056315
03/04/2025
Citrus Grove Post Acute
9025 Colorado Avenue Riverside, CA 92503
F 0584
Level of Harm - Minimal harm or potential for actual harm
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Based on observation, interview, and record review, the facility failed to provide adequate linens for two of three residents (Resident 2 and 3).
Residents Affected - Few This failure had the potential to delay care and unmet needs for Resident 2 and 3.
Findings: On February 13, 2025, at 11:05 a.m., during an interview with Resident 2, she stated she had to wait to be changed or showered due to facility had no linens, washcloths and towels available. Resident 2 further stated it gets frustrating, but the staff do what they can and try to find linens. On February 13, 2025, at 11:25 a.m., during an interview with Resident 3, she stated the facility do not have linens, washcloths and towels and she had to wait to be changed or showered until linens become available. On February 13, 2025, at 11:39 a.m., during a concurrent observation and interview of the linen closets in nursing stations one and two, with Licensed Vocational Nurse (LVN) 1, inside the linen closets, there were no linens, washcloths, and towels. LVN 1 stated he had received multiple complaints from Certified Nurse Assistants (CNA's) about not being able to provide resident care due to the lack of linen, towels, and washcloths. LVN 1 further stated this issue has been ongoing for one or two months and had been reported to the Administrator and Director or Nursing (DON). LVN 1 stated the residents had to wait for care until laundry services provided clean linens. LVN 1 further stated the facility should have enough linens to provide care to the residents and prevent delay in care. On February 13, 2025, at 12 p.m., during an interview with LVN 2, she stated the facility had ongoing linen shortage and reported receiving complaints from CNAs about the inability to care for residents without adequate linens. LVN 2 stated the facility should have linens, towels, washcloths to care for residents to prevent delay in care. On February 13, 2025, at 12:39 p.m., during an interview with CNA 2, she stated the linen shortage had been ongoing, causing residents to wait for changes and care. On February 13, 2025, at 12:45 p.m., during an interview with CNA 3, she stated acquiring linens had been difficult, leading to delays in resident care.
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056315
056315
03/04/2025
Citrus Grove Post Acute
9025 Colorado Avenue Riverside, CA 92503
F 0584
Level of Harm - Minimal harm or potential for actual harm
On February 13, 2025, at 1:18 p.m., during a concurrent observation and interview inside the laundry room's extra linen closet with the Housekeeping Manager (HM), the closet had no linens, washcloths, and towels. The HM stated the facility did not have extra linens, towels or washcloths and the staff had been reporting shortages for about a month. The HM further stated what linen we get from the facility will be washed, folded and delivered for use.
Residents Affected - Few On February 13, 2025, at 1:42 p.m., during a concurrent interview and record review with the Central Supply (CS), he stated he placed an order for additional linens two weeks ago but had no invoice or receipt for the order. On February 13, 2025, at 2:27 p.m., during an interview with the DON, she stated, the facility had limited availability of linens, towels, and washcloths and staff had reported shortages over a month ago. The DON stated, the CS ordered for more linens one a half weeks prior but lacked a receipt for the order. The DON further stated linens should have been ordered after the facility was made aware of the shortage to provide timely and quality care to residents and prevent delay in treatment and care. The DON stated the facility does not have a specific policy regarding linen quantity, but the expectation was to have sufficient linens and supplies to provide care to residents. A review of the facility policy and procedure titled, Homelike Environment, dated February 2021, indicated .Residents are provided with .comfortable and homelike environment .to the extent possible .The facility staff and management maximizes, to the extent possible the characteristics of the facility that reflect personalized, homelike setting .
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