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F0558
D

Failure to Provide Bariatric Bed and Trapeze for Resident Needing Accommodation

San Antonio, Texas Survey Completed on 11-25-2025

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

The facility failed to provide reasonable accommodation for a resident with significant medical needs, specifically by not ensuring the resident had the appropriate bariatric bed and overhead trapeze as recommended by the therapy department and ordered by the physician. The resident, who had a BMI over 70, morbid obesity, muscle weakness, and other complex medical conditions, required a 60-inch-wide bariatric bed and an overhead trapeze to facilitate self-positioning, self-transfer, and bed safety. Despite therapy and physician orders dating back to August, the resident continued to use a 48-inch-wide bed without a trapeze as of November, making it difficult for him to reposition and transfer independently. Interviews and record reviews revealed that the therapy department and physician had communicated the need for the equipment to the Administrator, DON, and Corporate RVP, but there was no evidence that the equipment was ordered or purchased in a timely manner. The Administrator stated she had placed the order as soon as she became aware, but could not provide a purchase order or delivery timeline. The DON was unable to explain the delay or provide documentation confirming the purchase, and conflicting statements were made regarding when staff were notified of the need. Facility policy confirmed the resident's right to reasonable accommodation, but the necessary adaptive equipment was not provided as required.

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