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F0558
D

Failure to Adjust LAL Mattress to Resident Comfort Level

Alhambra, California Survey Completed on 06-26-2025

Penalty

No penalty information released
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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

A deficiency occurred when the facility failed to accommodate the needs and preferences of a resident by not ensuring that the resident's Low Air Loss (LAL) mattress was set to the comfort level as ordered by the physician. The resident, who was admitted with diagnoses including scoliosis, chest and rib deformity, and muscle weakness, was dependent on staff for most activities of daily living and was moderately impaired in cognitive skills. Physician orders specified that the LAL mattress should be adjusted for the resident's comfort, yet observations revealed that the mattress had very little air, and the metal part of the bed could be felt with minor pressure. The resident repeatedly complained about the mattress being uncomfortable and lacking sufficient air. Interviews with staff and the resident's responsible party confirmed that complaints about the mattress had persisted for two to three months, with both the resident and their responsible party noting the mattress was hard and uncomfortable. Staff acknowledged that the mattress should be set to the resident's comfort level in accordance with physician orders and resident rights. Facility policies also required providing a comfortable mattress to promote comfort and prevent complications of immobility, but these were not followed in this instance.

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