Pennsylvania Department of Health
GUARDIAN HEALTHCARE MEADOWCREST
Patient Care Inspection Results

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GUARDIAN HEALTHCARE MEADOWCREST
Inspection Results For:

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GUARDIAN HEALTHCARE MEADOWCREST - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Findings of an abbreviated complaint survey completed on February 6, 2024 at Guardian Healthcare Meadowcrest identified no deficient practice under the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities as it relates to the Health portion of the survey process; however, deficient practice was identified under 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 staff interview it was determined that the facility administrative staff failed to provide a minimum of one nurse aide (NA) per twelve residents during the day shift, for one of 21 days (1/1/24).

Findings include:

Review of the facility census data, nursing time schedules, and deployment sheets from 12/24/23 through 1/13/24, revealed the following nurse aide staffing shortages:

On 1/1/24, the census was 44, which required 3.67 NAs during the day shift. Review of the nursing time schedules revealed 3.17 NAs provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

During an interview on 2/6/24, at 2:00 p.m. the Director of Nursing confirmed that the facility failed to provide a minimum of one nurse aide per twelve residents during the day shift on 1/1/24.



 Plan of Correction - To be completed: 02/22/2024

The facility will continue to take measures to adequately staff and meet the hours of direct nursing care per resident day.

The NHA or designee will conduct daily labor meeting and audit daily schedules to ensure minimum number of direct nursing care per resident are scheduled to meet the needs of the residents.

To help increase staffing facility has recruitment efforts with social media, partnership with local schools, referral, sign on bonuses, and shift pick up bonuses.

Education to be completed by RDO on staffing ratios with NHA, scheduler, and DON.

Staffing will be reviewed daily in labor meeting by NHA or designee. The results will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance has been met.

§ 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 40 residents during the night shift on nine of 21 days (12/26, 12/28/23, and 1/2, 1/3, 1/4, 1/5, 1/6, 1/7, and 1/11/24) and a minimum of one LPN per 30 residents during the evening shift on one of 21 days (1/11/24).

Findings include:

Review of facility census data indicated that on 12/26/23, the facility census was 40 which required 1.07 LPNs during the night shift. 1.03 LPNs provided care. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 12/28/23 and 1/2/24, the facility census was 44 which required 1.07 LPNs during the night shift. 1.03 LPNs provided care on 12/28/23 and 1.00 LPNs provided care on 1/2/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 1/11/24, the facility census was 42 which required 1.07 LPNs during the night shift and evening shift. On 1/11/24, 0.93 LPNs provided care during the night shift and 1.03 LPNs provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 1/3, 1/4, 1/5, 1/6, and 1/7/24, the facility census was 43 which required 1.07 LPNs during the night shift. The nursing time schedules indicated the following:

1/3/24 0.97 LPNs provided care on the night shift.
1/4/24 1.03 LPNs provided care on the night shift.
1/5/24 1.03 LPNs provided care on the night shift.
1/6/24 0.00 LPNs provided care on the night shift.
1/7/24 0.00 LPNs provided care on the night shift.

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

During an interview on 2/6/24 at 2:00 p.m., the Director of Nursing confirmed the above findings and that the facility failed to provide a minimum of LPNs per residents during the evening shift on one of 21 days for 1/11/24, and nine of 21 days during the night shift for 12/26/23, 12/28/23, 1/2/24, 1/3/24, 1/4/24, 1/5/24, 1/6/24, 1/7/24, and 1/11/24.



 Plan of Correction - To be completed: 02/22/2024

The facility will continue to take measures to adequately staff and meet the hours of direct nursing care per resident day.

The NHA or designee will conduct daily labor meeting and audit daily schedules to ensure minimum number of direct nursing care per resident are scheduled to meet the needs of the residents.

To help increase staffing facility has recruitment efforts with social media, partnership with local schools, referral, sign on bonuses, and shift pick up bonuses.

Education to be completed by RDO on staffing ratios with NHA, scheduler, and DON.

Staffing will be reviewed daily in labor meeting by NHA or designee. The results will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance has been met.

§ 211.12(f.1)(5) LICENSURE Nursing services. :State only Deficiency.
(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.
Observations:
Based on review of nursing time schedules and staff interview it was determined that the facility failed to provide a minimum of one Registered Nurse (RN) per 250 residents during the night shift for one of 21 days (12/27/23).

Findings include:

Review of the facility census data, nursing time schedules, and deployment sheets from 12/24/23 through 1/13/24, revealed the following Registered Nurse staffing shortages:

On 12/27/23 the census was 43, which required 1.07 RN's during the night shift. Review of the nursing time schedules revealed 1.00 RN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

During an interview on 2/6/24, at 2:00 p.m. the Director of Nursing (DON) confirmed that the facility failed to provide a minimum of one RN per 250 residents during the night shift on one of 21 days.



 Plan of Correction - To be completed: 02/22/2024

The facility will continue to take measures to adequately staff and meet the hours of direct nursing care per resident day.

The NHA or designee will conduct daily labor meeting and audit daily schedules to ensure minimum number of direct nursing care per resident are scheduled to meet the needs of the residents.

To help increase staffing facility has recruitment efforts with social media, partnership with local schools, referral, sign on bonuses, and shift pick up bonuses.

Education to be completed by RDO on staffing ratios with NHA, scheduler, and DON.

Staffing will be reviewed daily in labor meeting by NHA or designee. The results will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance has been met.


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