Nursing Home Resident Injured by Defective Bed Equipment Lacking Routine Safety Inspections
EL MONTE, CA - A resident at Sunset Manor Convalescent Hospital sustained a laceration requiring seven stitches after grabbing a broken bed remote control with exposed sharp edges, an incident that maintenance staff acknowledged could have been prevented through routine equipment inspections.
Equipment Failure Results in Hand Laceration
On December 17, 2024, a non-verbal resident with severely impaired cognition experienced a hand injury during what should have been a routine care interaction. The incident occurred when a Certified Nursing Assistant (CNA) was turning and repositioning the resident, who grabbed onto the facility's bed remote control. Unknown to staff, the outer plastic casing of the remote's coil line had broken away, leaving sharp edges and exposed internal wiring.
The resident, who was admitted in August 2024 with Type II diabetes, heart failure, and respiratory failure, was completely dependent on staff for all activities of daily living including transfers, dressing, and toileting. The laceration to the right palm, located between the thumb and index finger, required hospital transport and surgical repair with seven stitches at a local acute care facility.
According to the facility's maintenance assistant who investigated the incident, blood stains were found on the broken portion of the bed remote control coil, and the exposed inner wire created a sharp pointed edge where the hard plastic outer layer had peeled away.
Absence of Preventive Maintenance Protocol
The inspection revealed a critical gap in the facility's equipment safety program. The maintenance assistant reported that inspecting bed remote controls was not part of the department's routine tasks during the nine months prior to the incident. Instead, the maintenance department operated on a reactive basis, only checking equipment when problems were reported.
This reactive approach contradicts fundamental patient safety principles. Bed remote controls are high-touch medical devices that patients interact with multiple times daily. The plastic coatings on these devices degrade over time due to frequent handling, body oils, cleaning chemicals, and mechanical stress from the coiled cable design. Regular visual inspections can identify cracking, brittleness, or separation of protective coverings before they create hazardous conditions.
For residents with diabetes, even minor lacerations carry elevated risks. Diabetes compromises the body's wound-healing mechanisms by impairing immune response and reducing blood flow to extremities. What might be a superficial cut for a healthy individual can develop into a serious wound infection requiring extended antibiotic therapy or additional surgical intervention in diabetic patients.
Staff Acknowledge Preventable Injury
Multiple staff members recognized the failure in the facility's safety systems. The Licensed Vocational Nurse stated that staff needed to ensure equipment remained in good condition to prevent resident injuries, and that maintenance personnel should routinely check all devices to verify proper working condition. The maintenance assistant was direct in stating: "If the Maintenance Department performed a routine check and found the broken bed control coil line earlier, Resident 1's injury could have been prevented."
The facility's Director of Nursing acknowledged the systemic failure, stating that routinely checking all medical devices and maintaining them in good condition was essential for resident safety, and that this particular injury could have been avoided with proper equipment maintenance.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
SUNSET MANOR CONV HOSP in EL MONTE, CA was cited for violations during a health inspection on January 3, 2025.
The incident occurred when a Certified Nursing Assistant (CNA) was turning and repositioning the resident, who grabbed onto the facility's bed remote control.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.