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
Resources
Below are regulatory guidelines relevant to this citation:
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.
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.
Lack of Comfortable Chairs in Resident Rooms: Surveyors observed that five residents did not have a chair in their rooms, and each resident confirmed the absence of a chair during interview. The DON later stated that each resident should have a chair in the room.
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.
A resident with spinal stenosis, polyneuropathy, and unsteadiness on feet was found in a room with a closet missing a door and a top drawer, with clothes stored in plastic bags inside the open closet. The resident, CNA, MTD, and DON all confirmed the closet lacked the expected doors and drawers, and the resident stated the room had been without a closet door since moving in and felt like a slum.
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.
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.
Lack of Comfortable Chairs in Resident Rooms
Penalty
Summary
The facility failed to ensure that residents had a comfortable chair in their rooms. During random observations on 02/08/2026, the surveyor was unable to locate a chair in the rooms of Resident #40, #41, #12, #108, and #11, and each of these residents confirmed during interviews that they did not have a chair in their room. During a later interview on 02/18/2026, the DON was provided the room numbers of the residents without chairs and stated that each resident should have a chair in their room.
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.
Missing Closet Door and Drawer in Resident Room
Penalty
Summary
The facility failed to provide one of 22 sampled residents, Resident 74, with an appropriate closet with doors and drawers in the resident's room. Resident 74 was admitted with diagnoses including spinal stenosis, polyneuropathy, and unsteadiness on feet. The MDS dated 1/13/2026 indicated the resident was cognitively intact and required dependent assistance with oral hygiene, toileting, dressing, and sit to lying. During observation in the resident's room, Resident 74 stated the closet had no door, clothes were stored in plastic bags stacked inside the closet, and there was no door to the closet. The resident stated the closet had been without a door since moving into the room about a month earlier and said the room felt like a slum. CNA 2 confirmed the closet did not have a door and was missing the top drawer, stating there should be two drawers and a door for each resident's closet. The MTD also confirmed the closet door was missing and stated a resident should have a closet door to keep things out of the closet and feel comfortable in the room. The DON stated each resident should have a closet with doors and drawers in their room, and the facility policy on Resident's Right to Dignity and Privacy stated each resident shall be cared for in a manner that promotes dignity, respect, individuality, and privacy.
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