Failure to Maintain Clean Bed Linens and Incontinent Pads for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not ensuring clean bed linens for two residents. Surveyors observed that on 2/17/26, the beds of Resident #3 and Resident #4 had visibly soiled washable incontinent pads in place. The facility did not have a policy for bed linens or overall facility cleanliness when requested by the Administrator. Resident #3 was an older female with muscle wasting and atrophy, muscle weakness, need for assistance with personal care, depression, moderate cognition with a BIMS score of 10, and bowel and bladder incontinence. On observation of her bed at 9:59 a.m., the incontinent pad had a yellow stain on the lower right side, approximately 4 inches long and 3 inches wide in an oval shape. CNA A, when interviewed at 10:06 a.m., did not recall when she last changed Resident #3’s sheets and incontinent pad, acknowledged the stain, and stated she had gotten the resident up and ready but had not yet changed the sheets. She stated that not changing dirty sheets could lead to the spread of infection. Resident #4 was an older male with Huntington’s disease, need for assistance with personal care, urinary tract infections, and post-traumatic stress disorder, with severe cognitive deficits and a BIMS score of 7. He required substantial assistance with toileting and was occasionally incontinent of bladder. At 10:03 a.m., his bed was observed with an incontinent pad that had two small red circles on the right side, which CNA A stated looked like blood; she reported last changing his bed sheets the previous day and said she typically changed pads when she saw they were dirty but had not noticed this one. LVN C reported she had not been in Resident #4’s room since her shift began and had not checked his bed linens. CNA B stated linens should be changed on shower days or when visibly soiled, and the ADON stated incontinent pads should be changed with every incontinent care episode and that dirty sheets put residents at risk of skin breakdown. The DON and Administrator both stated linens should be changed when visibly soiled and on shower days, and that soiled linens could affect residents’ dignity and infection control, while also confirming there was no facility policy on bed linens or cleanliness.
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