Pennsylvania Department of Health
LECOM AT SNYDER MEMORIAL
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

LECOM AT SNYDER MEMORIAL
Inspection Results For:

There are 116 surveys for this facility. Please select a date to view the survey results.

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LECOM AT SNYDER MEMORIAL - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey, and an Abbreviated Complaint Survey completed on May 8, 2025, it was determined that Snyder Memorial Health Care 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:

483.20(g) REQUIREMENT Accuracy of Assessments:

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.

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

Observations:

Based on review of the Resident Assessment Instrument (RAI-manual that guides facilities with completing resident Minimum Data Set [MDS-periodic assessment of resident care needs] assessments), clinical records, facility documentation, and staff interviews, it was determined that the facility failed to complete the MDS to accurately reflect the resident's status at the time of the assessment for seven of 21 residents reviewed (R8, R9, R13, R15, R41, R55, and R76).

Findings include:

Review of the October 2024 RAI Manual revealed that restraints (a device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body) used in the seven-day assessment look-back period were to be documented in Section P (Restraints and Alarms) of the MDS, coding "0" for not used, "1" for used less than daily, and "2" for used daily.

Review of Resident R8's clinical record revealed an admission date of 10/09/08, with diagnoses that included epilepsy, bipolar disorder, and anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone). A Quarterly MDS dated 4/16/25, under Section P0100A, revealed that Resident R8's bed rails were coded as a restraint used daily. A physician's order dated 3/27/25, indicated Resident R8 was to have bilateral one-half side rails for bed mobility every shift. An incident report dated 2/28/25, revealed Resident R8 sustained a fall and was transferred to the hospital and returned with staples to the head. A Quarterly MDS dated 4/16/25, under section J1900, revealed Resident R8 had zero falls with major injury.

Observations between 5/5/25, and 5/8/25, revealed Resident R8 had two quarter-sized rails on the bed.

Review of Resident R9's clinical record revealed an admission date of 4/1/10, with diagnoses that included heart disease, mood disorder, and anxiety. A Quarterly MDS dated 3/12/25, under Section P0100A, revealed that Resident R9's bed rails were coded as a restraint used daily. A physician's order dated 3/27/25, indicated Resident R9 was to have left, one-half side rails for bed mobility every shift.

Observations between 5/5/25, and 5/8/25, revealed Resident R9 had one quarter-sized rail on the bed.

Review of Resident R13's clinical record revealed an admission date of 12/23/24, with diagnoses that included pulmonary embolism (blood clot in the lung), paraplegia (paralysis of both legs and lower part of body), and pressure ulcers (wounds caused by prolonged pressure). A Quarterly MDS dated 4/11/25, under Section P0100A, revealed that Resident R13's bed rails were coded as a restraint used daily. A physician's order dated 3/27/25, indicated Resident R13 was to have bilateral one-half side rails for bed mobility every shift.

Observations between 5/5/25, and 5/8/25, revealed Resident R13 had two quarter-sized rails on the bed.

Review of Resident R41s clinical record revealed an admission date of 10/10/19, with diagnoses that included atrial fibrillation (irregular heartbeat), heart failure, and alcohol abuse with alcohol induced psychotic disorder. A Quarterly MDS dated 2/27/25, under Section P0100A, indicated that Resident R41's bed rails were coded as a restraint used daily. A physician's order dated 3/27/25, indicated Resident R41 was to have one-half side rails two times a day for transfer.

Observations between 5/5/25, through 5/8/25, revealed Resident R41 had two quarter-sized rails on the bed.

Review of Resident R15's clinical record revealed an admission date of 3/15/21, with diagnoses that included hemiplegia (a condition where a person is paralyzed and unable to move one side of their body), anxiety, and diabetes (a health condition that caused by the body's inability to produce enough insulin). A Quarterly MDS dated 4/7/25, under Section P0100A, revealed that Resident R15's bed rails were coded as a restraint used daily. A physician's order dated 3/27/25, indicated Resident R15 was to have bilateral one-half side rails for bed mobility every shift.

Observations between 5/5/25, through 5/8/25, revealed Resident R15 had two quarter-sized rails on the bed.

Review of Resident R55's clinical record revealed an admission date of 11/19/18, with diagnoses that included pyschotic disorder, mood disorder, and profound intellectual disabillities. A Quarterly MDS dated 2/28/25, under Section P0100B, revealed that Resident R55 was coded as trunk restraint not used. A physician's order dated 4/16/25, indicated that Resident R55 had an order for PSD (pelvic safety device) in SBC (straight back chair) for periods of low stimulation and calm during mealtimes, check and release every two hours and as needed for 15 minutes.

Observations between 5/5/25, and 5/8/25, revealed Resident R55 had a PSD on while up in chair.

Review of Resident R76's clinical record revealed an admission date of 9/7/24, with diagnoses that included bipolar disorder, blindness in one eye, high blood pressure and anxiety. A Quarterly MDS dated 3/4/25, under Section P0100A, revealed that Resident R76's bed rails were coded as a restraint used daily. A physician's order dated 3/27/25, indicated Resident R76 was to have left one-half side rails for bed mobility every shift.

Observations between 5/5/25, and 5/8/25, revealed Resident R76 had one quarter-sized rail on the bed.

During an interview on 5/7/25, at 12:45 p.m. the Director of Nursing confirmed that Residents R8, R9, R13, R15, R41, R55, and R76 MDS's Section P0100A as listed above were coded incorrectly and the quarter-sized rails were not used as restraints.

During an interview on 5/7/25, at 1:45 p.m. the Nursing Home Administrator confirmed that Resident R8's MDS Section J1900 was coded incorrectly regarding falls with major injury.

28 Pa. Code 211.5(f)(i)(ii)(ix) Medical records

Plan of Correction - To be completed: 06/02/2025

The Minimum Data Set(MDS) assessments for the seven affected residents (R8, R9, R13, R15, R41, R55, and R76) were reviewed and corrected to reflect accurate clinical status as of the assessment reference date. Each corrected assessment was signed and submitted by the Registered Nursing Assessment Coordinator (RNAC) on 5/7/2025.
This alleged deficient practice has the potential to impact all residents. An audit of MDS assessments from the last thirty days will be completed by Administrator and/or designee to identify any additional inaccuracies by June 2nd, 2025.
All licensed nursing staff and members of the MDS team will receive re-education on accurate MDS coding per the Resident Assessment Instrument(RAI) guidelines, emphasizing validation of source documentation. This education was completed by the cooperate RNAC on May 14th,2025.
The administrator or designee will randomly audit 5 MDS assessments weekly for 12 weeks to ensure accuracy in coding and supporting documentation with falls with major injury and restraint usage. Results will be submitted to the Quality Assurance and Performance Improvement (QAPI) committee for review and further action as needed.
All residents with a restraint were assessed appropriately for need and MDS/care plan was updated to reflect a restraint being utilized.
All residents' side rails/enable bar/ grab bar orders were updated to reflect the correct verbiage.
An Ad hoc QAPI was completed with the IDT on 5/21/2025 to review citations.
All corrective actions will be completed by June 2, 2025.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on review of facility policies and clinical records, observations, staff interviews, and resident interview, it was determined that the facility failed to maintain proper infection prevention and control isolation by failing to remove isolation precautions for non-transmittable diseases which were confirmed by laboratory testing for three of five residents reviewed on droplet precautions (a type of transmission based precautions used to prevent the spread of respiratory infections) (Residents R56, R77, and R33).

Findings include:

Review of the facility policy entitled "Policy on Isolation and Infection Precautions" dated 4/1/25, revealed "when it is determined that a resident needs isolation or special infection precautions to prevent the spread of infection, the appropriate isolation and/or precautions are utilized."

Review of the facility policy entitled "Infection Prevention & Control Program" dated 4/1/25, revealed "prevention of spread of infections is accomplished by the use of Standard and Transmission based precautions and other barriers, appropriate treatment and follow-up ...Transmission based precautions chosen based on circumstances and are least restrictive as possible."

Review of Resident R56's clinical record revealed an admission date of 2/26/25, with diagnoses that included neuralgic amyotrophy (nerve damage and muscle wasting that causes severe pain), anxiety, depression, and other seasonal allergic rhinitis.

Review of Resident R56's clinical record revealed progress notes dated 4/21/25, indicating he/she was placed on droplet precautions and that rapid COVID testing was negative. Progress notes on 5/1/25, revealed he/she was tested for flu and COVID in the emergency room, which were both negative. Clinical record vitals indicated that Resident R56 remained afebrile (free of fever).

Resident R56's Brief Interview for Mental Status (BIMs-15-point cognitive screening measure that evaluates memory and orientation and includes free and cued recall items) was 15 (cognitively intact).

Interview conducted with Registered Nurse Employee E2 on 5/5/25, at approximately 2:00 p.m. revealed Resident R56 was on droplet precautions and he/she was unaware of any positive testing that would require droplet isolation.

Interview conducted with Resident R56 on 5/6/25, at approximately 9:30 a.m. revealed he/she is very dissatisfied with the isolation precautions because all testing has been negative. He/she prefers to be out and about to socialize, but is uncomfortable wearing a mask, therefore he/she stays in his/her room.

Review of Resident R77's clinical record revealed an admission date of 6/2/23, with diagnoses that included dementia (thinking and social symptoms that interfere with daily living), weakness, pulmonary embolism (blood clot in lung), and dysphagia (difficulty swallowing).

Review of Resident R77's clinical record revealed progress notes dated 4/29/25, indicating he/she was placed on droplet precautions and that rapid COVID testing was negative. Clinical record vitals indicated that Resident R77 remained afebrile.

Review of Resident R33's clinical record revealed an admission date of 2/25/23, with diagnoses that included dementia, anxiety, dysphagia, and hypertension (high blood pressure).

Review of Resident R33's clinical record revealed progress notes dated 4/29/25, indicating he/she was placed on droplet precautions and that rapid COVID testing was negative. Clinical record vitals indicated that Resident R33 remained afebrile.

Interview conducted with Licensed Practical Nurse (LPN) Employee E1 on 5/6/25, at 9:06 a.m. revealed Residents R56, R77, and R33 are generally not in their rooms. He/she indicated Resident R56 is alert and oriented and enjoys socializing, which is beneficial due to Resident R56 becoming more depressed related to some new diagnoses. LPN Employee E1 indicated Residents R77 and R33 are always brought out of their rooms and into the living room for stimulation and socialization and have not been able to do so related to the isolation.

During an interview on 5/6/25, at approximately 10:45 a.m. the Infection Control Infection Preventionist confirmed that Residents R56, R77, and R33's testing for transmittable diseases were negative and that isolation should have been discontinued at that time.

28 Pa. Code 201.14(a) Responsibility of licensee

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

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

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

Plan of Correction - To be completed: 06/07/2025

Isolation precautions were immediately discontinued on 5/6/2025 for Residents R56, R77, and R33 by the Infection preventionist upon confirmation of negative test results and the absence of symptoms consistent with a communicable disease. Residents were re-assessed by nursing and the Infection Preventionist to ensure safe reintegration into communal activities.
This alleged deficient practice has the potential to impact all residents. An audit of all residents currently on transmission-based precautions was conducted on 5/6/2025 and 5/7/2025 to ensure appropriateness of isolation status in accordance with current clinical presentation and testing.
Infection Preventionist was educated by the cooperate QA nurse on 5/8/2025. Floor staff will be educated by Staff Educator on or before 6/7/2025 on the facility's existing "Policy on Isolation and Infection Precautions," with emphasis on timely reassessment and discontinuation of isolation based on negative diagnostic results and absence of symptoms, in alignment with CDC and CMS guidelines.
The Infection Preventionist or designee will review all residents placed on transmission-based precautions three times per week for 90 days to ensure isolation status remains clinically appropriate. Findings will be reported to the QAPI Committee for ongoing monitoring and compliance oversight.
All corrective actions will be completed by June 7, 2025

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Observations:

Based on review of facility policies and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders for one of 25 residents reviewed (Resident R34).

Findings include:

Review of facility policy entitled "Oxygen Administration" dated 4/1/25, indicated "Check physician's order for liter flow ..."

Review of facility policy entitled "Documentation, Clinical" dated 4/1/25, indicated "Documentation shall be done by nursing staff according to the needs of the resident and the care provided."

Review of Resident R34's clinical record revealed an admission date of 7/6/23, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), chronic respiratory failure (a condition where your lungs don't exchange air properly), and sleep apnea (a condition when a person repeatedly stops and starts breathing when they are sleeping).

Review of Resident R34's physician's orders revealed an order for O2 (oxygen) via NC (nasal cannula-oxygen tubing that has prongs that go into the nostrils and loops around the ears to secure in place to ensure adequate oxygen delivery) 2-3LPM (liters per minute) continuous, goal sats (oxygen saturation percent) 88-92%, dated 10/14/23.

Review of Resident R34's oxygen saturation documentation revealed it lacked evidence that his/her oxygen saturation was obtained routinely to know if he/she was within his/her oxygen goal sats per physician orders.

During an interview on 5/7/25, at 1:40 p.m. the Director of Nursing (DON) confirmed that Resident R34's clinical record lacked evidence of his/her oxygen saturation percentages to ensure that he/she was within his/her oxygen goal sats. He/she also confirmed that Resident R34's oxygen saturation levels should be monitored to ensure he/she is within his/her oxygen goal sats per physician orders.

28 Pa. Code 211.10(c) Resident care policies

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

Plan of Correction - To be completed: 06/07/2025

Resident R34's oxygen saturation monitoring was immediately initiated by the director of nursing on 5/7/2025, and documentation of readings is now completed every shift to ensure they remain within the physician-ordered range of 88–92%. The physician was notified on 5/7/2025, and no additional changes to respiratory care were required.
This alleged deficient practice has the potential to impact all residents. A facility-wide audit was completed on 5/20/2025 for all residents with active oxygen orders to ensure oxygen saturation is documented if requiring titration by the Director of Nursing (DON) or designee.
Licensed nursing staff will be re-educated on following physician orders for oxygen therapy, including the frequency and documentation of oxygen saturation monitoring, as outlined in the facility's current policies by the Staff Educator. To be completed by 6/7/2025.
The Director of Nursing or designee will review a weekly report of all residents, including new admissions and readmissions with oxygen therapy for 12 weeks, to verify that oxygen saturation readings are documented and align with physician-ordered parameters. Audit results will be presented to the Quality Assurance and Performance Improvement committee for review and continued oversight.
All corrective actions will be completed by June 7, 2025.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

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.

§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations:

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for one of 21 residents reviewed (Resident R34).

Findings include:

Review of facility policy entitled "Care Plans" dated 4/1/25, indicated "The care plan will be reviewed, evaluated and updated with any significant change ...", and "Care plans will outline resident's care needs based on ... physician orders ..."

Review of Resident R34's clinical record revealed an admission date of 7/6/23, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), chronic respiratory failure (a condition where your lungs don't exchange air properly), and sleep apnea (a condition when a person repeatedly stops and starts breathing when they are sleeping).

Review of Resident R34's physician orders revealed an order for O2 (oxygen) via NC (nasal cannula-oxygen delivery) 2-3LPM (liters per minute) continuous, goal sats (oxygen saturation percent) 88-92%, dated 10/14/23.

Review of Resident R34's care plans revealed a plan of care for recent history of tracheostomy with interventions for oxygen via nasal cannula at 2L PRN (as needed), and a plan of care for ADL self-care deficit with an intervention of oxygen at 2L via nasal cannula continuously.

During an interview on 5/7/25, at 1:40 p.m. the Director of Nursing (DON) confirmed the care plans for Resident R34's oxygen were not reviewed/revised to reflect current resident care and services. He/she also confirmed that care plans should be reviewed and revised as necessary.

28 Pa. Code 211.5(f)(i) Medical records

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

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

Plan of Correction - To be completed: 06/07/2025

The care plan for Resident R34 was reviewed and revised on 5/7/2025 by the interdisciplinary team to reflect the current physician orders and oxygen needs. The updated plan now includes continuous oxygen at 2–3LPM via nasal cannula with target saturations of 88–92%.
This alleged deficient practice has the potential to impact all residents. A comprehensive audit of all current residents with oxygen orders will be reviewed by Director of nursing (DON) and Quality Assurance (QA) nurse to ensure the care plan is accurately reflective of the current physician orders.
Licensed nurses and interdisciplinary team members will receive re-education by Staff Educator on the timely review and revision of care plans following comprehensive assessments, quarterly reviews, or significant changes in condition, per existing facility policy and regulatory guidelines.

All Residents with active oxygen orders were audited by administrator to ensure their care plans match the order and Oxygen Saturation checks are being completed per Physicians orders.
The DON or designee will audit 10 careplans weekly including current residents, admissions and readmissions for 12 weeks to ensure that revisions are made within 7 days of each comprehensive or significant change assessment. Audit results will be reviewed by the Quality Assurance and Performance Improvement committee for further recommendations or interventions.

The DON or designee will also run a weekly report of oxygen orders in the facility and ensure that care plans match the current plan of care for 12 weeks. Audit results will be reviewed by the Quality Assurance and Performance Improvement (QAPI) committee for further recommendations or interventions.

DON or designee will audit new physician orders 5 days weekly and adjust careplans as needed for 12 weeks.

All corrective actions will be completed by June 7, 2025.

483.75(g)(1)(i)-(iii)(2)(i); 483.80(c) REQUIREMENT QAA Committee:

§483.75(g) Quality assessment and assurance.
§483.75(g) Quality assessment and assurance.
§483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and
(iv) The infection preventionist.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:
(i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

§483.80(c) Infection preventionist participation on quality assessment and assurance committee.
The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.

Observations:

Based on review of facility records and staff interview, it was determined that the facility failed to ensure required attendance of the Director of Nursing and Infection Preventionist to Quality Assurance and Performance Improvement (QAPI) Committee meetings for two of four quarterly QAPI Committee meetings.

Findings include:

Review of facility policy entitled "Leadership and Communication" dated 4/1/25, indicated the facility will have a QAPI steering committee which included the following members Administrator, Director of Nursing, Infection Control, Medical Director ... and Committee Members - Per CMS regulations ...

Review of the QAPI Committee Attendance Records for the October 2024 meeting revealed no evidence on the attendance sign-in for the required QAPI meeting that the Director of Nursing was in attendance.

Review of the QAPI Committee Attendance Records for the February 2025 meeting revealed no evidence on the attendance sign-in sheets for the required QAPI meeting that the Infection Preventionist was in attendance.

During an interview on 5/8/25, at 12:15 p.m. the Nursing Home Administrator (NHA) confirmed the facility lacked evidence that the Director of Nursing and the Infection Preventionist attended the Quarterly QAPI Committee meetings as required. He/she also confirmed that the Director of Nursing and the Infection Preventionist should be in attendance for the QAPI meetings as required.

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

Plan of Correction - To be completed: 06/02/2025

The Administrator immediately on 5/8/2025 met with the Director of Nursing and Infection Preventionist to address and document the absence from the QAPI meetings held in October 2024 and February 2025. Both individuals have reviewed the missed meeting agendas and submitted written summaries of their input to ensure continuity in QAPI oversight.
This alleged deficient practice has the potential to impact all residents. Administrator reviewed QAPI meeting attendance records on 5/20/2025 for the past 12 months to identify any other instances of non-compliance with required committee member participation.
The Director of Nursing, Infection Preventionist, and all QAPI-required members have been re-educated on the regulatory requirement by administrator on 5/20/2025 for consistent attendance and participation in quarterly QAPI meetings. This education emphasizes adherence to the facility's current "Leadership and Communication" policy, including expectations for advance notice and rescheduling if absence is unavoidable.
The Administrator or designee will maintain a QAPI meeting attendance log that is reviewed quarterly for compliance. Attendance compliance will be monitored and presented at each QAPI meeting for the next 6 months, and any discrepancies will be immediately addressed.
All corrective actions will be completed by June 2nd, 2025.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Plan of Correction - To be completed: 06/07/2025

On 5/7/2025 LNHA and DON reviewed the nursing schedule and immediately adjusted the staffing schedule to ensure that the required NA-to-resident ratios were met on all shifts. Contracted agency staff and PRN pool were engaged to supplement staffing shortfalls as an interim solution. No negative outcomes to residents were identified through communication of daily clinical report as a result of the staffing variances. However, all residents were considered potentially affected and monitored for any changes in condition. None were identified.
The LNHA/Director of Nursing were educated on 5/8/2025 on staffing ratios, by Corporate QA Nurse.
A retrospective audit of NA staffing levels for the 30 days prior to the survey was conducted by administrator to identify additional occurrences of noncompliance and assess the scope. Census and staffing data were reviewed to identify recurring trends, and any gaps were documented. The staffing matrix was revised to ensure real-time visibility of NA-to-resident ratios per shift. Facility began immediate daily compliance checks. Administrator and DON provided education on 5/21/2025 to Clinical Director and CNA supervisor on state staffing ratios.
The DON or designee will conduct random audits of staffing levels to ensure compliance with the minimum NA ratio for each shift. Audit results will be reported weekly to the Administrator and Quarterly to the QAPI Committee for six months. Any variance identified will result in immediate corrective action and follow-up audit. The QAPI Committee will analyze trends and take further action as needed.

All corrective actions will be completed by June 7, 2025.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(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.

Plan of Correction - To be completed: 06/07/2025

On 5/7/2025 LNHA and DON reviewed the nursing schedule and immediately adjusted the staffing schedule to ensure that the required LPN-to-resident ratios were met on all shifts. Contracted agency staff and PRN pool were engaged to supplement staffing shortfalls as an interim solution. No negative outcomes to residents were identified through communication of daily clinical report as a result of the staffing variances. However, all residents were considered potentially affected and monitored for any changes in condition. None were identified.
The LNHA/Director of Nursing were educated on 5/8/2025 on staffing ratios, by Corporate QA Nurse.
A retrospective audit of LPN staffing levels for the 30 days prior to the survey was conducted by administrator to identify additional occurrences of noncompliance and assess the scope. Census and staffing data were reviewed to identify recurring trends, and any gaps were documented. The staffing matrix was revised to ensure real-time visibility of LPN-to-resident ratios per shift. Facility began immediate daily compliance checks. Administrator and DON provided education on 5/21/2025 to Clinical Director on state staffing ratios.
The DON or designee will conduct random audits of staffing levels to ensure compliance with the minimum LPN ratio for each shift. Audit results will be reported weekly to the Administrator and Quarterly to the QAPI Committee for six months. Any variance identified will result in immediate corrective action and follow-up audit. The QAPI Committee will analyze trends and take further action as needed.

All corrective actions will be completed by June 7, 2025.

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