Pennsylvania Department of Health
EMBASSY OF SCRANTON
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

EMBASSY OF SCRANTON
Inspection Results For:

There are 163 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


EMBASSY OF SCRANTON - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a revisit and abbreviated complaint survey completed on November 1, 2024, it was determined The Gardens at Scranton failed to correct the deficiencies cited during the surveys of September 6, 2023 and August 9, 2024 and continued to be out of compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations

Plan of Correction:

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:

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.

§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.

Observations:

Based on clinical record review, facility policy review and staff interview, it was determined the facility failed to ensure that nursing services met professional standards of quality according to the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to implement nursing practices for the administration of an intravenous medication via central venous catheter for one of 6 residents reviewed. (Resident A1).

Findings include:

According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) requires the following:
The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. (b) The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: (d) The Board recognizes codes of behavior as developed by appropriate practical nursing associations as the criteria for assuring safe and effective practice.

Chapter 21.145b. IV therapy curriculum requirements;
(f) An LPN may perform only the IV therapy functions for which the LPN
possesses the knowledge, skill and ability to perform in a safe manner, except as
limited under 21.145a (relating to prohibited acts), and only under supervision
as required under paragraph (1).
(1) An LPN may initiate and maintain IV therapy only under the direction
and supervision of a licensed professional nurse or health care provider authorized
to issue orders for medical therapeutic or corrective measures (such as a
CRNP, physician, physician assistant, podiatrist or dentist).

(g) An LPN who has met the education and training requirements of 21.145b (relating to IV therapy curriculum requirements) may perform the following IV therapy functions, except as limited under 21.145a and only under supervision as required under subsection (f):
(1) Adjustment of the flow rate on IV infusions.
(2) Observation and reporting of subjective and objective signs of adverse reactions to any IV administration and initiation of appropriate interventions.
(3) Administration of IV fluids and medications.
(4) Observation of the IV insertion site and performance of insertion site care.
(5) Performance of maintenance. Maintenance includes dressing changes, IV tubing changes, and saline or heparin flushes.
(6) Discontinuance of a medication or fluid infusion, including infusion devices.
(7) Conversion of a continuous infusion to an intermittent infusion.
(8) Insertion or removal of a peripheral short catheter.
(9) Maintenance, monitoring and discontinuance of blood, blood components and plasma volume expanders.
(10) Administration of solutions to maintain patency of an IV access device via direct push or bolus route.
(11) Maintenance and discontinuance of IV medications and fluids given via a patient-controlled administration system.
(12) Administration, maintenance and discontinuance of parenteral nutrition and fat emulsion solutions.
(13) Collection of blood specimens from an IV access device.

There was no facility policy and procedure provided to the survey team at the time of the survey. The Director of Nursing stated to the survey team on November 1, 2024 at 5:00 PM that LPNs may not administer or withdraw fluids via a venous central line (PICC line).

Clinical record review revealed that Resident A1 was admitted to the facility on October 7, 2024 with diagnosis to include, bilateral lower extremity wounds, sepsis (an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever) and was admitted to the facility with a PICC line (a peripherally inserted central catheter a long catheter introduced through a vein in the arm and passed through to the larger veins into the heart).

Physicians orders dated October 10, 2024 revealed, administer Cefepime HCL (intravenous antibiotic) 2 grams IV (intravenously) every 8 hours for bilateral lower extremity wounds with no discontinuation date indicated.

A review of the October 2024 Medication Administration Record (MAR) revealed that between October 10, 2024 through October 31, 2024, Employee 2, LPN, Employee 3, LP, Employee 4, LPN, Employee 5, LPN, Employee 6, LPN, Employee 7, LPN, Employee 8, LPN and Employee 9, LPN signed the MAR as administering the IV antibiotic medication to Resident A1 through the PICC line.

Interview on November 1, 2024, at approximately 5:00 PM with Employee 10, LPN, stated he never administered medications through any resident's PICC lines at the facility. He confirmed he was never educated on the administration of medications through the PICC line. He stated he would call the RN to administer the IV through the resident's PICC line. He stated he, the LPN, would sign out on the MAR that he had administered the medication when the RN actually administered the IV medication through the resident's PICC line.

There was no evidence of any current education or supervision regarding IV administration as well as PICC line usage for any LPNs working at the facility.

During an interview on November 1, 2024, at approximately 5:30 PM the director of nursing (DON) stated that in the past several years that a few LPN's in the facility received education regarding the administration of medications through PICC lines. She could not provide evidence of the initial education or any yearly education regarding the PICC line medication administration for the facility or agency LPN's working in the facility.

The DON confirmed the nurse administering the medications are to sign the MAR indicating the medication was administered.

There was no evidence The LPN (who has completed the Board certified educational program) attends a yearly in-service of administration of intravenous fluids and medications.

28 Pa. Code 201.20(a) Staff Development.

28 Pa Code 211.12(5) Nursing services.

Plan of Correction - To be completed: 11/26/2024

The facility cannot retroactively correct the deficiency.

IV antibiotic medication orders were reviewed. No active IV Antibiotic orders were identified currently in the facility.

The DON/designee will ensure LPNs have an IV certification by a board-certified educational provider or an annual IV in-service if already currently certified. Prior to IV certification of a Licensed Practical Nurse, an RN will provide administration of IV medications and document the administration in the resident record for any residents under the care of the LPN.

The DON/designee will audit all current LPN's for current IV Certification and ensure newly hired LPN's are IV certified through a board-certified educational provider upon hire to the facility or arrange certification within 30 days of hire. Licensed Practical Nurses will receive an annual IV in-service provided by the ADON/Designee. Results of these audits will be discussed at the monthly QAPI meeting for further review and recommendations.

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:

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 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Observations:

Based on clinical record review and staff interview it was determined the facility failed to include, in the resident's baseline plan of care, minimum standards of care to fully address the resident's immediate needs upon admission for one resident out 6 sampled (Resident B1).

Findings include:

A review of a facility policy entitled "Resident Admission Procedure" (no date of policy development) that was provided by the facility on November 1, 2024, indicated the upon a resident's admission to the facility the nurse was to measure and record the resident's temperature, pulse, respiration, blood pressure, weight, and height. The nurse was to observe the general condition of the resident's skin (i.e., wounds, rashes, burns, bruises, scars, or surgical incisions), as well as his or her reaction to the admission. Additionally, the nurse was to notify the administrator, Director of Nursing (DON), attending/other involved physicians of the admission and acute issues such as respiratory or other distress, wounds, etc. that may need immediate attention. Determine if follow-up or other appointments are needed and complete the admission assessment and documentation.

A review of Resident B1's clinical record revealed the resident was admitted to the facility on October 29, 2024, with a cutaneous abscess (cavity filled with puss) of the buttocks, colostomy, Fournier gangrene (a type of necrotizing fasciitis, a flesh-eating disease that affects the scrotum, penis, or perineum), diabetes, and a scrotal abscess.

A review of nursing progress notes in Resident B1's clinical record revealed a general progress note completed by Employee 1, a Registered Nurse (RN), dated October 29, 2024, at 9:28 PM, revealed the resident was alert and oriented to person, place and time, able to make his needs known and denied pain. Resident has a colostomy to left lower abdomen, scrotal wound measuring 6 cm x 3 cm x 5cm and a sacrum wound with 100% slough measuring 7 cm x 4 cm 1cm with a catheter for sacral wound irrigation. The resident utilized a PICC Line (a peripherally inserted central catheter, is a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart and is used to deliver medications and other treatments directly to the large central veins near the heart) to right upper arm with double lumen.

Further review of Resident B1's baseline care plan (required to be developed within the first 48-hours of admission) failed to identify the resident's multiple skin impairments that required specific care and services and a PICC line to administer IV (intravenous) antibiotics. Additionally, the care plan failed to identify any goals and objectives and failed to include interventions that address the resident's current needs related to his medical conditions.

Interview with the Director of Nursing on November 1, 2024, at 4:26 PM, confirmed the facility failed to sufficiently address the care and management of Resident B1 on the resident's baseline plan of care.

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

Plan of Correction - To be completed: 11/26/2024

The facility reviewed and revised Resident B1's Admission Baseline Care Plan.

DON/Designee will review resident care plans for those admitted in the past 30 days to ensure that a baseline care plan was initiated that meets the resident's current needs.

The ADON/designee will re-educate the licensed clinical staff and Interdisciplinary care plan team on the facility's baseline care plan policy.

The DON/designee will audit new admission charts for timely completion of a Baseline Care Plan that includes interventions to ensure it addresses the resident's current needs weekly x 4 weeks, then monthly x 3 months.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Observations:

Based on a review of select facility policy, and clinical records, and staff interview, it was determined the facility failed to thoroughly assess and evaluate bowel function and implement individualized approaches to restore normal bowel function to the extent possible for one out of 6 sampled residents (Resident A2).

Findings include:

A review of the facility policy for incontinence management reviewed September 30, 2024 revealed, the facility will assess residents for their continence status, potential contributing factors and if incontinent, provide interventions to attempt to maintain or attain their highest level of continence.

The procedure includes:
A resident's continence status will be assessed within 2 weeks of admission, routinely and upon significant change in continence status,

If a resident is incontinent, the type of continence will be determined if able,

Interventions and treatment will be provided to help residents restore or improve bowel and or bladder function and prevent urinary tract infections to the extent possible.

A review of the clinical record revealed that Resident A 2 was admitted to the facility on March 15, 2023, with diagnoses to include, dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and atrial fibrillation (an abnormal heartbeat).

A review of a significant change MDS, Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 31, 2024 indicated the resident was frequently incontinent of bowel.

A review of Resident A 2'S quarterly Minimum Data Set assessment dated August 12, 2024, revealed that the resident was always incontinent of bowel.

A review of the resident's plan of care dated August 23, 2024 revealed that the resident is incontinent of bowel at times.

The residents plan of care dated October 17, 2024 revealed that the resident is incontinent of bowel. Planned interventions to include, assist resident to toilet as needed and identify an incontinence pattern and establish a toileting plan accordingly.

A review of toileting records dated October 13, 2024 through November 1, 2024 (past 18 days) indicted the resident was noted to be continent on one of the days and incontinent of bowel on the remaining days.

The facility failed to initiate a three day bowel activity assessment in order to determine the resident's pattern of incontinence in response to the documented resident's decline in bowel function. Further, the facility failed to identify the resident's habits or patterns of incontinence to develop an individualized toileting plan to restore bowel function to the extent possible for the resident.

Interview with the Director of Nursing on November 1, 2024, at approximately 6:00 PM confirmed the facility failed to thoroughly assess the resident's bowel and bladder function to identify the resident's habits, patterns and develop a plan to meet the residents' toileting needs to decrease incontinence to the extent possible.

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

Plan of Correction - To be completed: 11/26/2024

Facility reviewed Resident A2 Bowel and Bladder Rehabilitation program. Resident will be re-evaluated and placed on the appropriate Bowel and Bladder program based on the results of his 3-day bowel and bladder diary.

Facility completed reassessment of all residents currently on a Bowel and Bladder Rehabilitation program, which included a 3-day Bowel and Bladder diary and initiation of an appropriate rehabilitation program of one or more of the following: bladder training, toilet plans, or prompted voiding. All new admissions will be evaluated utilizing the same process.

ADON/designee will provide education to clinical staff regarding the Bowel and Bladder Rehabilitation programs, the 3-day diary, the bowel and bladder assessments, and the required documentation of the bowel and bladder programs implemented.

DON or designee will audit current and newly initiated Bowel and Bladder Rehabilitation programs for accuracy and completion. These audits will be completed weekly x4 and then monthly x3. Results of these audits will be discussed at the monthly QAPI meeting for further review and recommendations.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Observations:

Based on review of clinical records and staff interview, it was determined the facility failed to implement pharmacy procedures for medication administration and documentation for two of six residents sampled (Resident A1 and Resident B1 ).

Finding include:

Clinical record review revealed that Resident A1 was admitted to the facility on October 7, 2024 with diagnosis to include, bilateral lower extremity wounds, sepsis (an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever) and was admitted to the facility with a PICC line (a peripherally inserted central catheter a long catheter introduced through a vein in the arm and passed through to the larger veins into the heart) for medication administration.

Physicians orders dated October 10, 2024 revealed, an order to administer Cefepime HCl (an intravenous antibiotic), 2 grams IV (intravenously) every 8 hours for bilateral lower extremity wounds with no completion date indicated.

A review of Resident A1's Medication Administration Record for October 2024 revealed on
October 24, 2024, at 10:00 PM, October 26, 2024, at 6:00 AM and 10:00 PM, October 27, 2024, at 10:00 PM and October 27, 2024, at 10:00 PM,the antibiotic was not documented as administered.

During an interview November 1, 2024, at 6:00 PM, the Director of Nursing confirmed that on the above noted dates, it could not be determined if the doses of the antibiotic medication were administered to the resident.

A review of Resident B1's clinical record revealed the resident was admitted to the facility on October 29, 2024, with a cutaneous abscess (cavity filled with puss) of the buttocks, colostomy, Fournier gangrene (a type of necrotizing fasciitis, a flesh-eating disease that affects the scrotum, penis, or perineum), diabetes, and a scrotal abscess.

A review of Resident B1's physician orders dated October 29, 2024, at 7:17 PM, revealed an order for Metronidazole (an antibiotic and antiprotozoal medication used to treat various bacterial and protozoal infections) Intravenous Solution 500 MG/100 ML, use 500 mg intravenously every six hours for abscess for seven days.

A review of the resident's Medication Administration Record (the report that serves as a legal record of the drugs administered to a resident at a facility by a health care professional) dated October 29, 2024, through survey ending November 1, 2024, revealed the scheduled 6:00 AM dose of the physician prescribed antibiotic, Metronidazole, was not recorded to indicate that the medication was administered.

An interview with the DON on November 1, 2024 at 4:26 PM confirmed that documented evidence could not be provided to verify the physician prescribed antibiotic was administer as ordered to resident B1.

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

28 Pa Code 211.9 (a)(1)(j.1)(4)(k) Pharmacy services.

483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities:

§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.70(e) and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.70(e). Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§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:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.

Observations:

Based on a review clinical record, facility provided documents, the facility's plan of correction from the surveys ending on August 9, 2024, and on September 6, 2024, and the outcome of the activities of the facility's quality assurance committee it was determined the facility failed to develop and implement a quality assurance plan, which was able to identify, and correct ongoing quality deficiencies related to the assessment and implementation of bowel and bladder programs for one of 6 residents sampled (Resident A2).

Findings included:

During survey ending August 9, 2024 deficient facility practice was identified related to the facility's failure to assess and implement a program to maintain or restore this same resident's bowel function.

The facility developed a plan of correction that included, "The bowel and bladder documentation will be assumed by the nursing staff. The documentation will be audited daily by the nursing supervisor to ensure completion. The nursing staff will be educated on the new process for managing the facility bowel and bladder program. The bowel and bladder programs will be audited weekly for 4 weeks and then monthly to ensure the deficient practice does not recur".

A review of the clinical record revealed that Resident A2 was admitted to the facility on March 15, 2023, with diagnoses to include, dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and atrial fibrillation (an abnormal heartbeat).

A review of Resident A 2's quarterly Minimum Data Set assessment dated August 12, 2024, revealed that the resident was always incontinent of bowel.

A review of the resident's plan of care dated August 23, 2024 revealed the resident is incontinent of bowel at times.

The residents plan of care dated October 17, 2024 revealed that the resident is incontinent of bowel. Planned interventions to include, assist resident to toilet as needed and identify an incontinence pattern and establish a toileting plan accordingly.

A review of toileting records dated October 13, 2024 through November 1, 2024 (past 18 days) indicted the resident was noted to be continent on one of the days and incontinent of bowel on the remaining days.

The facility failed to initiate a three day bowel activity assessment in order to determine the resident's pattern of incontinence in response to the documented resident's decline in bowel function. Further, the facility failed to identify the resident's habits or patterns of incontinence to develop an individualized toileting plan to restore bowel function to the extent possible for the resident.

The facility's QAPI committee failed to identify the facility's corrective action plan was not developed and/or implemented in a manner consistent with the regulatory guidelines for the deficiency cited, to ensure that solutions to the problem was sustained.

Cross refer F690

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

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

Plan of Correction - To be completed: 11/26/2024

The facility cannot retroactively correct the deficiency.

The facility will hold a focused QAPI committee meeting to ensure that the plan of correction put in place for the Bowel and Bladder program is assessed and is being implemented in a manner consistent with the regulatory guidelines.

The Regional Director of Nursing/designee will oversee the additional QAPI meeting and provide education on the facility's QAPI policy.

A QAPI sub-committee consisting of the Administrator, Director of Nursing, and Assistant Director of Nursing will meet twice weekly to evaluate the plan of correction for the Bowel and Bladder program and assess if it is being successfully implemented. The Administrator will audit to ensure that the meetings are taking place and that the plan of correction is progressing as expected to meet the date of compliance. Results of these audits will be discussed at the monthly QAPI meeting for further review and recommendations.

§ 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: 11/26/2024

The facility will provide staffing ratio based on July 1, 2024, regulation of one nurse per 10 residents on the day shift, one nurse aide per 11 residents during the evening shift, and one nurse aide per 15 residents during the night shift.

All facility residents have the potential to be affected by this practice.

The administrator, the nurse management team, and the nursing scheduler will be re-educated concerning CNA minimal staffing ratios and the appropriate response to unplanned variations in ratios.

Administrator/designee during weekday daily review of nursing schedules will audit to ensure Certified Nurse Aide ratios are maintained. Results of these audits will be discussed at the monthly QAPI meeting for further review and recommendations.

§ 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.

Observations:

Based on a review of nursing time schedules and the resident census and staff interview, it was determined the facility failed to ensure the minimum licensed practical nurse (LPN) staff to resident ratio was provided on the day, evening, and night shifts for 4 shifts out of 21 reviewed (October 25, 2024, October 26, 2024, October 28, 2024, and October 29, 2024).

Findings include:

A review of the facility's weekly staffing records, revealed that on the following dates the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:25 on the day shifts, 1:30 on the evening shift, and 1:40 on the night shift based on the facility's census.

Review of facility census data indicated that on October 25, 2024, the facility census was 87, which required 2.18 LPN's during night shift. Review of the nursing time schedules revealed 2.06 LPN's worked the night shift on October 25, 2024.

Review of facility census data indicated that on October 26, 2024, the facility census was 88, which required 2.20 LPN's during night shift. Review of the nursing time schedules revealed 1 LPN worked the night shift on October 26, 2024.

Review of facility census data indicated that on October 28, 2024, the facility census was 88, which required 3.52 LPN's during the day shift. Review of the nursing time schedules revealed 3.5 LPN's worked the day shift on October 28, 2024.

Review of facility census data indicated that on October 29, 2024, the facility census was 90, which required 2.25 LPN's during night shift. Review of the nursing time schedules revealed 2.16 LPN's worked the night shift on October 29, 2024.

During an interview on November 1, 2024, at approximately 6:00 PM, the Nursing Home Administrator confirmed the facility failed to provide minimum licensed practical nurse staffing ratios on the above shifts.

Plan of Correction - To be completed: 11/26/2024

The facility will provide staffing ratio of one Licensed Practical Nurse per 25 residents on day shift, one Licensed Practical Nurse to 30 residents on evening shift, and one Licensed Practical Nurse per 40 residents on overnight shift.

All facility residents have the potential to be affected by this practice.

The Administrator, the Nurse Management team, and the Nursing Scheduler will be re-educated concerning Licensed Practical Nurse minimal staffing ratios and the appropriate response to unplanned variations in ratios.

Administrator/designee during weekday daily review of nursing schedules will audit to ensure License Practical Nurse ratios are maintained. Results of these audits will be discussed at the monthly QAPI meeting for further review and recommendations.

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