Incompatible Mattress and Bedframe for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident’s mattress was compatible with and properly fit the bedframe, as required by the expectation that all bed frames, mattresses, and bed rails be regularly inspected for safety and that mattresses attach safely to the bed frame. The affected resident had an admission date of 12/07/2023 and diagnoses including Myoneural Disorder, Paraplegia, Epilepsy, and Peripheral Vascular Disease, with a Quarterly MDS BIMS score of 6 indicating severe cognitive impairment. On 03/23/2026 at 11:39 a.m., surveyors observed the resident lying in bed with his feet hanging off the mattress, which appeared too small for the bedframe. On 03/24/2026 at 10:12 a.m., further observation showed the resident lying on his back with his head elevated on an air mattress that did not fit the bedframe properly, leaving approximately a 1-foot gap between the top of the bedframe and the head of the mattress, with the resident’s head partially above the mattress. At 12:48 p.m., a CNA confirmed the mattress did not fit the bedframe and explained that pulling the resident and mattress up in the bed would create a gap at the footboard. At 1:00 p.m., the ADON confirmed the mattress was not accommodating to the resident’s height and should be. At 3:00 p.m., the DON observed that the air mattress was approximately 1 foot smaller than the bedframe and confirmed that the bed was not accommodating the resident and that the mattress did not fit the bedframe properly.
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