Pennsylvania Department of Health
LINDEN HALL
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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LINDEN HALL - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a State Licensure survey and Civil Rights Compliance survey completed on February 29, 2024, it was determined that Linden Hall was not in compliance with the following requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.

Plan of Correction:

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:

§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Observations:

Based on clinical record review of staff interview it was determined the facility failed to develop a baseline care plan for a resident admitted with a pressure ulcer for one of 5 residents reviewed. (Resident R14)

Findings Include:

Review of Resident R14's Weekly Pressure Injury Record revealed Resident R14 was admitted to the facility on February 16, 2024 with a stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed) to the sacrum (a triangular bone in the lower back).

Review of Resident R14's clinical record failed to reveal a care plan addressing the care of the current pressure ulcer or the prevention of further pressure ulcers.

Interview with the Director of Nursing on February 28, 2024 at 11:30 a.m. confirmed there was no care plan developed for Resident R14 related to pressure ulcers upon admission.

28 Pa Code 201.18(b)(3) Management

28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 04/03/2024

The wound care plan was completed for Resident R14.

A 30 day look back took place to ensure new admissions have a wound care plan in place, if appropriate.

Licensed Nurses will be re-in serviced on ensuring new residents have a wound care plan within 48 hours of admission if wounds have been identified.

The Director of Nursing/designee will audit new residents' medical records within 48 hours of admission to ensure a wound care plan has been completed if a wound(s) has been identified.

Results of the audits will be reported to the Quality Assurance Performance Improvement Committee quarterly X 3 by the DON/designee for review and further recommendation.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:
Based on facility policy and procedure review, observations, and staff interview it was determined the facility failed to ensure proper set up of sanitation buckets and the three-compartment sink.

Findings Include:

Review of facility policy titled The Dietary Log, revised December 12, 2020, revealed " a daily log has been created and will be implemented on 12 April 2009. The following checks will need to be recorded on the log. D. the three-compartment sink. The following is how each will be accomplished. Sanitizing solution test will be taken in accordance with he 3 compartment sink policy. The Dietary Supervisor is to review the Daily Logs, sign, and date when it was reviewed. "

Review of the Daily Dietary Log revealed a section for the three-compartment sick where the cook is to sign off stating the sanitizing agent, (D.Q.S) is between 150-400 ppm.

Observation in the kitchen on February 27, 2024 at 9:45 a.m. revealed a sanitation bucket observed on a preparation table. Dietary Employee E3 test the sanitizing agent to determine the concentration of cleaning solution. The test strip did not react revealing there was no sanitizing agent (0 ppm) in the bucket only water. Employee E3 then tested the three-compartment sink with a test strip which also did not react (0 ppm). Employee E3 then asked Employee #4 who was cleaning pans in the three-compartment sick to see if the sanitizer container was empty. It was empty and needed to be replaced.

Review of the Daily Dietary Log for February 27, 2024 revealed the three-compartment sink had been signed out by Employee E4 as being checked that morning and was between 150-400 ppm of sanitizing agent.

Review of The Dietary Logs for the entire month of February 2024 revealed none had been singed as being reviewed by the Dietary Supervisor.

Interview with Employee E3 on February 27, 2024 at 10:00 a.m. confirmed the sanitary bucket and three-compartment sink did not have any sanitizing agent in them due tot eh container being empty and were not properly tested prior to the breakfast meal despite being signed out on the Daily Dietary Log as having been tested.

28 Pa. Code: 201.18(b)(3) Management

28 Pa. Code 211.6(d) Dietary services

Plan of Correction - To be completed: 04/03/2024

The sanitation buckets and the three-compartment sink are properly set up prior to each use of the sink. Sanitizing solution tests are taken and recorded on the log and the Dietary Supervisor is reviewing the logs daily, signing and dating when reviewed.

Dietary staff will be re-in serviced on the proper procedure for setting up the sanitation buckets and the three-compartment sink in addition to performing sanitizing solution tests in accordance with the three- compartment sink policy. Dietary Supervisors will be re in-serviced on reviewing the daily logs, signing and dating when the log was reviewed.

Random weekly audits will be done by the Dietary Director/Designee of the sanitation buckets and three-compartment sink set-up to ensure policy and procedure is being followed and, random weekly audits of the Daily Dietary Log will be done by the Dietary Director/designee to ensure the log has been reviewed daily, signed and dated when the review has occurred.

Results of the audits will be reported to the Quality Assurance Performance Improvement Committee quarterly X 3 by the Director of Dietary for review and further recommendation.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on facility policy and procedure review, observations, and staff interview it was determined the facility failed to follow infection control standards.

Findings Include:

Review of facility policy and procedure titled Isolation- Categories of Transmission-Based Precautions, undated, revealed for resident who are under droplet precautions, post a "STOP AT THE NURSES STATION BEOFRE ENTERING ROOM" sign on the resident's door.

Observations conducted of the facility on February 27, 2024 at 10:30 a.m. revealed there were five rooms with isolation carts outside of the rooms. Further observations failed to reveal signs on the doors of resident rooms to indicate if they were on isolation precautions or if staff/visitors were instructed to see staff prior to entering the room.

Interview with the Nursing Home Administrator and the Director of Nursing on February 28, 2024 at 11:00 a.m. confirmed these rooms were on droplet isolation due to positive COVID-19 residents and there should have been signs on the doors instructing people entering the room to speak to the nurse prior to entering.

28 Pa Code 201.18(b)(1)(3) Management

28 Pa Code 207.2(a) Administrator's responsibility

28 Pa. Code 211.10(c) Resident care policies

28 Pa Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 04/03/2024

Signs indicating "Stop at the Nurses Station Before Entering" were posted on the 5 doors of the resident rooms who were on droplet precautions.

Staff were re in-serviced on the policy to post stop at the nurse station before entering signs on resident room doors when under droplet precautions.

The Director of Nursing/designee will check to see that a sign that states – stop at nurse station before entering – has been posted on the door of the resident room when placed on droplet precautions.

Results of the checks will be reported by the Director of Nursing/designee to the Quality Assurance Performance Improvement Committee quarterly x 3 for review and further recommendation.

§ 201.23(c.1) LICENSURE Closure of facility.:

(c.1) The facility shall develop a closure plan that includes all of the following:

Observations:

Based on staff interview, it was determined that the facility failed to develop a plan in the event of a closure.

Findings include:

During entrance conference on February 27, 2024, at approximately 9:00 a.m., the Nursing Home Administrator (NHA) was asked to provide a copy of the facility's closure plan. At this time, the NHA revealed the facility did not have a plan in the event of a closure.

The facility's failure to have a plan in place in the event of a closure was discussed with and confirmed with the NHA on February 29, 2024, at approximately 11:00 a.m.

Plan of Correction - To be completed: 04/03/2024

A closure plan containing all the required components will be developed and presented to the Quality Assurance Performance Improvement Committee.

The Plan will be reviewed at least annually by the QAPI Committee and revised/updated as needed.

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