Pennsylvania Department of Health
MOUNTAIN LAUREL HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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MOUNTAIN LAUREL HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

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MOUNTAIN LAUREL HEALTHCARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a complaint survey and an incident survey completed on February 5, 2024, it was determined that Mountain Laurel Healthcare and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities 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 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.
§483.25(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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards for one of six residents (Resident 2) identified as an elopement risk.

Findings include:

The facility's policy regarding elopement, dated October 1, 2023, indicated that if staff discovered that a resident was missing from the facility, the facility would determine if the resident was out on an authorized leave or pass, initiate a search of the building and premises; and if the resident is not located, notify the Nursing Home Administrator and the Director of Nursing Services, the resident's legal representative, the attending physician, and law enforcement officials, provide search teams with resident identification information, and initiate an extensive search of the surrounding area.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated December 24, 2023, indicated that the resident was moderately cognitively impaired, used a wheelchair, and had diagnoses that included dementia. The resident's care plan, dated September 6, 2018, and elopement risk assessment, dated July 11, 2023, revealed that the resident was a risk for elopement.

A resident event report and facility investigation, dated January 29, 2024, revealed that Resident 2 walked out of the building through the front door and wheeled himself to the local shopping center that included a tobacco and liquor store. When Resident 2 was found at the shopping center he appeared intoxicated and the liquor store staff reported that they sold him vodka. Resident 2 reported that he self-propelled down a path to the shopping center.

Interview with the Nursing Home Administrator on February 5, 2024, at 4:01 p.m. revealed that no staff member in the facility was aware that Resident 2 had left the building and the resident timed his exit when there was no receptionist at the front door. He confirmed that he searched the local area and found Resident 2 at the shopping center and the resident appeared impaired.

28 Pa. Code 201.14(a) Responsibility of licensee.

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

28 Pa. Code 211.10(d) Resident care policies.

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




 Plan of Correction - To be completed: 02/21/2024

1. Resident 2 care plan updated to reflect application of wander guard to wheelchair.
2. The Director of Nursing and/or Designee will audit resident at risk for elopement to ensure accuracy of resident plan of care and orders.
3. The Director of Nursing and/or designee will provide education to nursing staff ensuring that the plan of care is implemented for all new residents at risk for elopement. All new and agency staff will be educated during orientation
4. The Director of Nursing and/or Designee will audit 3 residents a risk for elopement to ensure accuracy of plan of care and orders Clinical Meetings (M-F) weekly x 4 weeks then monthly x 2 month. The Director of Nursing and/or designee will summarize and report audit findings to the Quality Assurance Performance Improvement Committee. The Quality Assurance Performance Improvement Committee will determine the need for further audits and/or recommendations for systemic modification.

§ 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 schedules, review of staffing information provided by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one nurse aide (NA) per 12 residents on the evening shift for three of 21 days, and failed to ensure a minimum of one NA per 20 residents on the overnight shift for one of 21 days (24-hour periods) reviewed.

Findings Include:

Review of facility census data indicated that on indicated that on January 25, 2024, the facility census was 134, which required 11.17 (134 residents divided by 12) NA's during the evening shift. Review of the nursing time schedules revealed 11.12 NA's provided care on the evening shift on January 25, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on indicated that on February 3, 2024, the facility census was 133, which required 11.17 NA's during the evening shift. Review of the nursing time schedules revealed 10.41 NA's provided care on the evening shift on February 3, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on February 4, 2024, the facility census was 134, which required 11.17 NA's during the evening shift. Review of the nursing time schedules revealed 11.15 NA's provided care on the evening shift on February 4, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Interview with the Nursing Home Administrator on February 5, 2024, at 5:00 p.m. confirmed that the facility did not meet the required nurse aide-to-resident staffing ratios for the days listed above.




 Plan of Correction - To be completed: 02/21/2024

1. The administrator and/or designee will conduct a review of the last 30-days of nursing schedules to determine compliance with proper nursing hours.
2. The administrator and/or designee will conduct reviews at least 5-days per week for two weeks then 3-days per week for one month to ensure compliance. In the event of extensive call offs, we ask for volunteers with bonuses, then we will mandate, and should it become necessary we will stop admissions. We continue to meet regularly to determine We continue to recruit all levels of staff, Registered Nurses, Licensed Practical Nurse's, Certified Nurser's Aides. We also have staffing meetings each day to discuss staffing and census. We continue a bonus structure for: Open Shift
Bonus 4hrs 8hrs Registered Nurses, Licensed Practical Nurse's, Certified Nurser's Aides.
Dietary. Sign on Bonus Paid over
1-yr Registered Nurses, Licensed Practical Nurse's, Certified Nurser's Aides. Referral
Bonus Registered Nurses, Licensed Practical Nurse's, Certified Nurser's Aides. While we continue recruitment, we have established a Certified Nurses Aide class thru an outside contractor to develop more Certified Nurses Aide.
3. The results of the audits, along with a Root Cause Analysis of any identified issues, will be brought to the Quality Assurance and Performance Improvement
Committee for further analysis and corrective action.


§ 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 schedules, review of staffing information provided by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 25 residents during the day on the day shift for two of 21 days, failed to ensure a minimum of one LPN per 30 residents during the evening shift for one of 21 days, and failed to ensure a minimum of one LPN per 40 residents on the overnight shifts for one of 21 days (24-hour periods) reviewed.

Findings Include:

Review of facility census data indicated that on February 3, 2024, the facility census was 133, which required 5.67 LPN's during the day shift. Review of the nursing time schedules revealed 5.44 LPN's worked on the day shift on February 3, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on February 3, 2024, the facility census increased to 133 for the night shift, which required 3.57 LPN's during the night shift. Review of the nursing time schedules revealed 3.31 LPN's worked on the night shift on February 3, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on February 4, 2024, the facility census was 134, which required 5.72 LPN's during the day shift. Review of the nursing time schedules revealed 5.40 LPN's worked on the day shift on February 4, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on February 4, 2024, the facility census was 134, which required 4.76 LPN's during the evening shift. Review of the nursing time schedules revealed 4.44 LPN's worked on the day shift on February 4, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Interview with the Nursing Home Administrator on February 5, 2024, at 5:00 p.m. confirmed that the facility did not meet the required LPN-to-resident staffing ratios for the days listed above.




 Plan of Correction - To be completed: 02/21/2024

1. The administrator and/or designee will conduct a review of the last 30-days of nursing schedules to determine compliance with proper nursing hours.
2. The administrator and/or designee will conduct reviews at least 5-days per week for two weeks then 3-days per week for one month to ensure compliance. In the event of extensive call offs, we ask for volunteers with bonuses, then we will mandate, and should it become necessary we will stop admissions. We continue to meet regularly to determine We continue to recruit all levels of staff, Registered Nurses, Licensed Practical Nurse's, Certified Nurser's Aides. We also have staffing meetings each day to discuss staffing and census. We continue a bonus structure for: Open Shift Bonus 4hrs 8hrs Registered Nurses, Licensed Practical Nurse's, Certified Nurser's Aides. Sign on Bonus Paid over 1-yr LPN's, CNA's. Referral
Bonus RNs, LPN's, CNA's. While we continue recruitment, we have established a CNA class thru an outside contractor to develop more CNAs.
3. The results of the audits, along with a Root Cause Analysis of any identified issues, will be brought to the Quality Assurance and Performance Improvement
Committee for further analysis and corrective action.


§ 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 review of nursing schedules and staff interviews, it was determined that the facility failed to provide 2.87 hours of direct resident care for each resident for three of 21 days (24-hour periods) reviewed.

Findings include:

Nursing time schedules provided by the facility for the days of January 15 through February 4, 2024, revealed that the facility provided only 2.86 hours of direct care for each resident on January 21, 2024; 2.78 hours of direct care for each resident on February 3, 2024; and 2.65 hours of direct care for each resident on February 4, 2024.

Interview with the Nursing Home Administrator on February 5, 2024, at 5:00 p.m. confirmed that the facility did not meet the required direct resident care hours on the days listed above.


 Plan of Correction - To be completed: 02/21/2024

1. The administrator and/or designee will conduct a review of the last 30-days of nursing schedules to determine compliance with proper nursing hours.
2. The administrator and/or designee will conduct reviews at least 5-days per week for two weeks then 3-days per week for one month to ensure compliance. In the event of extensive call offs, we ask for volunteers with bonuses, then we will mandate, and should it become necessary we will stop admissions. We continue to meet regularly to determine We continue to recruit all levels of staff, Registered Nurses, Licensed Practical Nurse's, Certified Nurser's Aides. We also have staffing meetings each day to discuss staffing and census. We continue a bonus structure for: Open Shift Bonus 4hrs 8hrs Registered Nurses, Licensed Practical Nurse's, Certified Nurser's Aides, Sign on Bonus Paid over 1-yr Registered Nurses, Licensed Practical Nurse's, Certified Nurser's Aides. Referral
Bonus Registered Nurses, Licensed Practical Nurse's, Certified Nurser's Aides. While we continue recruitment, we have established a Certified Nurse's Aide class thru an outside contractor to develop more Certified Nurse's Aides.
3. The results of the audits, along with a Root Cause Analysis of any identified issues, will be brought to the Quality Assurance and Performance Improvement
Committee for further analysis and corrective action.



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