Pennsylvania Department of Health
 GREENWOOD CENTER FOR NURSING AND REHAB
Patient Care Inspection Results

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GREENWOOD CENTER FOR NURSING AND REHAB
Inspection Results For:

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GREENWOOD CENTER FOR NURSING AND REHAB - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a revisit survey completed on February 28, 2024, it was determined that Greenwood Center for Nursing and Rehab corrected the federal deficiencies cited during the surveys of January 24, 2024, under 42 CFR Part 483 Subpart B Requirements for Long Term Care but remained out of compliance with the following requirements of the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations



 Plan of Correction:


§ 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 the resident census and staff interviews, it was determined that the facility failed to provide a minimum one nurse aide per 12 residents during the day shift and evening shift and a minimum of one nurse aide per 20 residents during the night shifts on 12 shifts out of 21 shifts reviewed (2/20-2/26/2024).

Findings include:


The facility census on 2/20/2024, was 85 residents, which required 7.08 nurse aides during the evening shift. Review of the nursing time schedules revealed only 7.03 nurse aides on the evening shift on 2/20/2024.

The facility census on 2/20/2024, was 86 residents, which required 4.3 nurse aides during the night shift. Review of the nursing time schedules revealed only 4.0 nurse aides on the night shift on 2/20/2024.

The facility census on 2/21/2024, was 84 residents, which required 4.2 nurse aides during the night shift. Review of the nursing time schedules revealed only 3.97 nurse aides on the night shift on 2/21/2024.

The facility census on 2/22/2024, was 84 residents, which required 7.0 nurse aides during the day shift. Review of the nursing time schedules revealed only 6.84 nurse aides on the day shift on 2/22/2024.

The facility census on 2/22/2024, was 84 residents, which required 4.2 nurse aides during the night shift. Review of the nursing time schedules revealed only 3.0 nurse aides on the night shift on 2/22/2024.

The facility census on 2/23/2024, was 85 residents, which required 7.08 nurse aides during the evening shift. Review of the nursing time schedules revealed only 5.13 nurse aides on the evening shift on 2/23/2024.

The facility census on 2/23/2024, was 85 residents, which required 4.25 nurse aides during the night shift. Review of the nursing time schedules revealed only 4.06 nurse aides on the night shift on 2/23/2024.

The facility census on 2/24/2024, was 83 residents, which required 4.15 nurse aides during the night shift. Review of the nursing time schedules revealed only 3.5 nurse aides on the night shift on 2/24/2024.

The facility census on 2/25/2024, was 83 residents, which required 6.92 nurse aides during the day shift. Review of the nursing time schedules revealed only 6.91 nurse aides on the day shift on 2/25/2024.

The facility census on 2/25/2024, was 85 residents, which required 6.92 nurse aides during the evening shift. Review of the nursing time schedules revealed only 6.66 nurse aides on the evening shift on 2/25/2024.

The facility census on 2/26/2024, was 82 residents, which required 4.10 nurse aides during the night shift. Review of the nursing time schedules revealed only 4.06 nurse aides on the night shift on 2/26/2024.

During an interview on February 28, 2024, at 12:30 p.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a minimum nurse aide staffing ratios on the above shifts.



 Plan of Correction - To be completed: 04/16/2024

1. Facility cannot retroactively correct past nursing ratios.
2. Facility continues to recruit for open nursing positions through online systems and fliers. Sign on bonuses have been adjusted for applicable open positions, referral bonuses are offered open positions.
3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary ratios. Nursing scheduler was educated on this new process.
4. NHA will audit ratios weekly for 4 weeks and then monthly for 2 months to ensure CNA ratios are met.
5. Audits will be submitted to QAPI for review.

§ 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 the resident census and staff interviews, it was determined that the facility failed to provide a minimum one LPN (licensed practical nurse) per 25 residents during the day shift, a minimum one LPN per 30 residents during the evening shift and a minimum of one LPN per 40 residents on the night shift, on seven out of 21 shifts reviewed (February 20-26, 2024).

Findings include:

Review of the facility's census indicated that on 2/20/2024, the resident census was 86, which required 2.15 LPNs during the night shift. Review of the nursing time schedules revealed that the facility only had 2.06 LPNs on the night shift on 2/20/2024.

Review of the facility's census indicated that on 2/21/2024, the resident census was 85, which required 2.83 LPNs during the evening shift. Review of the nursing time schedules revealed that the facility only had 2.59 LPNs on the evening shift on 2/21/2024.

Review of the facility's census indicated that on 2/23/2024, the resident census was 85, which required 2.83 LPNs during the evening shift. Review of the nursing time schedules revealed that the facility only had 2.09 LPNs on the evening shift on 2/23/2024.

Review of the facility's census indicated that on 2/24/2024, the resident census was 83, which required 3.32 LPNs during the day shift. Review of the nursing time schedules revealed that the facility only had 3.13 LPNs on the day shift on 2/24/2024.

Review of the facility's census indicated that on 2/24/2024, the resident census was 83, which required 2.77 LPNs during the evening shift. Review of the nursing time schedules revealed that the facility only had 2.06 LPNs on the evening shift on 2/24/2024.

Review of the facility's census indicated that on 2/25/2024, the resident census was 83, which required 3.32 LPNs during the day shift. Review of the nursing time schedules revealed that the facility only had 3.13 LPNs on the day shift on 2/25/2024.

Review of the facility's census indicated that on 2/25/2024, the resident census was 83, which required 2.77 LPNs during the evening shift. Review of the nursing time schedules revealed that the facility only had 2.06 LPNs on the evening shift on 2/25/2024.

No additional excess higher-level staff were available to compensate this deficiency for failing to provide a minimum of 1 LPN per 25 residents on the day shift or for failing to provide a minimum of 1 LPN per 30 residents on the evening shifts on the above dates.

During an interview on February 28, 2024, at 12:35 p.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a minimum of one LPN per 25 residents during day shift and failed to provide 1 LPN per 30 residents on the shifts noted above.



 Plan of Correction - To be completed: 04/16/2024

1. Facility cannot retroactively correct past nursing ratios.
2. Facility continues to recruit for open nursing positions through online systems and fliers. Sign on bonuses have been adjusted for applicable open positions, referral bonuses are offered open positions.
3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary ratios. Nursing scheduler was educated on this new process.
4. NHA will audit ratios weekly for 4 weeks and then monthly for 2 months to ensure LPN ratios are met. 5. Audits will be submitted to QAPI for review.

§ 211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:

Based on a review of nurse staffing and resident census and staff interview, it was determined that the facility failed to consistently provide minimum general nursing care hours to each resident daily one day out of seven reviewed (February 25, 2024).

Findings include:

A review of the facility's weekly staffing records revealed that on the following date the facility failed to provide minimum nurse staffing of 2.87 hours of general nursing care to each resident:

February 25, 2024 - 2.71 nursing hours per resident per 24 hours.

On the above noted date, the facility failed to provide the minimum of 2.87 hours of direct nursing care daily for each resident.

An interview with the Nursing Home Administrator (NHA) on February 28, 2024, at 12:35 PM, confirmed that the facility failed to provide the minimum of 2.87 hours of direct nursing care daily for each resident.



 Plan of Correction - To be completed: 04/16/2024

1. Facility cannot retroactively correct past nursing hours.
2. Facility continues to recruit for open nursing positions through online systems and fliers. Sign on bonuses have been adjusted for applicable open positions, referral bonuses are offered open positions.
3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary nursing hours. Nursing scheduler was educated on this new process.
4. NHA will audit nursing hours weekly for 4 weeks and then monthly for 2 months to ensure nursing hours are met.
5. Audits will be submitted to QAPI for review.


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