Failure to Provide Clean and Homelike Bed Linens
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents, as evidenced by the use of stained and excessively worn bed linens. One resident, who was cognitively intact, was observed on multiple occasions lying directly on a fitted sheet that had several brown stains and was worn through to the point that the mattress was visible. This resident reported that staff provided her with clean sheets that were still stained and expressed a preference for linens without stains from previous users. A certified nurse aide confirmed that most resident bed linens were stained or worn to the point of being nearly transparent and stated that residents had complained about the condition of the linens. The aide also reported having informed management about the need for new linens. Another resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, was repeatedly observed lying on a fitted sheet with brown and grey stains, which was also worn through to the mattress. The laundry supervisor acknowledged that the facility had linens with tears, stains, and excessive wear, and stated that she attempts to remove inadequate linens during the laundry process. However, she noted that during her absence, some stained and worn linens may have continued to be used by residents. The facility's own pamphlet on resident rights specifies the obligation to provide services that maintain residents' physical and mental health and satisfaction.