Pennsylvania Department of Health
GARDENS AT SCRANTON, THE
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GARDENS AT SCRANTON, THE
Inspection Results For:

There are  156 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
GARDENS AT SCRANTON, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a revisit and abbreviated complaint revisit survey completed on February 14, 2024, it was determined that The Gardens at Scranton failed to correct the deficiencies cited during the surveys of October 20, 2023, and January 14, 2024, and continued to be out of compliance with 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:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on review of clinical records and select resident incident/accident reports and staff interview, it was determined that the facility failed to timely review and revise fall prevention interventions to prevent repeated falls of a similar nature, and promptly implement safety and supervision measures necessary to prevent repeated falls, and serious injury, a fractured hip, for one resident out of 10 sampled (Resident A2).

Findings include:

A review of the clinical record revealed that Resident A2 was admitted to the facility on June 2, 2023, with a diagnoses of dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), chronic obstructive pulmonary disease ( a chronic, progressive lung disease), paranoid schizophrenia and had a history of falls.

A Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated November 9, 2023, revealed that the resident was severely cognitively impaired with a BIMS score (It is a required screening tool used in nursing homes and other long-term care facilities to assess cognition, score of 0-7 indicates severe cognitive impairment) of 5 and required extensive assistance of two staff for bed mobility, transferring, and dressing, and required supervision of one staff member when moving about on the nursing unit.

The resident's care plan, initiated June 2, 2023, indicated that the resident was at risk for falls with planned interventions to anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage bed to the lowest position initiated June 3, 2023, a fall risk evaluation per protocol, initiated June 17, 2023, floor mats to left side of bed initiated June 19, 2023, review information on past falls and attempt to determine cause of falls and record
possible root causes, alter/remove any potential causes if possible, educate resident/family/caregivers as to causes, initiated June 25, 2023, a scoop mattress on the resident's bed initiated June 26, 2023, resident chooses to crawl out of bed to floor mat at times, initiated July 13, 2023 a floor mat to the right side of bed initiated September 5, 2023.

A review of the resident's clinical record revealed that the resident fell from bed on November 23, 2023, at 6:50 AM. There were no additions or revisions to the resident's fall prevention interventions/care plan at that time.

Clinical record review revealed that on January 29, 2024, at 11:37 AM. Resident A2 had a another fall out of bed. At time of the survey ending February 14, 2024, there was no documented evidence that the facility had evaluated this fall for potential contributing factors/surrounding circumstances, as noted in the resident's care plan. There was no evidence at the time of the survey that the facility investigated this fall. The nurses note dated January 29, 2024, solely noted that "the resident stated that he rolled out of bed." There were no additional interventions put into place to prevent future falls at that time or revision of existing fall prevention and safety measures.

A review of an incident report and nurses documentation dated February 2, 2024, at 8 AM revealed, staff found Resident A2 on the floor of his room. The resident's bed alarm was sounding. Staff noted that the resident was in bed prior to the fall. The nursing assessment of the resident at that time revealed, Resident A2's right lower leg was noted with external rotation and shortened. The resident complained of slight pain in that leg. Tylenol (a non narcotic pain medication) was given to the resident. The physician was contacted and ordered an x-ray of the resident's right leg. Nursing staff assessed the resident and placed him back into bed. No additional fall prevention interventions were put into place at that time or revisions to the resident's existing fall prevention care plan.

A review of an incident report dated February 2, 2024, at 12 PM revealed that staff found Resident A2 on the floor beside his bed, face down on the fall mat. The report noted that the resident rolled out of the bed this morning as well. The portable x-ray arrived after this second fall from bed, and was completed at that time due to the previous fall. The resident complained of slight pain in his right leg. Able to move his extremities. Staff placed the resident into his wheelchair and he was taken into the resident dining room for his lunch.

A review of an X-ray report dated February 2, 2024 at 3:52 PM revealed an x-ray of the right hip, unilateral with pelvis. The report indicated an acute, comminuted fracture (Comminuted fractures are a type of broken bone. It is termed comminuted as it involves fracture in at least 2 places in the same bone. The causes for this are severe trauma due to accidents) needing surgical correction at the intertrochanteric area of the right femur, with impaction of the major fracture fragments.

The physician was notified and the resident was transferred to the hospital for treatment on February 2, 2024, and scheduled for orthopedic surgery February 3, 2024. A review of a surgical report dated February 3, 2024, at 8:33 AM revealed, a pre-op diagnosis of right hip intertrochanteric fracture.

The resident was readmitted to the facility on February 7, 2024.

A review of a nurse's note dated February 10, 2024, at 12:43 AM indicated that an agency LPN wrote this entry as a "late note" for February 9, 2024 at 10:41 AM, noting that "\ had rolled out of bed three times between 3 PM and 6 PM."

There was no indication that the facility had evaluated the circumstances surrounding each of the resident's three falls from bed to identify possible contributing factors and root causes as noted in the resident's care plan and to timely implement necessary safety and fall prevention interventions to prevent repeated falls from bed. The facility failed to timely review and revise the resident's fall prevention and safety care plan to prevent similar falls from bed when the existing interventions proved ineffective.

A review of an incident report and nursing documentation dated February 9, 2024, at 12 PM revealed that on that date at 11:30 AM, direct care staff called a licensed nurse to Resident A2's room. Staff found Resident A2 on the floor on the floor mat. Nursing staff assessed the resident and returned the resident to bed. The physician was notified. The resident was then placed on a 1 to 1 staff supervision.

At time of the survey ending February 14, 2024, there was no documented evidence of timely review and revision of the resident's fall prevention and safety care plan to prevent repeated falls from bed. It was not until after four falls from bed, one of which resulted in a serious injury, a fractured hip, that the facility initiated 1 to 1 staff supervision of the resident.


An interview with the Nursing Home Administrator on February 14, 2024, at approximately 2 PM confirmed that the failed to timely implement effective fall prevention measures, consistent with Resident A2's assessed needs and planned care for frequent falls from bed, resulting in Resident A2 sustaining multiple falls from bed, one of which resulted in a fractured hip.


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






 Plan of Correction - To be completed: 04/08/2024

1. The facility cannot retroactively correct the cited deficiency.
2. Resident A2's care plan has been reviewed again to ensure that it has been updated with current fall interventions.
3. Direct care staff re-educated on the importance of implementing safety interventions immediately post incident and will be involved implementing immediate fall prevention interventions.
4. The current residents will be reviewed by IDT for appropriate fall interventions immediately implemented after incident. Care plans will be updated accordingly.
5. IDT will review and revise safety and fall prevention plans post falls to prevent further reoccurrence. 6. DON or designee will complete audit for four weeks and monthly for two months.
7. Audits to be submitted to QAPI for review and recommendations.


483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:


Based on a review of clinical records and select facility reports and staff interviews it was determined that the facility failed to develop and implement a person-centered care plan that fully addressed a resident's behavior management, included repeated non-compliance with the facility's leave of absence policy, to consistently meet the resident's safety needs for one resident out of 10 sampled (Resident A1).

Findings included:

A review of Resident A1's clinical record revealed admission to the facility on April 14, 2023, with diagnoses including diabetes, depression and a history of falling.

Resident A1's quarterly Minimum Data Set (MDS - a federally mandated assessment of a resident's abilities and care needs) dated December 13, 2023, revealed that the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status Score - a tool to assess cognitive function).

A review of Resident A1's care plan, initially dated April 21, 2023, indicated that Resident A1 has potential to exhibit increased behaviors as evidenced by ineffective coping and increased anxiety. Interventions planned were to document on Behavior Monitoring form each episode,
Elicit family input for best approaches for resident, Keep schedules routine & predictable,
remove resident from public area when behavior is disruptive/ unacceptable. Talk
with resident in a low pitch, calm voice to decrease/eliminate undesired behavior and
Praise/ reward resident for demonstrating consistent desired/ acceptable behavior. The care plan also noted that the resident exhibits increased behaviors as evidenced by inappropriate behavior; resistive to treatment/care (Refuses: medications/treatments, insulin, wound treatment changes, labs, wound vac (removes wound vac himself), non-compliant with therapy transfer recommendation; non-compliant with leave of absence facility policy, related to Anxiety diagnosis, initiated May 1, 2023.

A review of a nurses note dated June 5, 2023, at 2:25 P.M revealed that the resident was out of the facility in wheelchair, with family to celebrate his birthday.

A review of a nurses note dated June 6, 2023, at 12:27 AM revealed "called \ several times, about 4 or 5 times, he finally picks up and said he is with his friend and that his friend threw him a party. He also stated that he called the facility around 8:30 PM and left a voice mail. I advised he cannot be out passed midnight if he did not already state that he would be out that long. He understood and said he is coming back."

A review of a nurse's note dated June 6, 2023, at 12:51 AM revealed "called A1) again at 12:51 AM resident stated he is on his way, the person driving him had to stop for gas."

A review of a nurses note dated June 6, 2023, at 01:09 AM "called resident again, resident states he is 15 minutes away. " Nursing noted on June 6, 2023, at 01:37 AM revealed that Resident A1 was now back to facility and in room."

A nurse's note dated August 4, 2023, at 5 PM revealed that Resident A1 was on LOA with family. Nursing noted on August 4, 2023, at 11:03 PM revealed "nurse reported to this RN that resident isn't back to the facility. I advised calling him and when nurse called resident stated he is 15 minutes away."

A nurses note dated August 5, 2023 at 02:00 AM revealed "Nurse reported to this RN that resident isn't back to the facility. I advised calling him and when nurse called resident stated he is 15 min away." A review of a nurses note dated August 5, 2023, at 02:59 A.M. revealed that Resident A1 was back to facility now

A nurses note dated August 19, 2023, at 4 PM revealed, Resident LOA with friends to clean a house. A review of a nurses note dated August 20, 2023 at 12:14 AM revealed "Resident not yet back in the facility, gave him a call and he said he was coming."

A review of a nurse's note dated August 20, 2023, at 04:01 AM revealed "gave Resident a call and he confirmed he would be here shortly."Nursing noted on August 20, 2023 at 06:22 AM revealed that the resident not yet back from his evening out. A review of nursing documentation dated August 20, 2023 at 07:05 AM, revealed "Resident telephone line not recharged, voice mail left on the sister's phone." A nurses note dated August 20, 2023 at 08:28 AM revealed that the resident returned back to the facility.

A review of a nurse's note dated September 20, 2023, at 6:08 P.M. revealed "Resident LOA to a friend's house. Resident stated he'll be back some time tonight."

A review of a nurses note dated September 20, 2023, at 11:39 PM revealed "Resident called the facility to let this Nurse know that he was waiting for his ride and he would be back to the facility in about an hour. The resident was educated about coming back to the faculty on time."

A review of a nurses note dated September 21, 2023 at 1:32 A.M. revealed "Resident called the facility at 1:30 A.M. to let this Nurse know that he was still waiting for his ride. RN Supervisor made aware." A review of a nurses note dated September 21, 2023, at 4:22 AM revealed that the resident had yet to return to the facility. A review of a nurses note dated September 21, 2023, at 07:09 AM revealed "Resident LOA from facility for the tour of the shift. Spoke to resident several times during the night which he stated that he was waiting for a ride home. RN Supervisor made aware of the resident status. Will report to on boarding Nurse." A review of a nurses note dated September 21, 2023 at 08:42 A.M. revealed that the resident had returned to facility from LOA. The resident had been out of the facility from September 20, 2023, until September 21, 2023, at 8:42 AM.

A review of a facility investigation dated February 2, 2024, at 6:41 PM revealed that on February 1, 2024, at 2:05 PM Resident A1 left the facility with a friend. He had verbalized to nursing staff at approximately 12:45 PM that he "would not be needing lunch as he would be going out." The report noted that the resident did have an LOA (leave of absence) physician order and was aware of the facility policy to sign out with nursing prior to leaving the facility.
However, the resident left the facility without signing out according to the facility LOA policy.

The report further indicated that nursing staff attempted to contact the resident via his personal cell phone at approximately 4:38 AM on February 2, 2024, as the resident had yet to return to the facility. The resident did not answer his cell phone. Staff contacted the resident's emergency contact #2 and she did not know where the resident was at that time. The RN charge nurse was made aware per a nurses note in the clinical record. The Nursing Home Administrator (NHA) arrived at the facility at 7 AM on February 2, 2024. After reading the clinical nursing shift report, the NHA asked nursing staff if Resident A1 had returned to the facility as there was no documentation of the same in the resident's clinical record. Nursing staff, at that time had reported to the NHA that Resident A1 was still on leave of absence since 2:05 PM on February 1, 2024.

The immediate action noted was the NHA attempted to contact the resident via his personal cell phone three times, but the resident did not answer. A facility and ground search was conducted. All hospitals in the county were contacted for possible hospital admission. The local police department was contacted and a missing person report was filed.

On the facility security camera system, the NHA was able to identify the license plate number of the resident's friend who had left the facility with the resident. The resident was located at a local hotel with a friend by the local police department. The resident was deemed safe by the police and offered him a ride back to the facility by the facility van. Resident A1 refused, he reported to the NHA that he would be returning to the facility via his friend's car as soon as possible. Resident A1 returned to the facility February 2, 2024 at 12:48 PM.

The care plan was not updated until February 2, 2024, to include the following "\ was made aware by the nursing home administrator and social services director, regarding facility policy of leave of absence and expresses understanding of same."

During an interview on February 14, 2024, at approximately 2:00 p.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to timely address the resident's repeated behavior of leaving the facility for extended periods of time without the facility's knowledge of his whereabouts and continued non-compliance with the facility's leave of absence policy to ensure resident safety.





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






























 Plan of Correction - To be completed: 04/08/2024

Plan of Correction:
1. The facility cannot retroactively correct the failure to develop a person-centered care plan that timely addressed behavior management in resident A1's care plan.
2. Resident A1's care plan updated to reflect behaviors.
3. Behaviors will be reviewed in morning clinical start up with review of resident care plans to ensure revisions were completed as necessary.
4. DON or designee to complete random audits of resident care plans to ensure all behaviors are incorporated into each resident care plan as necessary weekly for four weeks and monthly for two months.
5. Audits will be submitted to QAPI for review and recommendations.

483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff: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.
§483.35(a) Sufficient Staff.
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

§483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (e) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

§483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
Observations:

Based on observation and a review of clinical records and staff and resident interviews it was determined that the facility failed to efficiently deploy sufficient nursing staff to consistently provide timely quality of care and services to maintain the physical and mental well-being of the residents in the facility, including experiences reported by four out of 10 residents sampled (Residents B1, B2, B3, and B4).

Findings include:

During interview with Resident B1, a cognitively intact resident, on February 14, 2024, at 12:40 PM the resident stated that nursing staff do not answer call bells timely and residents must wait times more than 15 minutes. Resident B1 stated that staff are busy and today and as result morning hygiene care was not provided as of 12:40 PM. Resident B1 stated that the facility has also reduced showers from twice per week to just once per week because of insufficient nurse staffing to provide showers twice a week.

During interview with Resident B2, a cognitively intact resident, on February 14, 2024, at 12:50 PM the resident stated when she rings for nursing staff assistance on the night shift for a brief change, the wait time for nursing staff to respond is often more than 30 minutes. Resident B2 stated that the facility is now only offering one shower per week because of staffing, and that she prefers two showers per week.

Observation on February 14, 2024, at 1:05 PM revealed that Resident B3 was in bed wearing a hospital gown. During interview with Resident B3, a cognitively intact resident, at this time the resident stated that he is one of the last residents to get care in the morning. Resident B3 stated that he does not like to complain, but staff say they will get to me but it's 1:05 PM and the resident was still in bed, and not up and dressed for the day. Resident B3 stated that his preferred time to get up is between 10:00 AM and 10:30 AM. Resident B3 stated that his brief was last changed between 5:00 AM and 6:00 AM that morning, and it was now 1:05 PM. Resident B3 stated that ringing the call bell to request assistance from nursing staff "is a joke" because nursing staff do not answer. Resident B3 stated that he feels the facility is short on nursing staff because of the lack of response to call bells and untimely care.

Interview with Employee 1 (agency nurse aide) on February 14, 2024, at 1:10 PM confirmed that when she works at this facility residents frequently complain about call bells not being answered and timely care not being provided.

During interview with Resident B4 on February 14, 2024, at 1:15 PM, revealed that the resident stated that her preferred time for morning care is 10:00 AM. Resident B4 stated that she rang the call bell for nursing staff assistance at 10:45 AM, this morning, because nursing staff had not come in yet to change her brief and provide care. Resident B4 stated that that Employee 2 (agency nurse aide) answered the call bell but was then was called out of the room to go to do resident weights. Resident B4 stated that Employee 2 (agency nurse aide) did not return and provide care until approximately 11:30 AM.

Interview with Employee 2 (agency nurse aide) at approximately 1:30 PM confirmed that at approximately 11:00 AM she entered Resident B4's room to answer the resident's call bell and provide morning care but was called out of the room to obtain residents' weights which further delayed Resident B4's care by approximately 10 minutes.

During interview on February 14, 2024, at approximately 2:45 PM the administrator confirmed that facility does not consistently have sufficient nurse staffing to provide more than one shower per week to residents. The administrator failed to provide evidence that the facility consistently deploys sufficient nursing staff in a manner to provide timely quality of care and services to residents as desired by residents.



28 Pa. Code 211.12 (c)(d)(1)(2)(5) Nursing services

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



 Plan of Correction - To be completed: 04/08/2024

Plan of Correction:
1. The facility cannot retroactively correct the failure that the facility did not have sufficient nurse staffing to provide more than one shower per week to residents nor sufficient nursing staff to provide timely quality of care and services to residents as desired by residents.
2. Audit to be completed of resident preferred AM care time (approximate) and to update care plans to reflect individual preferences.
3. Audit to be completed of resident preference re: scheduled showers per week and care plans to be updated to reflect individualized preference.
4. Call bell audits to be conducted, by RN supervisor, at random to ensure timely response.
5. The facility focuses on retaining current nursing staff and recruiting new nursing staff via recruitment team. Also, the facility is implementing staff incentives for current and new staff as well as reinforcing the call-off policy to deter unnecessary call outs. NHA or designee will educate staff on incentives and call off policy. NHA or designee will evaluate staffing patterns, deployment, and census management in efforts for sufficient staffing.
6. DON or designee to perform random audits to ensure wake up times and shower schedules are being followed appropriately well as call bells are being addressed timely.
7. Audits to be submitted to QAPI for review and recommendations.

§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on review of nursing time schedules and staff interviews, it was determined that the facility failed to provide a minimum of one nurse aide per 12 residents during the evening shifts, and one nurse aide per 20 residents during the night shift on 4 of 7 days (February 8, 2024, February 9, 2024, February 11, 2024 and February 12, 2024.

Findings include:

Review of facility census data indicated that on February 8, 2024, the facility census was 75, which required 6.25 nurse aides during the evening shift.

Review of the nursing time punch detail documentation revealed only 4 nurse aides provided care on the evening shift on February 8, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 9, 2024, the facility census was 73, which required 6.08 nurse aides during the evening shift.

Review of the nursing time schedules and time punch documentation revealed that only 5 nurse aides worked on the evening shift on February 9 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 11, 2024, the facility census was 73, which required 6.08 nurse aides during the evening shift.

Review of the nursing time schedules and time punch documentation revealed 4 nurse aides worked on the evening shift on February 11, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 12, 2024, the facility census was 73, which required 6.08 nurse aides during the day and evening shift.

Review of the nursing time schedules and time punch documentation revealed 5 nurse aides worked on the day shift on February 12, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of the nursing time schedules and time punch documentation revealed 5 nurse aide worked on the evening shift on February 12, 2024. No additional excess higher-level staff were available to compensate this deficiency.

An interview February 14, 2023 at 2 PM., the Nursing Home Administrator confirmed that the facility did not meet state minimum staffing for nurse aides.




 Plan of Correction - To be completed: 04/08/2024



Plan of Correction:
1. The facility cannot retroactively correct the cited days/shifts regarding facility not meeting CNA requirements.
2. The facility will continue to staff per required CNA ratios.
3. Staffing to continue to be reviewed daily by NHA or designee to ensure that all efforts are put forth for assuring staffing requirements are met. Census management to be reviewed, daily, by NHA or designee.
4. Incentives to be reviewed to recruit additional nursing staff.
5. Audits to be submitted to QAPI for review and recommendations



§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on review of nursing time schedules and staff interviews, it was determined that the facility failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift, 1 LPN per 30 residents on the evening shifts, and one LPN per 40 residents during the night shift on four of 7 days (February 6, 2024, February 8, 2023, February 10, 2023, February 11, 2024).

Findings include:

Review of facility census data indicated that on February 6,2024, the facility census was 75, which required 1.88 LPNs during the night shift.

Review of the nursing time schedules and time punch card documentation revealed 1 LPN provided care on February 6, 2024, provided care on the night shift.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 8, 2024, the facility census was 75, which required 1.88 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed 1 LPN worked the night shift on February 8, 2024.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 10, 2024, the facility census was 73, which required 1.83 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed 1 LPN worked the night shift on February 10, 2024.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 11, 2024, the facility census was 73, which required 1.83 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed 1 LPN worked the night shift on February 11,2024.

No additional excess higher-level staff were available to compensate this deficiency.

An interview February 14, 2024 at 2 P.M., the Nursing Home Administrator confirmed that the facility did not meet the state minimum nursing ratios for LPNs














 Plan of Correction - To be completed: 04/08/2024


Plan of Correction:
1. The facility cannot retroactively correct the cited days/shifts regarding facility not meeting LPN requirements.
2. The facility will continue to staff per required CNA ratios.
. Staffing to continue to be reviewed daily by NHA or designee to ensure that all efforts are put forth for assuring staffing requirements are met. Census management to be reviewed, daily, by NHA or designee.
4. Incentives to be reviewed to recruit additional nursing staff.
5. Audits to be submitted to QAPI for review and recommendations






Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port