Failure to Address and Monitor Ongoing Resident Laundry Losses
Penalty
Summary
The facility failed to develop and implement an effective plan to address ongoing issues with missing and delayed resident laundry items. Documentation review revealed that from December 2024 to December 2025, there were 53 reports of missing laundry items, including clothing and blankets, with some residents experiencing repeated losses. Residents reported that laundry was sometimes mixed with facility linens and sent to an outside vendor, resulting in items not being returned. Additionally, laundry was sometimes delivered to the wrong rooms, causing further delays, with some residents waiting over a week or more than 11 days to have their items returned. Despite staff education and signage, residents continued to report missing or delayed laundry. Interviews with residents and staff confirmed ongoing concerns. Residents at a council meeting expressed dissatisfaction with the timeliness and accuracy of laundry return, noting inconsistencies in how laundry attendants managed the process. The Administrator acknowledged awareness of the problem but admitted that no formal root cause analysis or structured plan had been initiated to resolve the issue or monitor the effectiveness of any interventions. The Maintenance Director, responsible for the laundry department, confirmed a recent change in linen vendors, but missing items reports persisted after the change. Review of the Quality Assessment and Assurance (QAA) Committee meeting minutes showed that missing laundry items were not consistently reviewed or addressed as part of the facility's grievance process, despite multiple reports each month. The QAPI plan required the committee to address all systems of care, prioritize problems, and use root cause analysis, but the missing items log was not considered as part of grievances, and missing laundry issues were not discussed in committee meetings. This lack of systematic review and follow-up contributed to the ongoing deficiency.