Pennsylvania Department of Health
ROSE CITY NURSING AND REHAB AT LANCASTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ROSE CITY NURSING AND REHAB AT LANCASTER
Inspection Results For:

There are 242 surveys for this facility. Please select a date to view the survey results.

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ROSE CITY NURSING AND REHAB AT LANCASTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance Survey, and a Complaint Investigation completed on March 15, 2024 it was determined that Rose City Nursing and Rehabilitation at Lancaster was not in 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 Regulation as they relate to the Health portion of the survey process.
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Plan of Correction:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.

�483.60(i) Food safety requirements.
The facility must -

�483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

�483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

Based on review of facility policy, observations and interview with staff, it was determined that the facility failed to maintain appropriate temperatures during dishwashing.

Findings include:

Review of facility policy, "Dish Machine Temperatures (High Temperature Machines)", revised July 2023, indicated a minimum wash temperature of 150 degrees Fahrenheit and a minimum rinse temperature of 180 degrees Fahrenheit. Additionally, the policy revealed that "if the temperature does not reach the required minimum, DO NOT run any dishes through a wash/rinse cycle". If minimum temperatures are not reached, the Culinary & Nutrition Services Manager and/or the Administrator should be notified.

Observation on March 14, 2024, at 9:15 a.m. with the Food Service Director (FSD), revealed staff using the dish machine, but the gauges were not working on the dish machine. The FSD indicated that the gauges had stopped working the day before and staff had used the three compartment sink to wash dishes. The FSD was not sure if the dish machine was a high temperature machine (uses heated water for sanitation) or low temperature machine (uses chemicals for sanitizing). The FSD indicated that staff put a thermometer through the machine to obtain a temperature and had switched to using chemicals, but had no way to measure the concentration of the sanitizer.

Review of the Dish Machine Temperature Log for March 2024 revealed that the wash temperature did not reach 150 degrees Fahrenheit on 16 of 36 occasions.

Additional interview with the FSD on March 15, 2024, 9:30 a.m. confirmed that the minimum wash temperatures had not been reached. The FSD indicated that earlier in the month maintenance adjusted the water temperature when the temperatures were noted to be below the minimum. The repair company was called on March 13, 2024, and had been in to make repairs on March 14, 2024. The repair company was observed working on the machine at the time of the interview.

Interview with the Nursing Home Administrator on March 15, 2024, at 11:30 a.m. confirmed that the minimum dish machine temperatures had not been met.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1) Management
Previously cited 12/1/23

28 Pa Code 201.18(b)(3) Management

Plan of Correction - To be completed: 05/01/2024

1. Facility cannot retroactively correct the dishwasher temps. However, repairs were made to the dishwasher on March 13, 2024.
2. There are no other dishwashers and the current dishwasher was repaired.
3. The Food Service Director, or designee, will educate the dietary staff on proper dishwasher temperatures and what to do if the temperatures fall below minimum temperatures.
4. The Food Service Director, or designee, will perform dishwasher temperature audits twice a week for two weeks, then weekly for two weeks, then monthly for two months. Results of audits will be submitted to monthly QAPI meetings for review and recommendations.

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:

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.

�483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

�483.10(f)(6) The resident has a right to participate in family groups.

�483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.

Observations:

Based on a review of the minutes from Residents' Council meetings and grievances lodged with the facility and staff and resident interviews it was determined that the facility failed to demonstrate efforts to respond and resolve resident complaints raised at resident group meetings including those voiced by four Residents (Residents 20, 65, 57, and Resident 24).

Findings include:

Review of resident concern/Grievance log revealed there were no grievances recorded for the months of August 2023, September 2023, October 2023, November 2023, or December 2023.

During resident council meeting on March 13, 2024, 10:00 a.m. four residents (Residents 20, 65, 57, and Resident 24) all reported filing grievances during the months listed above.

Interview conducted with the facility's social worker (SW) on March 14, 2024, at 11:28 a.m. revealed social worker started working in the facility near the end of December 2023. SW reported the previous SW did not keep any copies or list of grievances for the months of August 2023, September 2023, October 2023, November 2023, or December 2023. The social worker stated he/she was unable to provide any evidence that grievances were investigated or resolved during the months noted above.

During an Interview with the Nursing Home Administrator (NHA) on March 15, 10:14 a.m. The NHA revealed the facility has gone through three social workers since May 2023. The NHA also reported that since the turnover rate in the social work department has been high that the investigations into resident grievances have "fallen through the cracks." The above information was discussed with the Administrator who confirmed the facility administration is unable to provide evidence the facility investigated resident grievances during the months noted above.

28 Pa. Code: 201.18(e)(4) Management

28 Pa. Code: 201.29(i) Resident Rights

28 Pa. Code: 211.12(d)(3) Nursing Services

Plan of Correction - To be completed: 05/01/2024

Facility cannot retroactively log grievances from August-December 2023
2. NHA, or designee, will request to attend resident council to be able to respond and resolve resident complaints.
3. Social Services Director, or designee, will educate facility staff on proper resident grievance process.
4. NHA, or designee, will perform audits on SSD grievance logs twice a week for two weeks, then weekly for two weeks, then monthly for two months to ensure SSD is capturing resident grievances and logging appropriately. Results of audits will be presented to monthly QAPI meetings for review and recommendations.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

�483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

�483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

�483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

�483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Observations:

Based on clinical record review, facility policy and procedure review, and staff interview it was determined the facility failed to monitor the nutritional status for three of nine residents reviewed. (Residents 53, 69, and Resident 87)

Findings Include:

Review of facility policy and procedure titled "Weight Assessment and Intervention", revised March 2019, revealed the nursing staff will measure the resident weight on admission then weekly for four weeks. If no weight concerns are noted at this point, weights will be monitored monthly thereafter or as per Dietitian or MD. Weights will be recorded in each individual's medical record. Any weight change of 5 pounds or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the Physician and Dietitian. The threshold for significant unplanned and undesired weight loss will be based on the following criteria. 1 month - 5% weight loss is significant, 3 months- 7.5% is significant, 6 months 10% is significant.

Review of Resident 53's weights revealed weights on February 4, 2024 of 244.8 pounds and a weight on March 4, 2024 of 213.3 pounds after returning to the facility after a hospital stay. This was a significant weight loss of 13.1% loss over one month.

Further review of Resident 53's weights revealed there was no weight to determine the accuracy of the readmission weight on March 4, 2024.

Review of the progress notes revealed a Dietary entry on March 11, 2024 at 3:56 p.m. revealed the resident triggered for a significant weight loss and requested a re-weight to verify the weight loss and would follow-up pending the new weight.

Review of Resident clinical record revealed Resident 53 was sent out tot the hospital again on March 11, 2024 and the facility was unable to obtain the re-weight.

Review of Resident 69's weights revealed a weight on December 2, 2023 of 132 pounds and a weight on January 2, 2024 of 125.2 pounds, a significant weight loss of 5.15%.

Further review of Resident 69's weights revealed there was no re-weight to determine accuracy and the next weight was obtained on January 24, 2024 of 122.6 pounds.

Review of Resident 69's progress notes revealed a Dietary entry dated January 6, 2024 stating weight 130 pounds within normal limits. Monthly weight is stable.

Further review of Resident 69's progress notes revealed a Dietary entry dated January 25, 2024 stating weight loss with a weight on January 12, 2024 of 97.8 pounds and the resident tube feeding rate was increased for added calories.

Review of Resident 69's weights revealed there was no weight obtained by the facility on January 12, 2024 and the most current weight was January 24, 2024 which was not addressed by the dietitian on January 25, 2024.

Review of Resident 87's clinical record revealed they were admitted to the facility on November 17, 2023 with a weight 128 pounds.

Further review of Resident 87's weights revealed the next weight obtained was December 2, 2023 of 118.6 pounds a significant weight loss of 7.34%.

Further review of Resident 87's weights revealed the next weight obtained was on February 1, 2024 after the resident had signed on to hospice services.

Review of Resident 87's admission Nutritional Risk Assessment completed November 17, 2023 noted the weight admission 128 pounds.

Further review of Resident 87's clinical record revealed there was no further documentation by the dietitian until January 3, 2024 which did not address the significant weight loss since admission and had no recommendations due to a hospice eval which the resident was not admitted to until January 11, 2024.

Interview with the Nursing Home Administrator and the Director of Nursing on March 15, 2024 at 11:45 a.m. confirmed the facility failed to obtain re-weights and admission weight per policy and there was a delay in interventions being developed by the clinical dietitian to maintain residents' weights.

28 Pa. Code 211.5(f) Clinical Records

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

28 Pa Code: 211.10(c) Resident care policies

Plan of Correction - To be completed: 05/01/2024

Facility cannot retroactively obtain missed reweights for residents 53, 69 and 87.
2. DON, or designee, will audit current residents to ensure weights and reweights are up to date and documented accordingly.
3. DON, or designee, will educate nursing staff on weight and reweight policy of current residents and new admissions.
Dietician, or designee, will review weights/reweights to ensure appropriate interventions are in place for all residents.
4. NHA, or designee, will audit weights/reweights on current residents and new admissions twice a week for two weeks, then weekly for two weeks, then monthly for two months.
NHA, or designee, will audit Dietician responses to our residents weights/reweights to ensure appropriate interventions being implemented. Results of audits will be submitted to monthly QAPI meetings for review and recommendations.

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

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.

�483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

�483.12(a) The facility must-

�483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Observations:

Based upon clinical record review and review of facility documentation, it was determined the facility failed to protect a resident from abuse for one of 24 residents reviewed (Resident 91).

Findings include:

Review of Resident 91's diagnosis list revealed diagnoses including Dysphagia (inability/difficulty swallowing) and protein calorie malnutrition. Resident 91 expired on December 18, 2023, on hospice services.

Review of Resident 91's clinical record revealed multiple occasions between November 2023 and December 2023, when a family member was observed forcefully feeding Resident 91 and causing the resident to cough and choke.

Further review of the clinical record revealed staff members attempting to educate the family member, but the family member continued to provide the resident foods that were not on the resident's appropriate diet per physician's order.

Further review of the clinical record revealed an incident that occurred on December 11, 2023, which prompted the facility to halt visitation by the family member.

Review of Resident 91's progress notes dated December 11, 2023, and December 12, 2023, revealed the family member was continually force feeding the resident inappropriate food items and ultimately had to be physically removed from the premises by the local police department.

Interview with the Nursing Home Administrator and Director of Nursing on March 15, 2024, revealed that between November 2023 and December 11, 2023, no attempts were made to stop Resident 91's family member from feeding Resident 91 inappropriate food items. Multiple incidents occurred and were only met with re-education. The family member was continually permitted to visit Resident 91 and attempt to feed Resident 91 inappropriate items which was witnessed by multiple staff members.

The facility failed to protect Resident 91 from abuse by a family member.

28 Pa. Code 201.18(a)(b)(1)(2) Management

Plan of Correction - To be completed: 05/01/2024

Facility reported incident on 03/18/2024. ERS # 994862.
2. NHA, or designee, will audit current residents to ensure that no resident feels abused or neglected.
3. DON, or designee, will review and educate nurses regarding abuse policy to include potential abuse from staff, visitors, and family members.
4. NHA, or designee, will audit 24 hour notes to ensure there is no potential abuse documented. NHA, or designee, will perform audits 3 times per week for two weeks, then weekly for two weeks, then monthly for two months. Results of audits will be presented to monthly QAPI meetings for review and recommendations.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

�483.21(b) Comprehensive Care Plans
�483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations:

Based on clinical record review and staff interview it was determined the facility failed to review and revise the resident care plan quarterly for one of 24 residents reviewed. (Resident 53)

Findings Include:

Review of Resident 53's care plan revealed a target date of December 29, 2023.

Review of Resident 53's clinical record revealed no documented evidence of a care plan conference in the past year.

Interview with Social Worker E3 on December 15, 2024 at 11:30 a.m. confirmed Resident 53 has not had a care plan conference in the past year and the care plan was out of date.

28 Pa. Code 211.5(f) Clinical Records

28 Pa. Code 211.11(d) Resident Care Plan

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

Plan of Correction - To be completed: 05/01/2024

1. Resident 53 care plan target date revised to 03-29-2024. Resident 53 did have care plan conferences on 11/02/2022, 11//23/2022, and 03/13/2023 of the previous year.
2. Current residents will be audited to ensure that care conference target dates are up to date.
3. NHA, or designee, educated Social Service Director regarding updating next review/target date after resident care conferences; and completing detailed interdisciplinary progress note of attendees and content of conference.
4. NHA, or designee, will perform audits twice a week for two weeks, then weekly for two weeks, then monthly for two months to ensure care conferences are completed by target date and new target date entered correctly. Results of audits will be submitted to monthly QAPI meetings for review and recommendations.

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

�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 review of the Pennsylvania Professional Nursing Practice Act, facility policy and procedure review, observations and staff interview it was determined the facility failed to ensure staff met the professional standards for a Registered nurse during medications administration for one of three residents reviewed. (Resident 69)

Findings Include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and on going data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carrying out nursing care actions that promote, maintain and restore the well-being of individuals.

Review of facility policy and procedure titled Medication Administration- General Guidelines, undated, revealed medications are administered at the time they are prepared. Medications are not pre-poured.

Observations of medication administration on March 15, 2024 at 8:45 a.m. revealed Registered Nursing Employee E4 administering medications to a resident. This surveyor asked employee E4 if they were administering medications and would like to observe. Employee E4 stated they were going to administer medications to Resident 69 but had already prepared the medications because they needed to dissolve, Employee E4 then pulled a medications cup half filled with an orange liquid and dissolved medications inside that was unlabeled and uncovered. The surveyor stated that they needed to see medications administration from the beginning of preparation. Employee E4 then placed the medications cup back into the medications cart and proceeded to administer medications to two other residents before administering the pre-poured medications to Resident 69.

Interview with the Director of Nursing and the Nursing Home Administer on March 15, 2023 at 11:45 a.m. confirmed Licensed Nursing Employee E4 had no followed professional standards by not administering medications at the time it was prepared.

28 Pa. 211.10(c) Resident care policies

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

Plan of Correction - To be completed: 05/01/2024

1. Facility cannot retroactively correct the medication administration of pre-poured medications to resident 69.
2. DON, or designee, will perform random observations of medication administration to ensure that medications are not being pre-poured.
3. DON, or designee, educated employee E4. Employee E4 performed medication administration competencies
DON, or designee, will re-educate licensed staff on medication administration policies and complete random medication administration competencies.
4. NHA, or designee, will perform audits on DON's medication administration competencies twice a week for two weeks, then weekly for two weeks, then monthly for two months. Results of audits will be submitted to monthly QAPI meetings for review and recommendations.

483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More:

�483.45(f) Medication Errors.
The facility must ensure that its-

�483.45(f)(1) Medication error rates are not 5 percent or greater;

Observations:

Based on observations, staff interview, clinical record review and facility policy and procedure review it was determined the facility failed to administer medications accurately to one of three residents reviewed resulting in a medications administration error rate of 25%. (Resident 70)

Findings Include:

Review of Facility policy and procedure titled "Enteral Tube Medications Administration" undated, revealed crushed medications are not mixed together. The powder from each medication is mixed with water, or other suitable dilutant if water is unacceptable, before administration. Each medication is administered separately to avoid interaction and clumping.

Review of Resident 70's diagnosis list revealed a diagnosis of Gastrostomy (gastrostomy is the creation of an artificial external opening into the stomach for nutritional support).

Review of resident 70's physician orders revealed an order dated January 5, 2023 stating may crush meds and administer per PEG (feeding tube).

Observations of medications administration on March 15, 2024 at 8:45 a.m. revealed Registered Nursing Employee E4 preparing the following medications for Resident 70: midodrine 10mg (milligram) (increased blood pressure), Eliquis 5mg (blood thinner), glycopyrrolate 1mg (decreases drooling), Multivitamin, Senna plus 8.6-50mg (stool softener), Iron Sulfate 325mg (supplement), and Phos-Nak Packet (supplement). All the medications were crushed together and placed in a medication cup except for the Phos-Nak Packet which was poured into the same medication cup. The medication was then dissolved in approximately 15 milliliters of water in the medication cup. A piston syringe was attached to the residents PEG tube and flushed with 30 milliliters of water followed by the liquid containing all the medications then another 30 milliliters of water flushed through the tube.

Interview with the Director of Nursing and the Nursing Home Administrator on March 15, 2024 at 11:45 a.m. confirmed the medications were administered incorrectly per policy.

28 Pa. Code 211.10(c) Resident care policies

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

Plan of Correction - To be completed: 05/01/2024

1. Facility cannot retroactively correct the medication administration for resident 70.
2. DON will perform random audits of current residents utilizing a PEG tube for medication administration to ensure that medications are prepared separately and flushed between each medication administration
3. DON, or designee, educated employee E4 on proper procedure for administering medications via PEG tube.
DON, or designee, will educate licensed nursing staff on proper procedure for administering medications via PEG tube.
4. DON, or designee, will perform audits of licensed staff for administering medications via PEG twice a week for two weeks, then weekly for two weeks, then monthly for two months. Results of audits will be submitted to monthly QAPI meetings for review and recommendations.

483.65(a)(1)(2) REQUIREMENT Provide/Obtain Specialized Rehab Services:

�483.65 Specialized rehabilitative services.
�483.65(a) Provision of services.
If specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability or services of a lesser intensity as set forth at �483.120(c), are required in the resident's comprehensive plan of care, the facility must-

�483.65(a)(1) Provide the required services; or

�483.65(a)(2) In accordance with �483.70(g), obtain the required services from an outside resource that is a provider of specialized rehabilitative services and is not excluded from participating in any federal or state health care programs pursuant to section 1128 and 1156 of the Act.

Observations:

Based upon clinical record review, it was determined the facility failed to ensure a Speech Therapy Evaluation was completed as ordered for one of 24 residents reviewed (Resident 91).

Findings include:

Review of Resident 91's diagnosis list revealed diagnoses including Dysphagia (inability/difficulty swallowing) and protein calorie malnutrition.

Review of Resident 91's physician's orders dated November 21, 2023 revealed an order for a speech evaluation and treatment.

Review of Resident 91's clinical record revealed Resident 91 expired on December 18, 2023.

Review of Resident 91's clinical record failed to reveal evidence that a Speech Evaluation was completed.

Interview with the Nursing Home Administrator and Director of Nursing on March 15, 2023 at 11:00 a.m. confirmed a speech evaluation was never completed for Resident 91 as per physician's order.

28 Pa. Code: 201.18(e)(4) Management

28 Pa. Code: 211.12(d)(3) Nursing Services

Plan of Correction - To be completed: 05/01/2024

1. Resident 91 ceased to breathe on December 18, 2023
2. NHA, or designee, will audit current resident to ensure ST orders completed as ordered.
3. NHA, or designee, will educate the Director of Rehab regarding the need to follow through with orders obtained for Speech therapy in a timely manner.
4. NHA, or designee, will perform audits of therapy orders to ensure therapy department follows through with evaluations of orders. Audits will be performed twice a week for two weeks, then weekly for two weeks, then monthly for two months. Results of audits will be submitted to monthly QAPI meetings for review and recommendations.

� 211.12(f.1)(2) LICENSURE Nursing services. :

(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 facility staffing data, it was determined that the facility failed to ensure a minimum of one nurse aide per 20 residents on evening and day shifts for 14 of fourteen days of facility staffing reviewed.

Findings Include:

Review of the staffing for the days of February 26, 2024 through March 10, 2024, revealed the facility did not meet the minimum staffing ratios for one nurse aide for every 20 residents on the following days and shifts.

February 27, 2024 on evening shift
March 1, 2024 on evening shift
March 2 on evening shift
March 4, 2024 on day and evening shift
March 7 on evening shift
March 10, 2024 on day shift

Interview with the Nursing Home Administrator on March 15, 2024 at 11:45 a.m. confirmed that the aide staffing ratios were not met on the above days and shifts.

Plan of Correction - To be completed: 05/01/2024

1. Facility cannot retroactively correct staffing schedule to meet required CNA ratios for 2/27/24 evening shift, 03/01/24 for evening shift, 03/02/24 for evening shift, 03/04/24 for day or evening shift, 03/07 for evening shift, or 03/10/24 for day shift.
2. NHA, DON, and staffing scheduler have weekday meetings to ensure CNA staffing ratios are above minimum requirement of 1:12 for day and evening shifts and 1:20 for night shifts
3. NHA, or designee, will educate DON and nursing scheduler on CNA staff ratio requirements.
4. NHA, or designee, will perform audits of CNA ratios twice a week for two weeks, then weekly for two weeks, then monthly for two months. Results will be submitted to monthly QAPI meetings for review and recommendations.

� 211.12(i)(1) LICENSURE Nursing services.:

(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 facility staffing data, 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) for one day of two weeks reviewed (February 26-March 10 2024).

Findings include:

Review of the staffing sheets revealed the on March 4, 2024 the facility only had a PPD of 2.70.

The facility staffing PPD being below state minimum standard were confirmed by the Nursing Home Administrator on March 15, 2024 at 11:45 a.m.

Plan of Correction - To be completed: 05/01/2024

1. Facility cannot retroactively correct staffing schedule to meet required PPD hours for March 4 2024.
2. NHA, DON, and staffing scheduler have weekday meetings to ensure daily PPD hours are above minimum requirement of 2.87
3. NHA, or designee, will educate DON and nursing scheduler on daily PPD requirements.
4. NHA, or designee, will perform audits of daily PPD requirements to ensure facility meets 2.87 hours. Audits will be performed twice a week for two weeks, then weekly for two weeks, then monthly for two months. Results will be submitted to monthly QAPI meetings for review and recommendations.

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