure to provide individual closet space for a resident in a shared room. Surveyors observed two stand-alone closets on one resident’s side of the room, both filled with another resident’s clothing, while the resident repeatedly tried to close the closet door near the bed and indicated it was bothering them. An LPN was unsure whose clothing was in the closets, and the roommate confirmed the clothing and both closets were theirs; the roommate had a BIMS score of 15.
Non-Functioning Dressers in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that furniture provided in resident rooms, including dressers, was functional and accessible to each resident. During observations on the second floor, surveyors found that 13 of 28 rooms had non-functioning dressers. The concerns were identified during general observations and a tour related to complaints 3047231 and 3029891, when dresser drawers were seen hanging open off the tracks from the doorway or were unable to be easily opened after permission was obtained from the resident. On a follow-up tour with the NHA, the same concern was acknowledged in multiple resident rooms on unit 2, including rooms 203, 205, 206, 208, 212, 214, 216, 218, 219, 220, 221, 223, and 225.
Missing Fitted Sheets on Bariatric Beds
Penalty
Summary
The facility failed to ensure that two residents with bariatric beds had fitted sheets on their beds. R15’s quarterly MDS indicated intact cognition, chronic respiratory failure with hypoxia, morbid obesity, chronic pain, bilateral impairment of the lower extremities, and dependence on staff for toileting and transfers. During observation, R15 was lying in a bariatric bed on top of a blanket with large areas of the bare mattress exposed, and R15 stated the facility never put a fitted sheet on the bed because they did not have any sheets that fit. Staff later confirmed there was no fitted sheet on the bed and stated the facility did not have enough bariatric sheets, with one NA reporting the issue had been ongoing for months and another stating it had been a problem since January. R53’s quarterly MDS indicated intact cognition, anxiety, morbid obesity, sleep deprivation, substantial assistance with toileting, and partial assistance with transfers. During multiple observations, R53 was lying in bed on top of a blanket with parts of the bare mattress exposed, and there was no fitted sheet on the bed. R53 stated the facility did not have sheets that fit her bed and that she preferred a fitted sheet that fit properly and did not fall off. A NA verified there was no sheet on the bed and said there should have been one. The DON stated she would expect all residents to have sheets on their beds. The facility policy for making an unoccupied bed listed sheets as required supplies.
Worn and Stained Mattress Not Replaced
Penalty
Summary
The facility failed to ensure that each resident was provided with a clean and comfortable mattress, affecting 1 of 30 residents reviewed, Resident #13, on [NAME] Hall. On 5/29/2026, the resident was observed seated in a wheelchair in the common area, and staff obtained permission to enter the resident’s room to observe the bed alarm. In the room, the surveyor observed a small yellow stain on the top sheet. CNA #3 stated she was in the process of changing the resident’s linen and removed the soiled linens with her bare hands, placing them in a clear plastic bag. The resident’s mattress was observed to be worn, with a notable dip in the center, multiple rips on the left lateral side, and multiple brown discolored spots on various parts of the mattress. CNA #3 stated the mattress needed to be replaced. Housekeeping staff stated mattresses were cleaned once per month and replaced if found to be in poor condition, and the Director of Housekeeping stated the mattress shown to him needed to be replaced. The DON stated CNAs should inspect mattresses when making beds and notify the UM if a mattress was not intact, and the LNHA stated mattresses should be maintained clean, intact, and in working condition. The resident’s cognition was severely impaired when the surveyor attempted to interview them.
Broken Dresser Not Maintained in Safe Condition
Penalty
Summary
Resident #7’s room furnishings were not maintained in safe and functional condition when a dresser drawer broke apart during use. On 5/13/26 at 11:15 am, the resident was observed holding the facing of a dresser drawer after the drawer had fallen apart, and her belongings were lying on the floor. While the surveyor was present, a maintenance assistant entered the room and initially began to repair the wrong piece of furniture before being redirected to the broken dresser drawer. The assistant picked up the broken wood, said someone would sweep the floor, and stated the drawer would be fixed. The resident reported that the drawer facing had struck her knee when it fell apart. During interview, Resident #7 stated she had asked several times for the dresser to be replaced because two to three drawer facings would come off when the drawers were opened and the dresser was broken. The maintenance director stated he had assumed the resident wanted an additional dresser and did not check the dresser, and he was unaware it was broken until the previous day when repairs were initiated. Facility documentation stated the facility would provide a safe, clean, comfortable, and homelike environment and allow residents to use personal belongings to the extent possible, but the dresser in the resident’s room had not been maintained in safe and functional condition before the surveyor’s observation.
Insufficient Private Closet Space Due to Facility Pillows Stored in Resident Closet
Penalty
Summary
The facility failed to ensure accessible and adequate private closet space for Resident 88, who was readmitted with diagnoses including cerebral infarction, epilepsy, and dysphagia and was dependent on staff for ADLs. The resident’s H&P indicated he had capacity to make medical decisions. His care plan included a goal that resident rights would be honored and respected, and the facility’s Resident Rights policy stated residents should retain and use personal possessions to the maximum extent space and safety permit. During interview, Resident 88 stated he wanted his own closet and did not want to share closet space with his roommate because he wanted a place for his belongings instead of having them scattered around the room. Observation of the room showed his backpack on the floor, clothing piled on a chair, and multiple pillows and two sweaters stored on hangers in his closet. Staff stated the pillows took up most of the closet space, leaving insufficient room for the resident’s personal belongings. The Housekeeping Manager stated it was not appropriate to store facility pillows in residents’ closets, and the DON stated resident belongings were to be stored in their own assigned closet or alternative storage furniture. The facility’s Dignity policy stated residents’ private space and property are respected at all times.
Failure to Provide Individual Closet Space
Penalty
Summary
The facility failed to provide individual closet space for a resident in a shared room during the annual re-certification survey. During observation, two stand-alone closets were located on one resident’s side of the room behind the dividing curtain, and the resident repeatedly tried to close the closet door near the bed and indicated that the open door was bothering them. Both closets contained shirts and pants, and when asked whose clothing was inside, the roommate stated that all of the clothing in both closets belonged to them. Staff were unable to immediately confirm ownership of the clothing when questioned, and the roommate again stated that both closets and all of the clothing belonged to them. The roommate had a BIMS score of 15 on 1/12/2026. To verify ownership, surveyors removed clothing items from the closets on the resident’s side of the room, and the roommate confirmed the items were theirs as well as all other clothing in the closets. A UM later acknowledged that the roommate’s clothing was occupying the other resident’s closet space.
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