East Park Care Center: Air Mattress Set Wrong for Months - OH
The resident, identified in inspection records only as Resident #10, was admitted to East Park Care Center on an undisclosed date. His list of diagnoses runs long: cerebral infarction, anoxic brain damage, traumatic brain injury, hemiplegia of the left side, peripheral vascular disease, adult failure to thrive, and a feeding tube. He could not speak. He could not care for himself in any way. Inspectors noted he had severely impaired cognition and was dependent on staff for every activity of daily living, including an indwelling urinary catheter. He received his nutrition through a tube.
He also had an active wound at his sacrum. A physician's order from October 2, 2025, called for wound care every three days: cleanse with saline, pat dry, apply barrier cream and a dry dressing. He had been on a prescribed air mattress with bolsters since May.
The air mattress was set to 610 pounds.
He weighed 165.
The Proactive Protek Aire mattress that East Park had placed under this man is designed to be calibrated to the resident's actual body weight. Its operating manual specifies a pressure range adjustable by weight, with settings running from 90 to 650 pounds. The purpose of that calibration is to distribute pressure correctly across a body. For a resident who cannot reposition himself, who has vascular disease and an open sacral wound, that pressure distribution is not a comfort preference. It is the mechanism by which the mattress is supposed to work.
A state inspector observed the 610-pound setting on October 7, 2025, at 1:55 in the afternoon, standing alongside the Director of Nursing. The DON confirmed the number on the display. Her response was that the resident was comfortable.
The mattress had not been adjusted by the following morning. An observation at 11:30 a.m. on October 8 found it still at 610 pounds. A second observation that afternoon, at 2:00 p.m., confirmed the same reading. A licensed practical nurse, identified as LPN #226, was present. When asked about it, she said she had been told the setting was in his care plan, that it was his preference so he could be elevated higher to watch television.
There was no such documentation. The DON confirmed this herself later that same day, at 4:15 p.m., telling inspectors there was nothing in Resident #10's plan of care supporting a 610-pound setting as a resident preference or for any other reason.
So the explanation was wrong, and the care plan that was supposed to contain it did not exist.
What that leaves is a man who cannot speak, cannot move himself, cannot tell anyone that something is wrong, lying on a mattress misconfigured by hundreds of pounds for an unknown length of time. The physician's order placing him on the air mattress dated to May 8, 2025. The wound care order was dated October 2. Inspectors arrived October 7. At no point in that span did anyone at East Park document a clinical reason for the setting, and no one corrected it until inspectors were standing in the room.
CMS rated the harm level as minimal. The inspection covered three residents total reviewed for preventive interventions. East Park Care Center had 48 residents at the time of the survey.
Resident #10 remained at the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for East Park Care Center from 2025-10-14 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
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 23, 2026 · Our methodology
EAST PARK CARE CENTER in BROOK PARK, OH was cited for violations during a health inspection on October 14, 2025.
The resident, identified in inspection records only as Resident #10, was admitted to East Park Care Center on an undisclosed date.
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.