Failure to Maintain Resident Bed in Safe Working Condition
Penalty
Summary
The facility failed to maintain a resident’s right to a safe, comfortable, and homelike environment by not ensuring that a bed was in proper working order. The facility’s Resident Rights policy dated 9/22/25 stated that residents have the right to a safe, clean, comfortable environment and to receive treatment and support for daily living safely. One resident, admitted on the documented admission date, had an MDS dated 1/10/26 reflecting diagnoses of diabetes, heart failure, and depression, and a physician order dated 9/29/25 for a low air loss mattress with instructions to check placement and functioning every shift. During an interview on 2/25/26 at 1:50 p.m., the resident reported that on 2/22/26 the motor for the foot portion of the bed broke, and since then they had been unable to raise or lower their legs while in bed. An observation on 2/25/26 at 1:55 p.m. showed that when the resident used the bed control to move the leg area, the bed made a loud noise and the bottom portion did not move. In a 2/25/26 interview at 2:07 p.m., the Maintenance Director stated that his department had been notified that the bed was broken and needed a new motor, that he had taken the specifications from the bed to place an order, but he did not know if the motor had actually been ordered. At 3:15 p.m. on the same day, the DON confirmed that the facility failed to maintain resident rights by not having the bed in working condition for this resident.
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