Failure to Accommodate Resident Needs and Preferences in Environment
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of three residents in relation to their environment. One resident, admitted after shoulder surgery and at risk for pressure ulcers, repeatedly expressed that their bed was too narrow and uncomfortable, but staff were either unaware of the concern or informed the resident that a larger bed was not available. Another resident, who required a mechanical lift and assistance from two staff for transfers due to a stroke, reported that their shared room lacked sufficient space for safe transfers and wheelchair maneuvering. Staff confirmed that the room setup often required moving the bed at an angle or leaving the door open during transfers, which sometimes compromised privacy. A third resident, with cognitive intactness but impaired extremities from a stroke and heart disease, was observed without their call light within reach after care was provided. The resident stated this was a recurring issue, and staff acknowledged that the call light was not checked or placed within reach before leaving the room, despite care plan instructions. These deficiencies were identified through observations, resident and staff interviews, and record reviews.