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F0584
E

Linen Shortage During Night Shifts Impacts Incontinent Care

Madera, California Survey Completed on 04-16-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a consistent supply of clean linen, specifically towels and washcloths, for incontinent residents during night shifts. Observations and interviews revealed that linen closets in all three hallways were frequently understocked or empty of essential items, particularly during the night. Staff reported having to use non-linen items such as toilet paper and cleaning spray to provide incontinent care when washcloths and towels were unavailable. This shortage was confirmed by multiple staff members across different shifts, with some stating that the problem was ongoing and typical for night shifts. Laundry and central supply staff indicated that new washcloths were regularly ordered, but many were being thrown away or went missing, leading to persistent shortages. Housekeeping staff also reported finding dirty washcloths in resident trash cans, which they reported to supervisors. Documentation from a recent staff meeting showed that the issues of linen hoarding and improper disposal were discussed, but the problem persisted, as evidenced by the lack of linen during subsequent observations and staff interviews. The deficiency affected a significant portion of the facility's population, with over half of the 64 residents being incontinent and requiring regular pericare. Staff consistently reported that the lack of proper linen made it difficult to provide adequate care, especially during the night when linen supplies were depleted at the start or during the shift. Both the Administrator and DON acknowledged that the available linen was insufficient to meet resident needs throughout the evening and night shifts.

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