Pennsylvania Department of Health
GREENWOOD CENTER FOR NURSING AND REHAB
Patient Care Inspection Results

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GREENWOOD CENTER FOR NURSING AND REHAB
Inspection Results For:

There are  162 surveys for this facility. Please select a date to view the survey results.

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GREENWOOD CENTER FOR NURSING AND REHAB - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Complaint Investigation completed on January 2, 2025, at Greenwood Center for Nursing and Rehabiitation, it was determined that there were no federal deficiencies, related to the Health portion of the survey process, identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care as they relate to the Health portion of the survey process; however, the facility was not in compliance with 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 a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 8 shifts out of 24 reviewed.

Findings include:

Review of the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, Nursing Services, dated July 1, 2023, indicated the following subsections.

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse aide staff of 1:12 on the day and evening shifts and 1:20 on the night shift based on the facility's census per the regulation that was effective July 1, 2023.

October 9, 2024 - 3.03 nurse aides on the evening shift, versus the required 7.83 for a census of 94.
October 11, 2024 - 7.03 nurse aide on the evening shift, versus the required 7.92 for a census of 95.
October 11, 2024 - 4.38 nurse aides on the night shift, versus the required 4.75 for a census of 95.
October 13, 2024 - 7.03 nurse aide on the day shift, versus the required 7.92 for a census of 95.
October 13, 2024 - 7.41 nurse aides on the evening shift, versus the required 7.83 for a census of 94.
October 14, 2024 - 7.34 nurse aides on the day shift, versus the required 7.83 for a census of 94.
October 14, 2024 - 4.38 nurse aides on the night shift, versus the required 4.65 for a census of 94.
October 15, 2024 - 7.19 nurse aides on the evening shift, versus the required 7.75 for a census of 35.

On the above dates mentioned no additional excess higher-level staff were available to compensate this deficiency.

An interview with the Nursing Home Administrator on October 16, 2024, at approximately 2:15 PM, confirmed the facility had not met the required nurse aide to resident ratios on the above dates.


 Plan of Correction - To be completed: 11/20/2024

1. Facility cannot retroactively correct past nursing ratios.
2. Facility continues to recruit for open nursing positions through online systems and fliers and utilize agency staff.
3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the
necessary ratios. Nursing scheduler was educated on this new process.
4. NHA will audit ratios weekly for 4 weeks and then monthly for 2 months to ensure CNA ratios are
met.
5. Audits will be submitted to QAPI for review.

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

Observations:

Based on review of nursing time schedules and staff interviews, it was determined the facility failed to provide a minimum of one nurse aide per 10 residents during the dayshift, one nurse aide per 11 residents during the evening and one nurse aide per 15 residents during the night shift on 7 of 7 days reviewed (October 9, 2024, October 10, 2024, October 11, 2024, October 12, 2024, October 13, 2024, October 14, 2024, October 15, 2024).

Findings include:

Review of the facility census data indicated that on October 9, 2024, the facility census was 94, which required 9.4 nurse aides during the day shift.

Review of the nursing time schedules and time punch documentation revealed 8 nurse aides provided care on the day shift on October 9, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on October 9, 2024, the facility census was 94, which required 8.55 nurse aides during the evening shift.

Review of the nursing time schedules and time punch documentation revealed 8.13 nurse aides provided care on the evening shift on October 9, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on October 10, 2024, the facility census was 94, which required 9.4 nurse aides during the day shift.

Review of the nursing time schedules and time punch documentation revealed 8.13 nurse aides provided care on the day shift on October 10, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on October 10, 2024, the facility census was 94, which required 8.55 nurse aides during the evening shift.

Review of the nursing time schedules and time punch documentation revealed 8.13 nurse aides provided care on the evening shift on October 10, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on October 10, 2024, the facility census was 94, which required 6.27 nurse aides during the night shift.

Review of the nursing time schedules and time punch documentation revealed 6 nurse aides provided care on the night shift on October 10, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on October 11, 2024, the facility census was 94, which required 9.4 nurse aides during the day shift.

Review of the nursing time schedules and time punch documentation revealed 8.13 nurse aides provided care on the day shift on October 11, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on October 11, 2024, the facility census was 95, which required 8.64 nurse aides during the evening shift.

Review of the nursing time schedules and time punch documentation revealed 7.03 nurse aides provided care on the evening shift on October 11, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on October 11, 2024, the facility census was 95, which required 6.33 nurse aides during the night shift.

Review of the nursing time schedules and time punch documentation revealed 4.38 nurse aides provided care on the night shift on October 11, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on October 12, 2024, the facility census was 95, which required 9.5 nurse aides during the day shift.

Review of the nursing time schedules and time punch documentation revealed 8.53 nurse aides provided care on the day shift on October 12, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on October 12, 2024, the facility census was 95, which required 8.64 nurse aides during the evening shift.

Review of the nursing time schedules and time punch documentation revealed 8.53 nurse aides provided care on the evening shift on October 12, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on October 12, 2024, the facility census was 95, which required 6.33 nurse aides during the night shift.

Review of the nursing time schedules and time punch documentation revealed 6.03 nurse aides provided care on the night shift on October 12, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on October 13, 2024, the facility census was 95, which required 5.07 nurse aides during the day shift.

Review of the nursing time schedules and time punch documentation revealed 7.03 nurse aides provided care on the day shift on October 13, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on October 13, 2024, the facility census was 95, which required 8.55 nurse aides during the evening shift.

Review of the nursing time schedules and time punch documentation revealed 7.4 nurse aides provided care on the evening shift on October 13, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on October 14, 2024, the facility census was 94, which required 9.4 nurse aides during the day shift.

Review of the nursing time schedules and time punch documentation revealed 7.34 nurse aides provided care on the day shift on October 14, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on October 14, 2024, the facility census was 93, which required 8.45 nurse aides during the evening shift.

Review of the nursing time schedules and time punch documentation revealed 7.78 nurse aides provided care on the evening shift on October 14, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on October 14, 2024, the facility census was 93, which required 6.20 nurse aides during the night shift.

Review of the nursing time schedules and time punch documentation revealed 4.38 nurse aides provided care on the night shift on October 14, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on October 15, 2024, the facility census was 93, which required 9.3 nurse aides during the day shift.

Review of the nursing time schedules and time punch documentation revealed 8.97 nurse aides provided care on the day shift on October 14, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on October 14, 2024, the facility census was 93, which required 8.45 nurse aides during the evening shift.

Review of the nursing time schedules and time punch documentation revealed 7.19 nurse aides provided care on the evening shift on October 14, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on October 14, 2024, the facility census was 93, which required 6.20 nurse aides during the night shift.

Review of the nursing time schedules and time punch documentation revealed 5.81 nurse aides provided care on the night shift on October 14, 2024. No additional excess higher-level staff were available to compensate this deficiency.

During an interview conducted on October 16, 2024, at 2:00 PM, the Nursing Home Administrator confirmed the facility did not meet minimum staffing ratios for nurse aides on the above date.


 Plan of Correction - To be completed: 11/20/2024

1. Facility cannot retroactively correct past nursing hours.
2. Facility continues to recruit for open nursing positions through online systems and fliers and utilizing agency staff.
3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the
necessary nursing hours. Nursing scheduler was educated on this new process.
4. NHA will audit nursing hours weekly for 4 weeks and then monthly for 2 months to ensure CNA
Nursing hours are met.
5. Audits will be submitted to QAPI for review


§ 211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:

Based on a review of nurse staffing and resident census and staff interview, it was determined that the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Findings include:

Review of the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, Nursing Services, dated July 1, 2023, indicated the following subsections.
(i) A minimum number of general nursing care hours shall be provided for each 24-hour period as follows:
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

A review of the facility's staffing levels revealed that on the following dates the facility failed to provide minimum nurse staffing of 2.87 hours of general nursing care to each resident per the regulation effective July 1, 2023:

October 9, 2024 -2.39 direct care nursing hours per resident.
October 11, 2024 -2.64 direct care nursing hours per resident.
October 12, 2024 -2.86 direct care nursing hours per resident.
October 13, 2024 -2.71 direct care nursing hours per resident.
October 14, 2024 -2.74 direct care nursing hours per resident.

The facility's general nursing hours were below minimum required levels on the dates noted above.

An interview with the Director of Nursing on October 16, 2024, at approximately 2:15 PM confirmed the facility failed to consistently provide minimum general nursing care hours to each resident daily.


 Plan of Correction - To be completed: 11/20/2024

1. Facility cannot retroactively correct past nursing hours.
2. Facility continues to recruit for open nursing positions through online systems and fliers and utilizing agency staff.
3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the
necessary nursing hours. Nursing scheduler was educated on this new process.
4. NHA will audit nursing hours weekly for 4 weeks and then monthly for 2 months to ensure CNA
Nursing hours are met.
5. Audits will be submitted to QAPI for review

§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on a review of nurse staffing and resident census and staff interview, it was determined that the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Findings include:

A review of the facility's weekly staffing records October 9, 2024, through October 15, 2024, revealed that on the following dates the facility failed to provide minimum nurse staffing of 3.20 hours of general nursing care to each resident:

October 9, 2024 - 2.39 direct care nursing hours per resident
October 10, 2024 - 3.09 direct care nursing hours per resident
October 11, 2024 - 2.64 direct care nursing hours per resident October 12, 2024 - 2.86 direct care nursing hours per resident October 13, 2024 - 2.71 direct care nursing hours per resident October 14, 2024 - 2.74 direct care nursing hours per resident October 15, 2024 - 3.01 direct care nursing hours per resident
The facility's general nursing hours were below minimum required levels on the dates noted above.

During an interview on October 16, 2024, at approximately 2:05 PM with the Nursing Home Administrator (NHA) confirmed the facility failed to consistently provide minimum general nursing care hours to each resident daily.



 Plan of Correction - To be completed: 11/20/2024

1. Facility cannot retroactively correct past nursing hours.
2. Facility continues to recruit for open nursing positions through online systems and fliers and utilizing agency staff.
3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the
necessary nursing hours. Nursing scheduler was educated on this new process.
4. NHA will audit nursing hours weekly for 4 weeks and then monthly for 2 months to ensure CNA
Nursing hours are met.
5. Audits will be submitted to QAPI for review


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