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F0584
E

Unstable Beds and Toileting Equipment Compromise Resident Safety

Mountain View, California Survey Completed on 07-14-2025

Penalty

Fine: $12,735
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed multiple environmental safety deficiencies during a facility inspection. One resident bed was found to be unstable, remaining movable even when its wheels were braked. Additionally, five out of eight toilet seats and five out of six toilet-seat risers were not stable, with one resident reporting the need to repeatedly reposition her portable toilet-seat riser to ensure stability before use. In one room, a toilet tank was covered with a lid that was the wrong size and shape, lying loosely on top of the open tank. Interviews with the maintenance director confirmed awareness of these hazards, including the accident risk posed by the improper toilet tank lid. Facility policies reviewed by surveyors required that beds be locked when not being moved and that all toileting equipment be maintained in safe working condition, including regular inspection for hazards such as loose fittings. The observed conditions were not in compliance with these policies and had the potential to compromise resident health and safety.

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