F0908

F

Failure to Maintain Operable Crash Carts and Laundry Equipment Leading to Linen Shortages

Monroeville, Pennsylvania Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain essential emergency and laundry equipment in safe and operable condition. Surveyors observed that the 100-Hall crash cart was missing multiple items listed on the Emergency Cart Daily Checklist, including a blank code book, band-aids, needles with syringes, gowns, masks, goggles or face shield, alcohol-based hand rub, an ambu-bag, 14 French suction kits, Christmas tree adapters, a non-rebreather mask, and a nasal cannula. Review of the 100-Hall Emergency Cart Checklist showed multiple days where the cart contents were not documented, and several days where the checklist was marked complete without a staff signature; there was also no checklist available for a subsequent month. The 200-Hall crash cart was also found missing numerous required items, including a blank code book, blood pressure cuff and stethoscope, glucometer, flashlight or penlight, alcohol pads, band-aids, disposable razors, needles with syringes, gloves, gowns, masks, goggles or face shield, IV start kits, alcohol-based hand rub, an ambu-bag, a full oxygen tank (all three present were empty), a nebulizer kit, and 14 French suction kits. Documentation for the 200-Hall cart similarly showed multiple days without documentation of items present, and on some days the glucometer was noted as missing.

The deficiency also includes failure to maintain operable dryers and adequate linen supply. In the laundry room, surveyors observed an uncountable number of bags and carts filled with soiled linen, and a laundry worker reported that the facility’s industrial dryers had been inoperable for several days, requiring use of a smaller, non-commercial resident dryer that could not keep up with laundry volume. Multiple observations of linen carts on both the 100-Hall and 200-Hall revealed repeated shortages or absence of towels and washcloths, with some carts having none and others having only a few. Staff interviews confirmed that residents were not receiving showers due to lack of clean towels, that staff were cutting up bath blankets to make washcloths, and that some staff were using personally purchased baby wipes, dry wipes, or clothing protectors to bathe and dry residents. The Nursing Home Administrator and DON acknowledged that the facility failed to ensure two crash carts and two facility dryers were in safe operating condition.