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
Below are regulatory guidelines relevant to this citation:
Missing Fitted Sheets on Bariatric Beds: Two residents with bariatric beds were observed lying on blankets with large areas of bare mattress exposed because fitted sheets were not on their beds. Staff stated the facility did not have enough bariatric sheets, and one resident said the sheets never fit properly. The DON stated all residents should have sheets on their beds, and the facility policy listed sheets as required bedding supplies.
Broken Dresser Not Maintained in Safe Condition: A resident’s dresser drawer fell apart while in use, leaving belongings on the floor and striking the resident’s knee. The resident said she had asked several times for the dresser to be replaced because multiple drawer facings came off when opened. The maintenance director said he had assumed she wanted an additional dresser and had not checked the unit, and the dresser was not maintained in safe and functional condition before the surveyor observed it.
A resident with stroke, epilepsy, and dysphagia was dependent on staff for ADLs and had capacity to make medical decisions, but his assigned closet was being used to store facility pillows. During observation, his backpack was on the floor and clothing was piled on a chair because the pillows took up most of the closet space. Staff and the DON acknowledged that residents have a right to private closet space and that resident belongings were supposed to be stored in the resident’s own closet or alternative storage furniture.
Failure to provide individual closet space for a resident in a shared room. Surveyors observed two stand-alone closets on one resident’s side of the room, both filled with another resident’s clothing, while the resident repeatedly tried to close the closet door near the bed and indicated it was bothering them. An LPN was unsure whose clothing was in the closets, and the roommate confirmed the clothing and both closets were theirs; the roommate had a BIMS score of 15.
Shared Closet Space in Semi-Private Rooms: The facility failed to ensure residents in semi-private rooms had private designated closet space. Observations showed multiple rooms with two residents sharing one closet, where only the hanging clothes were minimally separated by a tag or wood block on the bar, while the shelf and floor space remained shared and not private. The Administrator and BMA-A confirmed this arrangement during the observation.
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.
Missing Fitted Sheets on Bariatric Beds
Penalty
Summary
The facility failed to ensure that two residents with bariatric beds had fitted sheets on their beds. R15’s quarterly MDS indicated intact cognition, chronic respiratory failure with hypoxia, morbid obesity, chronic pain, bilateral impairment of the lower extremities, and dependence on staff for toileting and transfers. During observation, R15 was lying in a bariatric bed on top of a blanket with large areas of the bare mattress exposed, and R15 stated the facility never put a fitted sheet on the bed because they did not have any sheets that fit. Staff later confirmed there was no fitted sheet on the bed and stated the facility did not have enough bariatric sheets, with one NA reporting the issue had been ongoing for months and another stating it had been a problem since January. R53’s quarterly MDS indicated intact cognition, anxiety, morbid obesity, sleep deprivation, substantial assistance with toileting, and partial assistance with transfers. During multiple observations, R53 was lying in bed on top of a blanket with parts of the bare mattress exposed, and there was no fitted sheet on the bed. R53 stated the facility did not have sheets that fit her bed and that she preferred a fitted sheet that fit properly and did not fall off. A NA verified there was no sheet on the bed and said there should have been one. The DON stated she would expect all residents to have sheets on their beds. The facility policy for making an unoccupied bed listed sheets as required supplies.
Broken Dresser Not Maintained in Safe Condition
Penalty
Summary
Resident #7’s room furnishings were not maintained in safe and functional condition when a dresser drawer broke apart during use. On 5/13/26 at 11:15 am, the resident was observed holding the facing of a dresser drawer after the drawer had fallen apart, and her belongings were lying on the floor. While the surveyor was present, a maintenance assistant entered the room and initially began to repair the wrong piece of furniture before being redirected to the broken dresser drawer. The assistant picked up the broken wood, said someone would sweep the floor, and stated the drawer would be fixed. The resident reported that the drawer facing had struck her knee when it fell apart. During interview, Resident #7 stated she had asked several times for the dresser to be replaced because two to three drawer facings would come off when the drawers were opened and the dresser was broken. The maintenance director stated he had assumed the resident wanted an additional dresser and did not check the dresser, and he was unaware it was broken until the previous day when repairs were initiated. Facility documentation stated the facility would provide a safe, clean, comfortable, and homelike environment and allow residents to use personal belongings to the extent possible, but the dresser in the resident’s room had not been maintained in safe and functional condition before the surveyor’s observation.
Insufficient Private Closet Space Due to Facility Pillows Stored in Resident Closet
Penalty
Summary
The facility failed to ensure accessible and adequate private closet space for Resident 88, who was readmitted with diagnoses including cerebral infarction, epilepsy, and dysphagia and was dependent on staff for ADLs. The resident’s H&P indicated he had capacity to make medical decisions. His care plan included a goal that resident rights would be honored and respected, and the facility’s Resident Rights policy stated residents should retain and use personal possessions to the maximum extent space and safety permit. During interview, Resident 88 stated he wanted his own closet and did not want to share closet space with his roommate because he wanted a place for his belongings instead of having them scattered around the room. Observation of the room showed his backpack on the floor, clothing piled on a chair, and multiple pillows and two sweaters stored on hangers in his closet. Staff stated the pillows took up most of the closet space, leaving insufficient room for the resident’s personal belongings. The Housekeeping Manager stated it was not appropriate to store facility pillows in residents’ closets, and the DON stated resident belongings were to be stored in their own assigned closet or alternative storage furniture. The facility’s Dignity policy stated residents’ private space and property are respected at all times.
Failure to Provide Individual Closet Space
Penalty
Summary
The facility failed to provide individual closet space for a resident in a shared room during the annual re-certification survey. During observation, two stand-alone closets were located on one resident’s side of the room behind the dividing curtain, and the resident repeatedly tried to close the closet door near the bed and indicated that the open door was bothering them. Both closets contained shirts and pants, and when asked whose clothing was inside, the roommate stated that all of the clothing in both closets belonged to them. Staff were unable to immediately confirm ownership of the clothing when questioned, and the roommate again stated that both closets and all of the clothing belonged to them. The roommate had a BIMS score of 15 on 1/12/2026. To verify ownership, surveyors removed clothing items from the closets on the resident’s side of the room, and the roommate confirmed the items were theirs as well as all other clothing in the closets. A UM later acknowledged that the roommate’s clothing was occupying the other resident’s closet space.
Shared Closet Space in Semi-Private Rooms
Penalty
Summary
The facility failed to ensure that residents in semi-private rooms had their own private designated closet space. A review of the facility’s Resident Rooms policy and Safe and Homelike Environment policy, both dated 03/2026, stated that each resident bedroom would have individual private closet space and sufficient individual closet space in each resident room. However, a review of the Daily Census dated 04/01/2026 showed 87 residents in the facility, including 26 semi-private rooms and 52 residents with shared closets. Observations on 03/30/2026 found multiple semi-private resident rooms with only one closet and one door for two residents. In each observed room, the hanging clothes appeared to be separated only by a small square on the bar, while the upper shelf and floor space were not separated or private. During an observation with the Administrator and BMA-A on 04/02/2026, they confirmed that all semi-private rooms only had one closet and that the only separation was a small white square tag on the bar or a small wood block through the closet bar, with the upper shelf and floor areas not separated and not private.
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.
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