Failure to Provide Adequate Linens and Ensure Call Light Accessibility
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of residents by not supplying adequate linens, specifically washcloths, and by not ensuring that call lights were within reach for multiple residents. Certified Nursing Assistants (CNAs) reported running out of washcloths over a period of weeks, resorting to using pillowcases, cutting up towels, or purchasing wipes with their own money to provide basic hygiene care. Observations confirmed that linen carts and shower rooms were frequently empty of washcloths and towels, and residents were unable to obtain necessary items for personal care, such as shaving. The facility administrator acknowledged awareness of supply issues and stated that linens are delivered daily to an off-site laundry house, but there was no formal process or designated responsibility for restocking linen carts or rooms, leading to inconsistent availability of supplies. Multiple residents were observed with call lights out of reach, either placed on the floor, clipped high on curtains, or wrapped around fixtures, making it difficult or impossible for them to summon assistance when needed. Residents with varying degrees of cognitive impairment and physical limitations, including those at risk for falls, expressed frustration and concern about their inability to access call lights. Staff interviews corroborated that call lights were not always left within reach, and residents sometimes had to attempt to retrieve them, increasing their risk of harm. The facility's own policy requires that call lights be within easy reach of residents when they are in bed or confined to a chair. Despite this, both staff and residents reported ongoing issues with call light accessibility. The lack of a structured process for linen distribution and call light placement directly contributed to the deficiencies observed, affecting residents with significant medical histories such as orthopedic injuries, chronic diseases, cognitive impairment, and mobility challenges.