Inadequate Bed Size Leads to Resident Harm
Summary
The facility failed to provide a resident with a bed of proper size and height, which was necessary for the resident's safety and comfort. The resident, who was 80 inches tall, had been admitted with diagnoses including end-stage renal disease and chronic diabetic ulcers on both feet. Upon admission, the resident informed the staff that the bed was too small and uncomfortable, as his feet pressed against the footboard. Despite this, the facility did not initially provide a suitable bed, leading to the resident's feet hanging over the edge of the mattress and resting on a mattress extension. Interviews with staff revealed that the resident's bed was indeed too small, and the footboard had been removed after the resident developed diabetic ulcers on his feet. The Licensed Vocational Nurse (LVN) reported the issue to the Administrator (ADM), Director of Nursing (DON), and Assistant Director of Nursing (ADON), but was told that the bed was the largest available. The DON acknowledged that a mattress extension had been ordered upon the resident's admission but was misplaced, necessitating a reorder. The ADM confirmed the bed's length was measured and deemed sufficient, but the resident's mobility caused him to slide down, exacerbating the issue. The facility's policy on bed safety required the interdisciplinary team to assess the resident's sleeping environment, considering factors such as safety, medical conditions, and comfort. However, the failure to provide a bed of appropriate size resulted in harm to the resident, as evidenced by the development of diabetic ulcers on January 9, 2025. The facility's actions and inactions in addressing the resident's needs led to this deficiency, as the resident's comfort and safety were compromised due to inadequate bed accommodations.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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 was found to be sleeping on a low air flow therapeutic mattress with a dark brown circular stain. An LVN reported that the stain did not look appealing and that the mattress should have been changed. The DON and DOH later reviewed a photograph of the mattress and confirmed the dark brown stain, acknowledging it should have been removed and replaced. This situation occurred despite a facility policy stating that residents are to be provided with a safe, clean, comfortable, and homelike environment.
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.
A resident experienced ongoing discomfort due to an inadequate mattress and reported the issue to multiple staff members over several months. Despite these reports, no documentation or maintenance work order was submitted, and the mattress was not replaced, even though other mattress replacements were processed for different residents during the same period.
A resident was provided with a makeshift closet area consisting of a PVC pipe and a portable metal rack, without any shelving or a proper wardrobe. The family had to add a curtain to make the space more homelike, as the facility did not meet its policy of providing sufficient individual closet space.
Multiple rooms on one unit were found to be missing bed frames, mattresses, and functional furniture, with some rooms also being used for storage instead of resident accommodation. The NHA confirmed these rooms were not available for resident use and lacked required furnishings as mandated by regulations.
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.
Failure to Provide a Clean Therapeutic Mattress
Penalty
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.
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.
Failure to Timely Replace Uncomfortable Mattress After Resident Complaints
Penalty
Summary
A deficiency was identified when a resident reported having an uncomfortable mattress that felt as though it had a hole and caused them to feel the bed frame. The resident stated this issue had persisted since their admission approximately six months prior and that they had informed various staff members about the problem during this time. Despite these reports, the mattress was not replaced, and the resident continued to experience discomfort. Observations confirmed the mattress had a visible wrinkle and a compressed, softer center, supporting the resident's complaint. Interviews with staff, including a CNA and an LPN, confirmed that the resident had repeatedly voiced concerns about the mattress over several months. However, there was no documentation in the resident's progress notes regarding these complaints, and a review of the facility's maintenance reporting system (TELS) showed no work order had been submitted for a mattress replacement for this resident. Administrative staff confirmed that all staff are trained to enter work orders into TELS, and other mattress replacements had been processed for different residents during the same period. Maintenance staff also indicated that no work order had been received for this issue.
Failure to Provide Adequate Closet Space and Shelving
Penalty
Summary
The facility failed to provide adequate closet space with shelving for one resident. According to a family member, the resident's room was located at the end of the hall and did not contain an actual closet or a portable wardrobe. Instead, the facility had installed a PVC pipe from the ceiling, forming a box-like structure intended for hanging clothes, but there were no shelves available. The family had to purchase a curtain and tension rod to make the space more homelike, as the original setup was not considered homelike. Observation of the room confirmed the absence of a built-in wardrobe or closet. The only available storage was a portable metal clothes rack and the PVC pipe structure, with no shelving present. The facility administrator acknowledged that the wardrobe had been removed from the room and that maintenance had installed the PVC pipe, but no shelves were provided. The facility's own policy requires sufficient individual closet space for each resident, which was not met in this case.
Missing Beds, Mattresses, and Furniture in Resident Rooms
Penalty
Summary
Surveyors observed that multiple resident rooms on the third floor were missing essential furnishings, including bed frames, mattresses, and functional furniture. Both single and dual occupancy rooms were affected, with some rooms lacking one or two bed frames and mattresses, as well as necessary furniture. Additionally, one double occupancy room was found to have a key lock on the doorknob and was being used for storage rather than for resident accommodation. These findings were based on direct observation during the survey. During an interview, the Nursing Home Administrator confirmed that the rooms in question were not readily available for resident use as required. The absence of proper beds, mattresses, and furniture was acknowledged, and it was stated that these items were on order. The deficiency was cited under federal and state regulations requiring that each resident be provided with a separate bed of proper size and height, a clean and comfortable mattress, appropriate bedding, and functional furniture suitable to the resident's needs.
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