Pennsylvania Department of Health
EDISON MANOR NURSING & REHAB CENTER
Patient Care Inspection Results

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EDISON MANOR NURSING & REHAB CENTER
Inspection Results For:

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EDISON MANOR NURSING & REHAB CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Follow-up Survey completed on March 28, 2024, it was determined that Edison Manor Nursing and Rehabilitation Center corrected the federal deficiencies cited during the survey ending January 17, 2024, under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities, however continued to be out of compliance under the requirements of the 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 the facility staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one Nurse Aide (NA) per 12 residents for the day shift for one of seven days reviewed (3/17/24); failed to ensure a minimum of one NA per 12 residents for the evening shifts for two of seven days reviewed (3/15/24 and 3/19/24); and failed to ensure a minimum of one NA per 20 residents for the overnight shift for four of seven days reviewed (3/14/24, 3/15/24, 3/16/24, and 3/17/24).

Findings include:

Review of facility staffing ratio information from 3/13/24 through 3/19/24, revealed the following NA staffing shortages for the day shift where the NA ratios were not met:

3/17/24census of 109 residents6.27 NAs worked and 9.08 were required

Review of facility staffing ratio information from 3/13/24 through 3/19/24, revealed the following NA staffing shortages for the evening shift where the NA ratios were not met:

3/15/24 census of 107 residents 6.87 NAs worked and 8.92 were required
3/19/24census of 105 residents8.70 NAs worked and 8.75 were required

Review of facility staffing ratio information from 3/13/24 through 3/19/24, revealed the following NA staffing shortages for the overnight shift where the NA ratios were not met:

3/14/24 census of 105 residents 4.71 NAs worked and 5.25 were required
3/15/24census of 107 residents4.20 NAs worked and 5.35 were required
3/16/24census of 106 residents4.90 NAs worked and 5.30 were required
3/17/24census of 109 residents4.70 NAs worked and 5.45 were required


During an interview on 3/28/24, at approximately 3:25 p.m. the Nursing Home Administrator confirmed the NA ratios were not met for the above dates and shifts.



 Plan of Correction - To be completed: 04/16/2024

No residents were found to be affected by this deficient practice.
All residents have the potential to be affected if the nursing assistant staffing ratio does not meet the requirement.
To prevent reoccurrence of not meeting the nursing assistant staffing ratio all open shifts will be reviewed by the Scheduler and the DON/Designee daily to ensure that the nursing assistant staffing ratio is met. Use of overtime and pick-up shift bonus will be offered as needed. Open positions will be advertised through external as well as internal sites and applications will be responded to promptly. The facility has contracted with several agencies to ensure open shifts are filled.
In order to monitor compliance, the projected two-week schedule will be reviewed to ensure the minimum nursing assistant staffing ratio is being met. Daily compliance (day before, current day and next day) will be audited daily by DON/ designee for two weeks, two times weekly for 2 weeks and once weekly x 2 weeks or until compliance is reached.
The results of the audits will be submitted to the QAPI committee for further review and recommendation.

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 review of nursing schedules, review of staffing information furnished by the facility, and staff interview, it was determined that the facility failed to ensure the total number of general nursing care hours provided in each 24-hour period be a minimum of 2.87 hours per patient day (PPD) of direct care for each resident for one of seven days reviewed (3/17/24).

Findings include:

Review of staffing information furnished by the facility for the time period 3/13/24 through 3/19/24, revealed the following days that did not meet the minimum of 2.87 PPD hours of direct care for each resident:

3/17/242.59 PPD

During an interview on 3/28/24, at approximately 3:25 p.m. the Nursing Home Administrator confirmed that the day listed above did not meet the minimum 2.87 hours PPD of direct care for each resident.



 Plan of Correction - To be completed: 04/16/2024

No residents were found to be affected by this deficient practice.
All residents have the potential to be affected if staffing PPDs do not meet the requirement.
To prevent reoccurrence of not meeting daily PPD requirements schedules all open shifts will be reviewed by the Scheduler and the DON/Designee daily to ensure that direct care staff scheduling meet PPD requirement. Use of overtime and pick-up shift bonus will be offered as needed. Open positions will be advertised through external as well as internal sites and applications will be responded to promptly. The facility has contracted with several agencies to ensure open shifts are filled.
In order to monitor compliance, the projected two-week schedule will be reviewed to ensure minimum staffing meets the required 2.87 PPD hours of direct care for each resident. Daily compliance (day before, current day and next day) will be audited daily by DON/ designee for two weeks, two times weekly for 2 weeks and once weekly x 2 weeks or till compliance is reached.
The results of the audits will be submitted to the QAPI committee for further review and recommendation.


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