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F0584
D

Failure to Provide Clean, Undamaged Bed Linen

South Pasadena, California Survey Completed on 07-24-2025

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

A deficiency was identified when a resident was found to have bed linen that was damaged with over thirty small holes near the bottom of the sheet. The resident, who had chronic obstructive pulmonary disease, type 2 diabetes mellitus with chronic kidney disease, and muscle weakness, required varying levels of assistance with daily activities but had no cognitive impairment and was able to make his own decisions. During an observation, the damaged bed sheet was noted, and the resident expressed discomfort and dissatisfaction with the condition of the linen. Interviews with staff confirmed that the damaged sheet was uncomfortable and could negatively affect residents' self-esteem, and that such conditions do not provide a homelike environment. The facility's policy requires that residents be provided with clean and good condition linens as part of a safe, clean, and comfortable environment. The failure to provide undamaged bed linen was observed and acknowledged by both direct care staff and facility management.

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