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

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HAVENCREST HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  102 surveys for this facility. Please select a date to view the survey results.

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HAVENCREST HEALTHCARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid, State Licensure and Civil Rights survey completed on January 26, 2024, it was determined that Havencrest 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 REQUIREMENT Quality of Care: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.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for four of seven residents reviewed (Residents R9, R10, R24, and R33).

Findings include:

The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it ' s untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds.

Review of the facility policy "Diabetes - Clinical Protocol" reviewed 3/6/23, indicated the physician will order desired parameters for monitoring and reporting information related to diabetes ot blood sugar management. The staff will identify and report complications.

Review of the facility policy "Nursing Care of the Resident with Diabetes Mellitus" reviewed 3/6/23, indicated documentation should reflect the carefully assessed diabetic resident and include vital signs, level of consciousness, assessment of the skin, blood sugar results. The approximate reference ranges for hypoglycemia are:

Mild hypoglycemia - 55-70
Moderate hypoglycemia - 40-55
Severe hypoglycemia - <40

Review of the facility policy "Obtaining a Fingerstick Glucose Level" reviewed 3/623, indicated to report results promptly to the supervisor and physician and report other information in accordance with facility policy and professional standards of practice.

Review of the facility policy "Change in Resident ' s Condition or Status" reviewed 3/6/23, indicated the facility shall promptly notify the resident, his/her doctor, and representative of changes in the resident ' s medical/mental condition and/or status. The nurse will notify the doctor or the doctor on call when there has been a significant change in the resident ' s physical/emotional/mental condition, and when specific instructions to notify the doctor of changes in the resident ' s condition. The nurse will record in the resident ' s medical record information relative to changes in the resident ' s medical/mental condition or status.

Review of the facility policy "Charting and Documentation" reviewed 3/6/23, indicated all services provided to the resident, progress toward the care plan, or any changes in the resident ' s medical, physical, functional, or psychosocial condition shall be documented in the resident ' s medical record. Documentation of procedures and treatments will include care-specific details, including the date and time procedure/treatment was provided, assessment data and/or any unusual findings, and notification of family, physician, or other staff if indicated.

Review of the clinical record indicated Resident R9 was re-admitted to the facility on 11/7/19, with diagnoses that included diabetes, high blood pressure, and muscle weakness.

Review of Resident R9 ' s Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 12/23/23, indicated the diagnoses remain current.

Review of a physician ' s order dated 12/28/21, indicated to inject Novolog insulin per sliding scale, if blood glucose less than 70 or greater than 400 call the doctor. Further review of a physician ' s order dated 3/17/23, indicated to call the doctor if blood sugar is less than 70 or greater than 400.

Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows:

On 11/5/23, at 5:37 p.m. CBG was noted to be 447.
On 12/21/23, at 12:09 p.m. CBG was noted to be 65

Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hyper-/hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, failed to follow facility protocol, and the physician was not notified of abnormal results on the above listed dates.

Review of the care plan revised 7/8/20, indicated to administer diabetic medications per physician ' s orders. Obtain glucometer readings and report abnormalities as ordered. Report symptoms of hyper-/hypoglycemia.

Review of a clinical record indicated Resident R10 was re-admitted to the facility on 6/8/21, with diagnoses that included diabetes, heart failure (progressive heart disease that affects pumping action of the heart muscles), and high blood pressure.

Review of the MDS dated 1/18/24, indicated the diagnoses remain current.

Review of physician ' s orders dated 3/17/23, indicated to call doctor for hypo/hyperglycemic episodes or if blood sugar is less than 70/greater than 400. Further review of a physician order dated 8/17/22 indicated to inject Novolog (a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours.) insulin per sliding scale, If blood sugar is 401 or greater give 10 units, call doctor if blood glucose is less than 70 or greater than 400.

Review of Resident R10's eMAR revealed that the resident's CBG's were as follows:

On 12/7/23, at 8:42 a.m. CBG was noted to be 63.
On 1/14/24, at 8:32 a.m. CBG was noted to be 63.

A review of Resident R10's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, failed to follow interventions of the care plan, blood sugar was not rechecked, and the physician was not notified of abnormal results.

A review of Resident R10's care plan dated 12/12/18, indicated to administer insulin medications per physician orders. Report symptoms of hypo-/hyperglycemia. Further review of the care plan dated 11/23/23, indicated to obtain glucometer readings and report abnormalities as ordered.

Review of the clinical record indicated Resident R24 was re-admitted to the facility on 10/14/22, with diagnoses that included diabetes, dementia (group of symptoms affecting memory, thinking and social abilities), and anxiety.

Review of Resident R24 ' s MDS dated 11/14/23, indicated the diagnoses remain current.

Review of physician orders dated 4/13/23, indicated to call the doctor if blood sugar is less than 70/greater than 400. For symptomatic hypoglycemia and responsive, give rapidly absorbed glucose (juice, soda) recheck in 15 minutes and repeat if indicated.

Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows:

On 12/24/23, at 8:49 a.m. CBG was noted to be 53.

Review of Resident R24's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates.

Review of the care plan dated 10/15/22, indicated to administer diabetic medications per physician orders. Obtain glucometer readings and report abnormalities as ordered. Report symptoms of hypoglycemia.

Review of the clinical record indicated Resident R33 was re-admitted to the facility on 1/3/24, with diagnoses that included diabetes, depression, and muscle weakness.

Review of Resident R33' s MDS dated 1/9/24, indicated the diagnoses remain current.

Review of physician orders dated 1/4/24, indicated to call the doctor if blood sugar is less than 70/greater than 400. Inject Admelog (Lispro) per sliding scale if greater than 400 give 12 units and notify doctor.

Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows:

On 1/5/24, at 12:17 p.m. CBG was noted to be 429.
On 1/5/24, at 4:40 p.m. CBG was noted to be 403.
On 1/5/24, at 5:14 p.m. CBG was noted to be 403.
On 1/22/24, at 9:30 a.m. CBG was noted to be 49.


Review of Resident R33's eMAR and clinical progress notes indicated the resident was not assessed for hypo-/hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed dates and failed to follow the physician ' s order.

Review of the care plan dated 1/4/24, indicated to administer medications per physician orders. Obtain glucometer readings and report abnormalities as ordered. Report symptoms of hypo-/hyperglycemia.

During an interview on 1/25/24, at 8:13 a.m. Licensed Practical Nurse (LPN) Employee E2 stated for blood sugar under 60-70, they would notify the doctor and provide a snack. If the blood sugar was over 200, they would check the orders for parameters, and call the doctor accordingly.

During an interview on 1/25/24, at 8:17 a.m. Registered Nurse (RN) Employee E3 stated for blood sugars over 400, they would check the parameters, give the baseline insulin, complete an assessment, and call the provider. If the blood sugar was less than 70 they would offer a snack, call the doctor, and monitor the resident.

During an interview on 1/25/24, at 8:20 a.m. RN Employee E4 stated for blood sugars over 300-400, they would check the orders for parameters, give the ordered insulin, complete an assessment and call the doctor. If the blood sugar was less than 60, follow protocol, offer snack, complete assessment, and recheck in 15 minutes.

During an interview on 1/25/24, at 2:08 a.m. LPN Employee E5 stated for blood sugars less than 70 they would give snack, notify the doctor if needed and recheck in 15 minutes. For blood sugars over 400, they would give the ordered insulin, notify the doctor, and recheck in 30 minutes.

During an interview on 1/26/24, at 10:30 a.m. the Director of Nursing confirmed the facility failed to notify the doctor of a change in condition related to blood glucose, failed to follow the care plan interventions, and failed to recheck blood sugars for Residents R9, R10, R24, and R33.

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

28 Pa. Code: 201.29(d) Resident rights.

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

28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.





 Plan of Correction - To be completed: 03/05/2024

During review of blood glucose readings for residents R9, R10, R24, & R23, it was confirmed with the MD that he was notified of blood glucose readings & documentation was completed by the Director of Nursing. It was not, however, documented by the nurse on duty that the MD was notified. All licensed staff will be educated on hypo/hyperglycemic policy & procedure, charting & documentation, & change in residents condition by the Director of Nursing/Designee by March 5, 2024. The Director of Nursing/Designee will review blood glucose readings daily & supporting documentation that MD was notified by the nurse on duty x 4 weeks followed by weekly x 3 months. Results will be monitored in the QA/QI meetings until compliance is met.
483.25(l) REQUIREMENT Dialysis: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(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:
Based on review of clinical records and staff interviews, it was determined that facility staff failed to maintain ongoing communication with the dialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for one of 12 residents reviewed (Resident R43).


Findings include:

Review of the facility policy "End-Stage Renal Disease, Care of a Resident with" last reviewed on 3/6/23, indicated residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Staff caring for residents with ESRD, including residents receiving dialysis care outside of the facility, shall be trained in the care and special needs of these residents.

A review of the clinical record indicated that Resident R43 was admitted to the facility on 12/2/23, with diagnoses that included ESRD (the kidneys permanently fail to work), cancer, and dependence on renal dialysis.

A review of the Minimum Data Set (MDS - periodic assessment of care needs) date 11/17/23, indicated the diagnoses remain current.

A review of a physician ' s order dated 12/18/23, indicated Resident R43 was to receive dialysis three days a week on Monday, Wednesday, and Fridays.

Review of a care plan dated 12/6/23, indicated arrange for transportation to and from dialysis facility on dialysis days. Confer with physician and/or dialysis treatment facility regarding changes in medication administration times/dosage pre-dialysis as needed. Check access site for lack of thrill/bruit, evidence of infection, swelling, or excessive bleeding. Report abnormalities to physician. Coordinate dialysis care with dialysis treatment facility.

Review of the dialysis communication sheets from 12/18/23 through 1/22/24, indicated eight of eight communication sheets not completed pre-dialysis treatment, and nine communication sheets were not located.

During an interview on 1/26/24, at 10:45 a.m. Registered Nurse Employee E1 confirmed the dialysis communication sheets "Communication for Transition of Care between Dialysis and Skilled Nursing Facility" sheets are received from the dialysis center. They are not the facility ' s communication sheets.

During an interview on 1/26/23, at 10:48 a.m. the Director of Nursing confirmed the facility failed to ensure the dialysis communication forms for Resident R43 were completed following each dialysis treatment day.


28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.


 Plan of Correction - To be completed: 03/05/2024

For resident R43, the dialysis communication record will accompany them every Monday-Wednesday-Friday & for all like residents on dialysis days. All licensed staff will be educated on the facilities policy for End Stage Renal Disease, Care of a resident with by the Director of Nursing/Designee by March 5, 2024. An audit of all dialysis residents weekly for presence of dialysis communication record by the Director of Nursing/Designee x 4 weeks followed by monthly x 2 months. Results will be monitored in the QA/QI meetings x 3 months.
§ 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 twelve residents during the dayshift on two of 21 days (12/25/23 and 1/23/24) , failed to provide one nurse aide per twelve residents during the evening shift on nine of 21 days (12/25/23, 12/26/23, 12/27/23, 12/29/23, 1/1/24, 1/2/24, 1/3/24, 1/22/24 and 1/23/24) and failed to provide one nurse aide per 20 residents during the night shift on 13 of 21 days (12/27/23, 12/29/23, 12/30/23, 12/31/23, 1/1/24, 1/2/24, 1/3/24, 1/4/24, 1/5/24, 1/6/24, 1/19/24, 1/23/24 and 1/25/24).

Findings include:

Review of facility census data indicated that on 12/24/23, the facility census was 39, which required 1.56 Licensed Practical Nurse's (LPN) on the daylight shift with 1.0 LPN's scheduled and the facility census was 40 on the evening shift which required 1.33 LPN's with 1,03 LPN's scheduled. The additional excess higher level staff were calculated to compensate but did not meet the requirements.

During an interview on 1/24/24, at 2:00 p.m., the Nursing Home Administrator confirmed that the facility failed to provide a minimum of one nurse aide per 12 residents on daylight and evening shifts and one nurse aide per 20 residents on the overnight shift.


 Plan of Correction - To be completed: 03/05/2024

The facility will persist in taking measures to provide adequate staff to meet resident needs including the required nurse aide to resident ratios on day shift, evening shift, & night shift. The Director of Nursing/Designee will re-educate the scheduler, RN supervisors, and HR, on minimum staff ratios by March 5, 2024. The Director of Nursing/Designee will audit daily staffing schedules to ensure the minimum number of nurse aide to resident ratios are being met x 2 weeks followed by weekly x 4 weeks. Results will be monitored in QA/QI x 3 months.
§ 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 administrative staff failed to provide a minimum of one licensed practical nurse per 25 residents on ten of 21 days during the dayshift (12/24/23, 12/26/23, 12/28/23, 12/31/23, 1/4/24, 1/5/24, 1/6/24, 1/19/24, 1/21/24, and 1/24/24), one LPN per 30 residents on nine of 21 days during the evening shift ( 12/24/23, 12/26/23, 12/27/23, 12/30/23, 1/2/24, 1/3/24, 1/6/24, 1/20/24 and 1/21/24) and one LPN per 40 residents overnight on 19 of 21 days (12/25/23, 12/26/23, 12/27/23, 12/28/23, 12/29/23, 12/30/23, 12/31/23, 1/1/24, 1/2/24, 1/3/24, 1/5/24, 1/6/24, 1/19/24, 1/20/24, 1/21/24, 1/22/24, 1/23/24, 1/24/24 and 1/25/24).

Findings include:

Review of facility census data indicated that on 12/24/23, the facility census was 39, which required 1.56 licensed practical nurses(LPN) during the dayshift and the census for the evening shift was 40, which required 1.33 LPN's.

Review of nursing time schedules and deployment sheets revealed 1.0 LPN's provided care on the daylight shift and 1.03 LPN's provided care that evening. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 12/25/23, the facility census was 39, which required 1.0 LPN's during the overnight shift.

Review of nursing time schedules and deployment sheets revealed there were zero LPN's that provided care that overnight shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 12/26/23, the facility census was 40, which required 1.6 LPN's during the dayshift, 1.33 LPN's for the evening shift and 1 LPN for the overnight shift.

Review of nursing time schedules and deployment sheets revealed 1.5 LPN's provided care on the daylight shift, 1.31 LPN's provided care that evening and zero LPN's provided care on the overnight shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 12/27/23, the facility census was 42, which required 1.40 LPN's during the evening shift and 1.05 LPN's for the overnight shift.

Review of nursing time schedules and deployment sheets revealed 1.0 LPN's provided care on the evening shift and zero LPN's provided care on the overnight shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 12/28/23, the facility census was 42, which required 1.68 LPN's during the dayshift and the census for the overnight shift was 43, which required 1.08 LPN's.

Review of nursing time schedules and deployment sheets revealed 1.0 LPN's provided care on the daylight shift and zero LPN's provided care the overnight shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 12/29/23, the facility census was 42, which required 1.05 LPN's during the overnight shift.

Review of nursing time schedules and deployment sheets revealed zero LPN's provided care on the overnight shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 12/30/23, the facility census was 42, which required 1.40 LPN's during the evening shift and the facility census was 43 on the overnight shift which required 1.08 LPN's for the overnight shift.

Review of nursing time schedules and deployment sheets revealed 1.03 LPN's provided care on the evening shift and zero LPN's provided care on the overnight shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 12/31/23, the facility census was 43, which required 1.72 LPN's during the dayshift and 1.08 LPN's for the overnight shift.

Review of nursing time schedules and deployment sheets revealed 1.0 LPN's provided care on the daylight shift and zero LPN's provided care the overnight shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 1/1/24, the facility census was 41, which required 1.03 LPN's during the overnight shift.

Review of nursing time schedules and deployment sheets revealed zero LPN's provided care on the overnight shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 1/2/24, the facility census was 41, which required 1.37 LPN's during the evening shift and 1.03 LPN's for the overnight shift.

Review of nursing time schedules and deployment sheets revealed .78 LPN's provided care on the evening shift and zero LPN's provided care on the overnight shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 1/3/24, the facility census was 43, which required 1.43 LPN's during the evening shift and 1.08 LPN's for the overnight shift.

Review of nursing time schedules and deployment sheets revealed 1.09 LPN's provided care on the evening shift and zero LPN's provided care on the overnight shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 1/4/24, the facility census was 44, which required 1.76 LPN's during the daylight shift.

Review of nursing time schedules and deployment sheets revealed 1.47 LPN's provided care on the daylight shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 1/5/24, the facility census was 43, which required 1.72 LPN's during the dayshift and 1.08 LPN's for the overnight shift.

Review of nursing time schedules and deployment sheets revealed 1.50 LPN's provided care on the daylight shift and zero LPN's provided care the overnight shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 1/6/24, the facility census was 43, which required 1.72 LPN's during the dayshift, 1.43 LPN's for the evening shift and 1.08 LPN for the overnight shift.

Review of nursing time schedules and deployment sheets revealed 1.0 LPN's provided care on the daylight shift, .78 LPN's provided care that evening and zero LPN's provided care on the overnight shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 1/19/24, the facility census was 45, which required 1.80 LPN's during the dayshift and the facility census was 46 for the overnight shift which required 1.15 LPN's for the overnight shift.

Review of nursing time schedules and deployment sheets revealed 1.38 LPN's provided care on the daylight shift and zero LPN's provided care the overnight shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 1/20/24, the facility census was 45, which required 1.50 LPN's during the evening shift and 1.13 LPN's for the overnight shift.

Review of nursing time schedules and deployment sheets revealed 1.0 LPN's provided care on the evening shift and zero LPN's provided care on the overnight shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 1/21/24, the facility census was 45, which required 1.80 LPN's during the dayshift, 1.5 LPN's for the evening shift and 1.13 LPN's for the overnight shift.

Review of nursing time schedules and deployment sheets revealed 1.0 LPN's provided care on the daylight shift, .81 LPN's provided care that evening and zero LPN's provided care on the overnight shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 1/22/24, the facility census was 46, which required 1.15 LPN's during the overnight shift.

Review of nursing time schedules and deployment sheets revealed zero LPN's provided care on the overnight shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 1/23/24, the facility census was 46, which required 1.15 LPN's during the overnight shift.

Review of nursing time schedules and deployment sheets revealed .97 LPN's provided care on the overnight shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 1/24/24, the facility census was 45, which required 1.80 LPN's during the dayshift and 1.13 LPN's for the overnight shift.

Review of nursing time schedules and deployment sheets revealed 1.0 LPN's provided care on the daylight shift and zero LPN's provided care the overnight shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 1/25/24, the facility census was 46, which required 1.08 LPN's during the overnight shift.

Review of nursing time schedules and deployment sheets revealed zero LPN's provided care on the overnight shift. No additional excess higher level staff were available to compensate this deficiency.

During an interview on 1/24/24, at 2:00 p.m., the Nursing Home Administrator confirmed that the facility failed to provide a minimum of one licensed practical nurse per 25 residents on the dayshift, one LPN per 30 residents during the evening shift and one LPN per 40 residents on the overnight shifts.


 Plan of Correction - To be completed: 03/05/2024

The facility will persist in taking measures to provide adequate staff to meet resident needs including the required Licensed Practical Nurse to resident ratios on day shift, evening shift, & night shift. The Director of Nursing/Designee will re-educate the scheduler, RN supervisors, and HR, on minimum staff ratios by March 5, 2024. The Director of Nursing/Designee will audit daily staffing schedules to ensure the minimum number of Licensed Practical Nurse to resident ratios are being met x 2 weeks followed by weekly x 4 weeks. Results will be monitored in QA/QI x 3 months.
§ 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 faciltiy policy, nursing time schedules, and staff interviews it was determined that the facility administrative staff failed to provide a minimum of one registered nurse (RN) for 250 residents on four of 21 days on the dayshift (12/31/23, 1/6/24, 1/19/24 and 1/21/24), one RN on three of 21 days on the evening shift (12/31/23, 1/5/23 and 1/19/24), one RN for on one of 21 days for the overnight shift(1/4/24).

Findings include:

Review of the facility policy "Staffing" last reviewed on 3/6/23, indicated that the facility provided adequate staffing to meet the needs of their resident population.

Review of the nursing time schedules indicated that from 12/24/23, through 1/6/24, and from 1/19/24, through 1/25/24 the facility census remained below 50 residents.

Review of the nursing schedule indicated that on 12/31/23, that the facility failed to provide a registered nurse on the day shift and evening shift, and failed to provide an additional licensed practical nurse to meet the requirement.

Review of the nursing schedule indicated that on 1/4/24, that the facility failed to provide a registered nurse on the overnights shift, and failed to provide an additional licensed practical nurse to meet the requirement.

Review of the nursing schedule indicated that on 1/5/24, that the facility failed to provide a registered nurse on the evening shift, and failed to provide an additional licensed practical nurse to meet the requirement.

Review of the nursing schedule indicated that on 1/6/24, that the facility failed to provide a registered nurse on the daylight shift, and failed to provide an additional licensed practical nurse to meet the requirement.

Review of the nursing schedule indicated that on 1/19/24, that the facility failed to provide a registered nurse on the daylight and evening shifts, and failed to provide an additional licensed practical nurse to meet the requirement.

Review of the nursing schedule indicated that on 1/21/24, that the facility failed to provide a registered nurse on the daylight shift, and failed to provide an additional licensed practical nurse to meet the requirement.

During an interview on 1/24/24, at 2:00 p.m., the Nursing Home Administrator confirmed that the facility failed to provide a minimum of one registered nurse (RN) for 250 residents on a total of eight of 21 days.


 Plan of Correction - To be completed: 03/05/2024

The facility will persist in taking measures to provide adequate staff to meet resident needs including the required Registered Nurse to resident ratios on day shift, evening shift, & night shift. The Director of Nursing/Designee will re-educate the scheduler, RN supervisors, and HR, on minimum staff ratios by March 5, 2024. The Director of Nursing/Designee will audit daily staffing schedules to ensure the minimum number of Registered Nurse to resident ratios are being met x 2 weeks followed by weekly x 4 weeks. Results will be monitored in QA/QI x 3 months.

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