Pennsylvania Department of Health
GRANDVIEW NURSING AND REHABILITATION
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GRANDVIEW NURSING AND REHABILITATION
Inspection Results For:

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GRANDVIEW NURSING AND REHABILITATION - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on an abbreviated complaint survey and revisit survey completed on December 4, 2025, it was determined that Grandview Nursing and Rehabilitation Center, correct the deficiencies cited during the surveys of October 4, 2025, and on October 22, 2025, however remained out of compliance under the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

§483.10(f)(6) The resident has a right to participate in family groups.

§483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.

Observations: Based on review of select facility policy, resident grievance forms, and resident and staff interviews, it was determined that the facility failed to make prompt and adequate efforts to resolve ongoing resident complaints regarding delayed call bell response times expressed during interviews, including those voiced by four of four residents interviewed. (Residents 1,3,4 and 5). Findings include: A review of a facility policy titled "Grievance Policy," last reviewed in January 2025, revealed it is the policy of the facility to ensure each resident has the ability to communicate grievances/concerns to appropriate facility staff for proper and timely follow up according to regulation and resident rights. A review of a quarterly Minimum Data Set assessment for Resident 5 (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated November 12, 2025 revealed a BIMS score of 14 (brief interview for mental status, a tool to assess the resident's attention, orientation and ability to register and recall new information, a score of 13 to 15 equates to being cognitively intact) A review of a written grievance submitted by Resident 5 dated November 9, 2025, revealed the resident reported waiting two hours for a nurse aide to return to her room to assist with setting up her bedside table and electronic tablet and headphones. The grievance included additional concerns about care issues. The grievance record indicated the complaint was listed as resolved on November 14, 2025, with the corrective action identified as staff education regarding answering call bells in a timely manner. During an interview on December 4, 2025, at 11:00 AM, Resident 5, a competent resident (competent meaning capable of making her own decisions and accurately reporting her experiences) residing on the Pavilion unit, stated she continues to wait more than 30 minutes at times for staff to answer her call bell. A review of an admission MDS for Resident 1 dated October 20, 2025, revealed a BIMS score, of 15. During an interview on December 4, 2025, at 10:00 AM, Resident 1, a competent resident residing on the west unit, complained that staff do not answer call bells in a timely manner on all shifts. The resident stated that he waits for more than 30 minutes for his call bell to be answered. A review of a quarterly MDS for Resident 3 dated October 30, 2025, revealed a BIMS score, of 14. During an interview on December 4, 2025, at 10:15 AM., Resident 3, a competent resident residing on the west unit, complained that staff do not answer call bells in a timely manner on all shifts. The resident stated that he waits for more than 30 minutes to sometimes up to 2 hours for his call bell to be answered. A review of a quarterly MDS for Resident 4 dated November 12, 2025, revealed a BIMS score, of 14. During an interview on December 4, 2025, at 9:30 AM, Resident 4, a competent resident residing on the west unit, complained that staff do not answer call bells in a timely manner on all shifts. The resident stated that she waits for more than 30 minutes for her call bell to be answered. The facility did not demonstrate that residents' repeated concerns regarding delayed call bell response times had been effectively resolved, despite a prior written grievance and multiple verbal grievances voiced during resident interviews conducted during the survey. Delayed call bell response impacts timely access to assistance with basic needs, including toileting, mobility, and safety. During an interview with the Nursing Home Administrator (NHA) on December 4, 2025, at 2:00 PM, the NHA was unable to provide documented evidence that the facility followed up with residents to determine whether the corrective actions taken in response to their complaints were effective in resolving ongoing concerns about call bell response times. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.29(a)(b) Resident Rights. 28 Pa. Code 211.10 (c) Resident care policies.

Plan of Correction - To be completed: 01/04/2026

1. Facility is unable to retroactively correct call bell answering cited.
2. Facility will audit call bell response times for the past week to identify any call bell times extending over 30 minutes and identify any trends related to unit, shift, mealtimes or patterns related to specific staff.
3. DON/designee will provide education to nursing staff on multiple resident concerns related to long call bell wait times and expectation that call bells will be answered timely.
4. DON or Designee will complete visual audits of call bell response times 3 x week alternating between all shifts and units to ensure that call bells are being answered timely. Audits will be completed 3 x week x 4 weeks, then weekly x 4 weeks. Results of audits will be reviewed at facility QAPI committee meeting.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:

§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.

Observations: Based on observations, resident and staff interview, and test tray results, and food committee minutes, it was determined that the facility failed to serve meals that were palatable, attractive, and at safe and appetizing temperatures for a test tray completed on East Unit during the lunch room tray service. Findings included: According to the federal regulatory guidance at 483.60(i)-(2) Food safety requirements the definition of "Danger Zone," found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness. A review of a facility evaluation form titled "Meal Evaluation Form -Temperatures" revealed that hot food items were assessed based on being greater than or equal to 120 degrees Fahrenheit and on palatability. "Palatable" means acceptable to taste, including appropriate temperature, texture, and flavor. A review of the facility's Menu Committee meeting minutes dated November 5, 2025, indicated residents reported that food was being served cold. A review of a grievance form filed by Resident 7, dated November 25, 2025, revealed Resident 7, who was cognitively intact, reported the turkey cutlet served was burnt and inedible and the green beans had no flavor. Interviews conducted on December 4, 2025, with alert and oriented residents on both the East and West Units revealed consistent concerns that meals arrived late to the units and were frequently unpalatable due to being served cold. These residents stated the dietary department was "short staffed," resulting in delayed meal carts. A review of the facility's meal cart delivery schedule revealed that the East Unit lunch cart was scheduled to arrive on the unit at 11:30 AM. A review of the planned lunch menu for Thursday, December 4, 2025, revealed the main entrwas breaded fish, and the alternate meal was beef tips with beef gravy, mixed vegetables, garden rice, and a brownie. An observation of the lunch tray pass on the East Unit on December 4, 2025, beginning at 11:30 AM, revealed that the meal cart scheduled for that time did not arrive on the unit until 12:23 PM, which was fifty-three minutes past the scheduled delivery time. Unit staff immediately began passing meal trays at that time. The final resident meal tray was provided at 12:33 PM. A test tray was then obtained from the meal cart, and the following food temperatures were recorded: Beef tips were served at 109.9 degrees Fahrenheit Garden rice was served at 108.5 degrees Fahrenheit Mixed vegetables were served at 118.2 degrees Fahrenheit Brownie was served at 72.1 degrees Fahrenheit A taste analysis of the test tray revealed the beef tips, garden rice, and mixed vegetables were lukewarm and not palatable in temperature or flavor. The rice was hard, crunchy, and bland. The mixed vegetables were unseasoned and bland. The brownies were served palatable. The facility did not deliver the lunch meal to the East Unit at the scheduled time and did not ensure the meal was served at temperatures and flavors that were palatable. An interview with the Nursing Home Administrator on December 4, 2025, at 1:45 PM indicated the results of the test tray were reviewed and that resident meals were expected to be served timely and at palatable temperatures and flavors. 28 Pa. Code 201.14(a)(b) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1) Management.

Plan of Correction - To be completed: 01/04/2026

1. Unable to retro-correct deficient practice.
2. An Initial Audit will be completed by Dietary Manager/designee for breakfast, lunch, supper meal delivery in dining room and on nursing units regarding delivery time.
3. Dietary Manager and Regional Director to review and revise meal service times as applicable to promote efficient dietary service. Dietary Supervisor/designee will provide additional education to dietary staff on meal service times, food temps and palatability. Additional education on recipes will be provided.
4. Dietary Supervisor/designee will audit meal service times, and food temp logs 5 x week at random meals. Dietary supervisor or designee will interview 10 residents weekly regarding their satisfaction with meal service, temperature and palatability. Audits will continue 5 x week x 4 weeks and weekly X 4 weeks. Results of audits will be reviewed at facility QAPI committee meeting.

483.60(a)(3)(b) REQUIREMENT Sufficient Dietary Support Personnel:

§483.60(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71.

§483.60(a)(3) Support staff.
The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

§483.60(b) A member of the Food and Nutrition Services staff must participate on the interdisciplinary team as required in § 483.21(b)(2)(ii).

Observations: Based on observation, resident and staff interviews, and review of the facility's meal service schedule, it was determined that the facility failed to consistently maintain sufficient staffing in the dietary department to effectively and efficiently carry out the functions of the food and nutrition service department. This failure resulted in delayed meal service and meals not served at palatable temperatures for residents on the East unit. Findings include: A review of resident interviews conducted on December 4, 2025, revealed multiple concerns about the timeliness and palatability (how acceptable food is to eat based on taste, smell, texture and serving temperature) of meals. Resident 8, interviewed at 10:15 AM, reported meals were often late by an hour or more and served cold and unpalatable. Resident 9, interviewed at 10:35 AM, stated that over the last several weeks, meals, especially dinner, were generally thirty minutes or more past the scheduled time and were "ice cold" and unpalatable. The resident's visitor reported bringing food from the minimart at times out of concern for the resident's timely nutritional intake, noting the resident received insulin and did not want their blood sugar to drop. (Insulin is a hormone used to lower blood sugar; a delay in eating after receiving insulin may increase the risk of low blood sugar.) Resident 10, interviewed at 11:25 AM, stated meals were never served hot or palatable and that dietary was short staffed. Additional interviews with nursing staff conducted on December 4, 2025, at 12:00 PM, revealed staff reported the meal carts were consistently delivered late to the nursing units. Staff requested anonymity. A document titled "Times Meals Arrive at Units" revealed that the first cart of lunch trays was expected to arrive at the East unit at 11:30 AM. An observation of the East unit lunch tray pass on December 4, 2025, at 11:30 AM, revealed that the first meal cart was scheduled to arrive at that time. The meal cart did not arrive until 12:23 PM, fifty-three minutes past the scheduled arrival time. Unit staff immediately began passing trays. The final resident tray was passed at 12:33 PM. A test tray (a tray pulled to assess temperature and palatability for quality control) was removed from the meal cart on December 4, 2025, at 12:33 PM. After the last resident received their meal. Temperatures were recorded as follows: Beef tips: 109.9 degrees Fahrenheit Garden rice: 108.5 degrees Fahrenheit Mixed vegetables: 118.2 degrees Fahrenheit Brownie: 72.1 degrees Fahrenheit Meals intended to be served hot are expected to be maintained at a sufficiently warm temperature, so they remain palatable to residents. A taste analysis revealed the beef tips, garden rice, and mixed vegetables were lukewarm and not served at a palatable temperature. The rice and vegetables were unseasoned and bland. The brownie was palatable. A review of the dietary department's schedule for breakfast and lunch on Thursday, December 4, 2025, revealed one AM cook, one prep cook, and four dietary aides. However, two 7AM-3PM dietary aides were scheduled off and not replaced due to lack of available staff, and no additional prep cook was available to fill the open position. Also, the dietary manager was the manager during day shift and working as the PM cook. The facility failed to provide adequate staffing levels in the dietary department to meet the needs of their current census at 168 residents as evidence of observed untimely meal delivery and unpalatable meals served. An interview with the Nursing Home Administrator on December 4, 2025, at 1:45 PM, revealed the dietary department had experienced staffing turnover. The NHA indicated the facility had been attempting to hire additional dietary staff and acknowledged ongoing concerns related to staffing levels. The facility failed to maintain sufficient dietary staff to prepare and serve meals in a timely manner and ensure meals were consistently served at palatable temperatures in accordance with regulatory requirements. Cross Ref. F804 28 Pa. Code 201.14(a)(b) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1) Management.

Plan of Correction - To be completed: 01/04/2026

1. The facility is unable to retroactively correct cited meal times and palatability issues.
2. The Dietary Manager revised the staffing schedule to provide adequate coverage for all meal periods. Any instances of staffing shortages or scheduled deviations will be logged with efforts to obtain coverage.
3. The Dietary Service Manager will meet with Regional Director to establish a plan to recruit, retain and retrain dietary staff. Dietary staff will be in-serviced on food temperature and palatability.
4. Regional Dietary Manager/designee will audit the dietary schedule 3 x week to ensure adequate coverage is maintained to serve meals timely, at appropriate temperature and palatability. Audits will continue X 8 weeks. Results of audits will be reviewed at facility QAPI committee meeting.

483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.

Observations: Based on observation, review of select facility policy and clinical records, and staff and resident interviews, it was determined that the facility failed to assess and determine a resident's capability to self-administer medications for one of 13 residents reviewed (Resident 1). Findings include: A review of the facility policy titled "Self-Administration of Medications," last reviewed September 2025, revealed that residents have the right to self-administer medications if the interdisciplinary team determines it is clinically appropriate and safe. The policy required: Residents who express the desire to self-administer medications will be assessed to determine ability to self-administer medications. In addition to the general evaluation of a resident's decision-making capacity, the nursing staff will perform a more specific skill assessment, including (but not limited to) the resident's ability to read and understand medication labels. The comprehension of the purpose and proper dosage and administration time for his or her medications. Comprehension of the purpose and proper dosage and administration time for his or her medications. The ability for safe storage of medications. If the team determines that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications For self-administering residents, the nursing staff will determine who will document medication administration. If the resident is able and willing to take responsibility for documenting their self-administration of medications, the resident will be instructed on how to complete a record indicating the administration of the medication. Self-administered medications must be stored in a safe and secure place, which is not accessible to other residents. A review of Resident 1's clinical record revealed admission on October 14, 2025, with diagnoses including aftercare following abdominal surgery, asthma (a chronic respiratory condition), anxiety, and depression. A review of an admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 20, 2025 revealed a BIMS score of 15 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact). A physician's order dated October 14, 2025, included the following medications: Bupropion HCL extended release 150 mg and 300 mg (antidepressant medications) Acidophilus 1 capsule twice daily (digestive aide) Docusate Sodium 100 mg twice daily (stool softener) Gabapentin 600 mg twice daily (antiseizure medication also used for nerve pain) Topiramate 100 mg twice daily (antiseizure medication also used for migraine prevention) Budesonide inhalation suspension 0.5 mg/2 ml once daily (inhaled corticosteroid for asthma) A physician's order dated October 15, 2025, included: Alfuzosin extended release 10 mg daily (treatment for enlarged prostate) Vitamin B2 100 mg tablets, four daily (nutritional supplement) Folic Acid 400 mcg, two tablets daily (nutritional supplement) Loratadine 10 mg daily (antihistamine used for allergies) Multivitamin one daily (nutritional supplement) Potassium Chloride extended release 20 mEq daily (electrolyte replacement) Senna 8.6 mg, two tablets daily (laxative medication) Sertraline HCL 100 mg, three tablets daily (antidepressant medication) Singulair 10 mg daily (medication for asthma or allergies) Spironolactone 25 mg daily (diuretic medication) A physician's order dated October 25, 2025, included: Ciprofloxacin HCL 500 mg one by mouth twice daily (antibiotic medication) During an observation and interview with Resident 1 on December 4, 2025, at 10:15 AM, the resident was seated on the side of the bed with an overbed table positioned in front of him. A plastic medication cup containing 22 pills was observed on the table. A respiratory nebulizer machine (a device used to deliver inhaled medications) was on the top of the dresser in front of the resident. The nebulizer cup already contained Budesonide inhalation solution, prepared and ready for administration. Resident 1 stated that nursing staff sometimes left his medications at the bedside and sometimes remained with him during administration. He stated that he planned to take the respiratory treatment after completing his morning care. During an interview on December 4, 2025, at approximately 10:30 AM, Employee 1 stated that she had left the medications and the prepared respiratory treatment at Resident 1's bedside. Employee 1 stated that she viewed the resident as cognitively intact and able to take his medications independently. She was not able to confirm that a required self-administration assessment had been completed or approved for Resident 1. During an interview on December 4, 2025, at 1:00 PM, the Director of Nursing stated that the resident's clinical record did not contain a current physician order authorizing self-administration, did not contain a self-administration assessment, and did not contain a care plan indicating that Resident 1 self-administers his medications. 28 Pa. Code: 211.9(a)(1)(k) Pharmacy services. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa Code 211.12 (d)(3)(5) Nursing services.

Plan of Correction - To be completed: 01/04/2026

1. Nursing staff to interview Resident #1 determine if he expresses a desire to self- administer his medications. If he does then appropriate evaluation and follow-up will be completed.
2. DON/designee will complete an audit of in-house residents to determine if any express a desire to perform self- administration of medications. Appropriate evaluations and follow-up will be completed on those who wish to self-administer.
3. Education will be provided by ADON/designee on policy related to self-medication administration to include evaluation and follow-up.
4. DON/designee will complete visual inspections of resident's rooms to ensure medications are not left at bedside for residents who have not been assessed to be able to safely self-administer meds. Audits will be completed 2 x week x 4 weeks, then weekly x 4 weeks. Results of audits will be reviewed at facility QAPI committee meeting.

51.3 (g)(1-14) LICENSURE NOTIFICATION:

51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.

Observations:

Based on resident and staff interviews, observations, and review of facility-provided information, it was determined that the facility failed to notify the State Licensing Agency, Pennsylvania Department of Health, Division of Nursing Care Facilities, of reportable disruptions in essential services, specifically an inoperable dietary dish machine and a malfunctioning elevator, which interrupted usual resident meal services for residents residing on the East, West, and Pavilion units. These disruptions resulted in untimely meal service and meals served at unpalatable and cold temperatures.

Findings include:
During the onsite survey conducted on December 4, 2025, interviews were conducted with several cognitively intact residents. Residents consistently voiced concerns that meals were frequently served cold and lacked palatability (palatability meaning the quality of food being acceptable in taste, temperature, and texture). Residents and nursing staff further reported that meal trays were routinely delivered late to the units.
An interview with the Nursing Home Administrator (NHA) on December 4, 2025, at 10:34 AM, revealed that on November 12, 2025, following breakfast service, the facility's dishwasher located in the dietary department malfunctioned, resulting in dishware being unable to be properly cleaned and sanitized. The NHA reported that in response to the malfunction, the facility served resident meals using disposable paper products. The NHA further reported that the dishwasher remained out of service from breakfast on November 12, 2025, through after dinner service on November 13, 2025.
Observation of the East unit lunch tray pass on December 4, 2025, at 11:30 AM, revealed that the first meal cart was scheduled to arrive on the unit at that time. However, the meal cart did not arrive until 12:23 PM, which was fifty-three minutes after the scheduled service time. Unit staff immediately began passing meal trays upon arrival.
The final resident meal tray was passed at 12:33 PM. A test tray was then obtained from the meal cart, and food temperatures were recorded as follows: beef tips at 109.9 degrees Fahrenheit, garden rice at 108.5 degrees Fahrenheit, mixed vegetables at 118.2 degrees Fahrenheit, and brownie at 72.1 degrees Fahrenheit. A taste analysis of the meal revealed that the beef tips, garden rice, and mixed vegetables were lukewarm and not served at a palatable temperature.
These observations demonstrated that the facility failed to serve meals in a timely manner and failed to ensure meals were served at temperatures and flavors consistent with acceptable dining standards.
During a subsequent interview with the NHA on December 4, 2025, at 1:45 PM, the results of the test tray were reviewed. The NHA further reported additional disruptions in essential services, specifically malfunctions of the facility's main elevator from November 19, 2025, through November 22, 2025. The NHA reported that due to the elevator malfunction, dietary staff were required to transport resident meal carts outside of the building to an alternative entrance in order to access the Pavilion unit, further disrupting the usual meal service process.

Plan of Correction - To be completed: 01/04/2026

1. NHA entered ERS reporting for cited dishwasher and elevator service interruptions.
2. NHA reviewed facility services to determine if there were any additional reporting requirements.
3. Regional operator/designee provided education to NHA and DON on requirement for notification of service interruptions.
4. NHA/designee will audit facility services to ensure that all service interruptions have been reported via ERS to DOH. Audits will continue weekly X 8 weeks. Results of audits will be reviewed at facility QAPI committee meeting.

§ 204.13 LICENSURE Linen.:

The facility shall have available at all times a quantity of linens essential for proper care and comfort of residents.

Observations: Based on observation and staff interviews, it was determined that the facility failed to ensure the availability of linens essential for the care and comfort of residents. Findings include: During an observation conducted on December 4, 2025, at 9:30 AM, the Pavilion Unit clean linen room was observed to contain no fitted sheets for residents' beds, five towels, and six reusable bed pads. Reusable bed pads are fabric urinary incontinence pads used to protect bedding and maintain resident skin integrity. An observation conducted on December 4, 2025, at 9:45 AM, of the West Unit clean linen room revealed one fitted sheet for residents' beds, six towels, and five reusable bed incontinence pads. An observation conducted on December 4, 2025, at 10:00 AM, of the East Unit clean linen room revealed no fitted sheets for residents' beds, six towels, and three reusable bed incontinence pads. During an interview conducted on December 4, 2025, at 9:35 AM, Employee 3, a nursing assistant who works the 7:00 AM to 3:00 PM shift, stated that at the beginning of the day shift there are not adequate supplies of linen available on the unit. The staff member stated that while there is typically enough linen to begin resident care, nursing staff must wait several hours into the shift for laundry to supply additional linens to the unit. An observation conducted on December 4, 2025, at 10:00 AM, of the laundry room revealed three overfilled bins of dirty linens located in the soiled area of the laundry room. Additionally, three bins of clean, wet linens were observed next to the dryers awaiting drying, while the two dryers were actively in use. During an interview conducted on December 4, 2025, at the time of the laundry room observation, Employee 4, a laundry aide, stated that laundry staff work from 7:00 AM to 3:00 PM. The staff member stated that prior to the end of the shift at 3:00 PM, laundry staff load linens into three washers and start the wash cycles. The staff member stated that when laundry staff return at 7:00 AM the following morning, the washed linens are transferred into laundry bins and await available dryers. The staff member confirmed that there is an approximately 24 hour backlog of linens in the laundry department due to inadequate staffing. The staff member further stated there is no second shift in the laundry department, and that to keep up with linen volume, washers must be started prior to staff leaving at the end of the shift. The staff member stated that at approximately 3:00 PM, clean linens are distributed to the nursing units to accommodate the 3:00 PM to 11:00 PM shift and the 11:00 PM to 7:00 AM shift, and confirmed that there are often very limited supplies of clean linens available on the units prior to the start of the day shift. During an interview conducted on December 4, 2025, at 10:15 AM, the Laundry and Housekeeping Director stated that nursing staff discard soiled linens rather than placing them in designated dirty linen bins for laundering. The director confirmed that the laundry department has experienced several staff terminations in the recent past and that the department has had difficulty keeping up with the volume of dirty linens. These findings demonstrate the facility failed to maintain an adequate supply of clean linens necessary to meet resident care and comfort needs.

Plan of Correction - To be completed: 01/04/2026

1. Facility unable to retroactively correct cited linen needs.
2. EVS Supervisor to complete an audit of linen on nursing units and compare with needs for each shift.
3. EVS Supervisor/designee will review and adjust PAR levels for linen supplied to each nursing unit for each shift. EVS Supervisor/designee will provide education to EVS staff on PAR levels designed to ensure adequate linen supply is readily available.
4. EVS Supervisor/designee to audit nursing units to ensure PAR levels are maintained. Audits will continue 3X week for 4 weeks then weekly X 4 weeks. Results of audits will be reviewed at facility QAPI committee meeting.

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