F0584

E

Inadequate Clean Linen Supply Due to Laundry Equipment Failures and Poor Linen Management

Chicago, Illinois Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate clean linens for multiple residents, resulting in limited access to necessary bedding and personal care items. During observations on several floors, surveyors noted that linen carts and clean utility room shelves were sparsely stocked or empty, particularly on the first and second floors. On the first floor, only a small number of gowns, wash cloths, sheets, underpads, and towels were available on a single linen cart, and the clean utility room cart had no linen. A registered nurse reported that laundry usually delivers linen late in the morning and that residents had been complaining about not having enough linen. On the second floor, one linen cart was completely empty and the others had minimal linen, and the clean utility room cart was also empty, despite staff stating that laundry had delivered linen.

Residents reported direct impact from the linen shortage. One recently admitted resident stated she had heard concerns about lack of linen and sometimes had to wait for linen to be provided. Another resident was observed keeping a clean towel folded on her chest in bed, explaining that if she did not keep it with her, she would not have a towel for her care; this resident also reported witnessing staff hide linen for later use and cut larger towels into smaller wash cloths due to insufficient supplies. A resident with paraplegia and documented pressure ulcers of the sacral region and right hip (stage 4) stated there was no linen available, that staff cited washer problems, and that his fitted sheet had not yet been changed while he was washing himself up. He reported telling the administrator he had no linen despite having bed sores and being told linen was coming from another company, but no linen arrived.

Additional information from staff and another resident further described ongoing linen and laundry capacity issues. Resident council minutes noted concerns about residents and staff hoarding linen. The housekeeping director stated that both linens and personal clothes are washed in-house, that washers had been down and clothes and linens had been sent to another facility, and that linen had to be ordered frequently because there was not enough. She also reported that currently a single working washer was being used for both linens and personal clothes. The maintenance director confirmed that of three washers, only one 60‑lb capacity machine was operational, with the other two older machines out of order and in poor condition, and one dryer also out of order. In the laundry area, only five gowns were observed on shelves, and additional wrapped linens in the housekeeping director’s office did not include gowns. Another resident with irritable bowel syndrome and frequent diarrhea reported that CNAs told him they had no linen because the washers were broken, that he had resorted to paying for outside laundry due to backed‑up dirty clothes, and that he continued to wear dirty clothes upon return because his clothing remained unwashed.