F0584

E

Inadequate Linens and Poor Room Maintenance Undermine Homelike Environment

Waukesha, Wisconsin Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment, including adequate bed and bath linens, as required by its own policy. On multiple units, surveyors observed that nurse storage closets had little to no linens, particularly bath towels and sheets, during morning care times. One cognitively intact resident, with diagnoses including congestive heart failure, schizoaffective disorder bipolar type, morbid obesity, hypertension, and major depressive disorder, reported that staff washed her up but did not have any towels available on her scheduled shower day. Staff on the unit confirmed that they had used all available towels for resident care and were waiting for more linens before they could provide showers or additional care.

Surveyors inspected the nurse storage closets on several units and found significant shortages. On one unit, the closet contained only a few pillowcases, washcloths, gowns, and bath blankets, but no bath towels or sheets. Another unit had only a small number of bath towels, washcloths, sheets, pillowcases, gowns, and one bath blanket, while a third unit’s closet had no linens or towels at all. CNAs reported that they typically relied on the closets being stocked but that on this day there were no linens on the floor, and they would have to go to the laundry if they needed supplies. One CNA stated she had started her shift earlier that morning and that the closet had not been stocked when she arrived, and another CNA stated she had to wait for towels to provide showers and would sometimes go back to the laundry to see if any were available.

The Housekeeping/Laundry Supervisor reported that one of the facility’s washing machines had been broken for about a week to a week and a half and that this affected linen delivery. She stated linens were usually delivered once a day around noon, but with the broken machine, only a small amount could be delivered in the morning and again around noon. She also indicated that when she started one and a half to two months earlier, the facility was already low on linens, and that she had placed two linen orders but received only one. She did not have established par levels for each unit and instead estimated daily quantities for the small closets. At the time of the survey, the available clean towels and washcloths on a linen cart were fewer than the facility’s census, and additional towels and washcloths ordered previously still needed to be washed. The supervisor acknowledged she had not checked the unit closets that morning due to being short-staffed.

In addition to linen shortages, surveyors observed multiple resident rooms with damaged walls, including gouges, holes, and unpainted patches, which affected the homelike environment. One resident’s room had a large patched area behind the headboard that had not been painted, and the resident stated that work had been started but not completed for some time. Other rooms, both occupied and unoccupied, had multiple gouges and holes of varying sizes in the wallboard behind beds and near outlets, as well as a missing corner guard extending several feet in one room. Some residents reported that the damage had been present for a while. The Maintenance Director stated he relied on CNAs to report such issues, that there was no set schedule for checking resident rooms for wall damage, and that he had not painted any rooms on one side of the building during his nearly two years at the facility, citing the need to move residents out of rooms to complete painting.

The facility’s written policy, last reviewed in February 2025, requires that housekeeping and maintenance services be provided as necessary to maintain a sanitary, orderly, and comfortable environment, and that bed and bath linens be provided and maintained in clean and good condition. Despite this, the observations and staff interviews showed that residents experienced delays in showers and personal care due to lack of towels, and that multiple rooms had unrepaired or incompletely repaired wall damage. When informed of the concerns about inadequate linens and environmental conditions, the Nursing Home Administrator and Director of Nursing did not provide additional information to the surveyor at that time.