Failure to Provide a Clean Therapeutic Mattress
Summary
Surveyors identified that the facility failed to provide a clean mattress for one of six sampled residents. On 2/8/26, a Licensed Vocational Nurse (LVN) observed that this resident’s low air flow therapeutic mattress had a dark brown circular stain and stated the stain did not look appealing and the mattress should have been changed. During a subsequent interview, the Director of Nursing (DON) and Director of Housekeeping (DOH) reviewed a photograph of the mattress taken on 2/8/26 and confirmed the presence of the dark brown stain, agreeing that the mattress should have been removed and replaced. As a result of this inaction, the resident slept on a stained mattress, with the report noting potential for skin irritation and respiratory issues. Review of the facility’s “Homelike Environment” policy dated 2001 indicated residents are to be provided with a safe, clean, comfortable, and homelike environment, which was not met in this instance. The deficiency centers on the facility’s failure to ensure the resident’s mattress was clean and appropriately maintained in accordance with its own policy and procedure for providing a safe and clean environment.
Penalty
Resources
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Lack of Comfortable Chairs in Resident Rooms: Surveyors observed that five residents did not have a chair in their rooms, and each resident confirmed the absence of a chair during interview. The DON later stated that each resident should have a chair in the room.
A resident with spinal stenosis, polyneuropathy, and unsteadiness on feet was found in a room with a closet missing a door and a top drawer, with clothes stored in plastic bags inside the open closet. The resident, CNA, MTD, and DON all confirmed the closet lacked the expected doors and drawers, and the resident stated the room had been without a closet door since moving in and felt like a slum.
A facility failed to provide individual closet space that kept residents' clothing separate from roommates' belongings in all double occupancy rooms. Observations in multiple rooms showed shared closets with no physical separation, and an LPN confirmed that residents shared one closet. A resident also stated they shared closet space with their roommate and no partition was present.
Surveyors found that all 46 semi-private rooms had only one shared closet without partitions, causing roommates’ clothing and personal items to touch and become intermingled on shelves and floors. A tour confirmed that no semi-private room closets had partitions to separate belongings, and the DON acknowledged that none of the closets provided private closet space for individual residents.
Bed Size and Positioning Did Not Meet Resident Needs: A resident was observed in bed with the feet hanging off the end and the ankles resting on the foot board, and the resident stated he/she could not sleep because the bed was too small. The resident had intact cognition and a height of 72 inches. The ADON and RDCS stated residents should be assessed for a larger bed or extender based on fit, comfort, height, weight, or preference, and the facility policy required ongoing evaluation of individual needs and preferences.
Missing Closet Doors Exposed Residents’ Belongings: Two residents’ rooms lacked closet doors, leaving personal belongings visible and accessible to others. One resident said the door had been removed months earlier because it was loose and unsafe, but the promised replacement and curtain never occurred. Maintenance staff reported multiple doors had been taken down because they were falling off the hinges, and the NHA said replacement timing was unknown.
Lack of Comfortable Chairs in Resident Rooms
Penalty
Summary
The facility failed to ensure that residents had a comfortable chair in their rooms. During random observations on 02/08/2026, the surveyor was unable to locate a chair in the rooms of Resident #40, #41, #12, #108, and #11, and each of these residents confirmed during interviews that they did not have a chair in their room. During a later interview on 02/18/2026, the DON was provided the room numbers of the residents without chairs and stated that each resident should have a chair in their room.
Missing Closet Door and Drawer in Resident Room
Penalty
Summary
The facility failed to provide one of 22 sampled residents, Resident 74, with an appropriate closet with doors and drawers in the resident's room. Resident 74 was admitted with diagnoses including spinal stenosis, polyneuropathy, and unsteadiness on feet. The MDS dated 1/13/2026 indicated the resident was cognitively intact and required dependent assistance with oral hygiene, toileting, dressing, and sit to lying. During observation in the resident's room, Resident 74 stated the closet had no door, clothes were stored in plastic bags stacked inside the closet, and there was no door to the closet. The resident stated the closet had been without a door since moving into the room about a month earlier and said the room felt like a slum. CNA 2 confirmed the closet did not have a door and was missing the top drawer, stating there should be two drawers and a door for each resident's closet. The MTD also confirmed the closet door was missing and stated a resident should have a closet door to keep things out of the closet and feel comfortable in the room. The DON stated each resident should have a closet with doors and drawers in their room, and the facility policy on Resident's Right to Dignity and Privacy stated each resident shall be cared for in a manner that promotes dignity, respect, individuality, and privacy.
Shared Closet Space Lacked Separation in Double Occupancy Rooms
Penalty
Summary
The facility failed to provide individual closet space that kept each resident's clothing separate from their roommate's belongings in all double occupancy rooms. During observations, double occupancy rooms 120, 128, 215, 221, 225, 228, and 229 were found to have no physical separation of items in the shared closet. An LPN stated that residents in double occupancy rooms shared one closet, along with a large dresser and individual side tables. A resident interviewed in one of the rooms stated they shared the closet space with their roommate, and no partition was noted inside the closet to separate belongings. The concern about the lack of private closet space was then addressed with the Nursing Home Administrator.
Failure to Provide Private Closet Space in Semi-Private Rooms
Penalty
Summary
The facility failed to provide private closet space for residents in all 46 semi-private rooms, resulting in roommates’ clothing and personal items being intermingled. Observation of semi-private room closets on January 5, 2026, showed that each room had only one shared closet without any partition, causing roommates’ clothing to touch and personal items on the shelf and floor to be mixed together. A tour of all semi-private rooms confirmed that none of the closets contained a partition to separate residents’ belongings. In an interview on December 5, 2026, at 2:30 PM, the DON confirmed that no closets in the semi-private rooms had partitions to provide private closet space for individual residents. These findings demonstrate noncompliance with the requirement to ensure adequate and private closet space for each resident, as required under 28 Pa. Code 201.18(b)(2) Management.
Bed Size and Positioning Did Not Meet Resident Needs
Penalty
Summary
The facility failed to ensure that Resident #118’s bed and mattress were properly positioned and adjusted to meet the resident’s needs and ensure safety and comfort. During the initial tour, the surveyor observed the resident in bed with the feet extended over the mattress and the ankles resting on the foot board. The resident stated he/she could not sleep at night because the feet were always hanging off the bed and said he/she thought a nurse had been told that the bed was too small. The resident’s MDS showed a BIMS score of 14, indicating intact cognition, and a height of 72 inches. During interviews, the ADON stated residents are assessed for a larger bed if it is noticed that they do not fit or if they say they are uncomfortable, and that residents’ feet should never be hanging off the end of the bed. The RDCS stated that reasons a resident might need a different bed or an extender could include height, weight, or preference, and confirmed that Resident #118 now had a bed extender. The facility policy on Accommodation of Needs stated that the resident’s individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and on an ongoing basis.
Missing Closet Doors Exposed Residents’ Belongings
Penalty
Summary
The facility failed to ensure that residents had enclosed closet space protected from casual access by others because closet doors were missing in 2 of 21 resident rooms observed during the annual survey. During a tour of the A wing nursing unit, the Surveyor observed that Resident #41 and Resident #57 did not have closet doors, and their personal belongings were visible. During an interview, Resident #57 stated that the closet door had been removed months earlier because it was loose and posed a safety issue. The resident said the door was supposed to be replaced and a curtain provided in the meantime, but that this never happened and the resident felt uncomfortable with personal belongings exposed to anyone entering the room. On a later environmental tour, the Surveyors again confirmed the missing closet doors in both residents' rooms. Maintenance Director #12 stated that multiple closet doors had been taken down because they were falling off the hinges and posed a safety issue, and that replacing them had been difficult because the company no longer made that model to fit properly. The NHA stated the facility was discussing curtains and was in the process of ordering new cabinets, but could not determine when the missing closet doors would be replaced.
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