Observations:
Based on review of facility documentation, observations, and interviews with staff and residents it was determined that the facility failed to have sufficient quantity of linens available for resident care and comfort for 8 of 10 residents reviewed (Resident R1, R2, R3, R4, R5, R7, R8, and R9).
Findings Included:
Review of facility documentation "Resident Council Meeting Minutes" revealed problems regarding having sufficient quantity of linens available was addressed in the minutes on April 21, 2026, and June 8, 2026.
Observations on June 18, 2026, at 10:30 a.m. during a tour of the facility revealed linen carts on the 2nd, 3rd, and 4th floor East and West nursing units had little linens available.
Observations on June 18, 2026, at 10:30 a.m. during a tour of the facility revealed the following:
Observations on the 4th floor nursing unit, East and West wing, it was observed that the linen carts only had one towel, one gown, no washcloths, three fitted sheets, and one top sheet.
Observations on the 3rd floor nursing unit, East and West wing, it was observed that the linen carts had no linens available on the carts.
Observations on the 2nd floor nursing unit, East and West wing, it was observed that the linen carts had no washcloths, only three towels, no gowns, four fitted sheets, and four top sheets.
Review of facility documentation revealed the facility had the following established linen par levels:
The Par level for the 2nd floor: 42 towels, 42 washcloths, 42 pads, 21 flat sheets, 21 fitted sheets, 13 pillowcases, 13 gowns, and 13 blankets.
The Par level for the 3rd floor: 59 towels, 59 washcloths, 59 pads, 29flat sheets, 29 fitted sheets, 19 pillowcases, 19 gowns, and 19 blankets.
The Par level for the 4th floor: 58 towels, 58 washcloths, 58 pads, 29 flat sheets, 29 fitted sheets, 19 pillowcases, 19 gowns, and 19 blankets.
Interviews conducted on June 18, 2026, between 10:00 a.m. and 11:30 a.m. with Resident's R1, R2, R3, R4, R5, R7, R8, and R9, residents' reported concerns regarding not having enough linens available for care such as lack of sheets, towels, and washcloths.
Interview on June 18, 2026, at 11:45 a.m. with Licensed Nurse, Employee E5, and Licensed Nurse, Employee E7, confirmed insufficient availability of linens available on the nursing units.
28 Pa. Code 205.74 Linen
| | Plan of Correction - To be completed: 07/27/2026
Residents R1, R2, R3, R4, R5, R7, R8 and R9 had the potential to be affected by insufficient linen availability on the nursing units. Immediately upon identification of the deficient practice, all nursing unit linen carts were restocked to meet or exceed the facility's established par levels for towels, washcloths, gowns, fitted sheets, flat sheets, pillowcases, incontinent pads, and blankets. Nursing staff verified that adequate linens were available to provide resident care, hygiene, comfort, and timely linen changes. Any resident requiring immediate linen changes received clean linens without delay.
All residents residing in the facility had the potential to be affected by this deficient practice.
A facility-wide audit of all nursing unit linen carts, clean linen storage areas, and central linen inventory was completed to verify that each nursing unit maintained the required established par levels. Any deficiencies identified during the audit were corrected immediately through replenishment of linens, including placing a new order for more supplies. Environmental Services Director completed an inventory of facility linen supplies to ensure an adequate overall inventory was available to support resident care needs and established par levels. Nursing Staff Educator provided nursing staff education on proper linen handling and disposal procedures to ensure supplies are being utilized accordingly.
Director of environmental services will complete daily audits of linen carts on all nursing units for 4 weeks and then monthly for 2 months to ensure compliance with established par levels. Findings of the audits will be reported to the Quality Assurance and Performance Improvement (QAPI) Committee. The Committee will make any recommendations if needed.
Date of expected compliance: 07/27/2026
|
