Pennsylvania Department of Health
COMPLETE CARE AT BERKSHIRE LLC
Patient Care Inspection Results

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COMPLETE CARE AT BERKSHIRE LLC
Inspection Results For:

There are  80 surveys for this facility. Please select a date to view the survey results.

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COMPLETE CARE AT BERKSHIRE LLC - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated survey in response to a complaint completed on April 8, 2024, at Complete Care at Berkshire, it was determined that there were no federal deficiences identified under the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care; however, the facility was not in compliance with 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 a review of nursing time schedules and staff interview, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for five of 22 days reviewed.

Findings include:

Review of nursing schedules for 22 days from March 17, 2024, to April 7, 2024, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for 12 residents on day shift (7:00 a.m. to 3:00 p.m.) on March 17, 29, and 31, 2024.

The facility failed to meet the minimum NA to resident ratio of one NA for 12 residents on evening shift (3:00 p.m. to 11:00 p.m.) on April 5, 2024.

The facility failed to meet the minimum NA to resident ratio of one NA for 20 residents on night shift (11:00 p.m. to 7:00 a.m.) on April 2, 2024.

During an interview on April 8, 2024, at 2:45 p.m., the Nursing Home Administrator confirmed that the facility did not meet the minimum required nursing staff to resident ratios on the days identified.


 Plan of Correction - To be completed: 05/10/2024

Staffing Manager or designee will staff the daily nursing staff to meet the minimum ratios of 1 CNA per 12 residents during 7AM-3PM shift, 1 CNA per 12 residents 3PM-11PM shift, and 1 CNA per 20 residents during 11PM-7AM shifts.

Nursing staff ratio audits will be conducted by DON or designee daily as well as running the actual hours worked report from timeclock software.

Reports will be reviewed at monthly QAPI meetings.

211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:
Based on a review of nursing time schedules and staff interview, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for six of 22 days reviewed.

Findings include:

Review of nursing schedules for 22 days from March 17, 2024, to April 7, 2024, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on night shift (11:00 p.m. to 7:00 a.m.) on March 22, 25, 2024, and April 1, 2, 3, 5, 2024.

During an interview on April 8, 2024, at 2:45 p.m., the Nursing Home Administrator confirmed that the facility did not meet the minimum required nursing staff to resident ratios on the days identified.


 Plan of Correction - To be completed: 05/10/2024

Staffing Manager or designee will staff the daily nursing staff to meet the minimum ratios of 1 LPN per 25 residents during 7AM-3PM shift, 1 LPN per 30 residents 3PM-11PM shift, and 1 LPN per 40 residents during 11PM-7AM shifts.

Nursing staff ratio audits will be conducted by DON or designee daily as well as running the actual hours worked report from timeclock software.

Reports will be reviewed at monthly QAPI meetings.

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 nursing time schedules and staff interview, it was determined that the facility failed to provide a minimum of 2.87 hours of direct care for each resident for six of 22 days reviewed.

Findings include:

Review of nursing schedules for 22 days from March 17, 2024, to April 7, 2024, revealed the following total nursing care hours below minimum requirements:

Friday, March 22, 2024, 2.76 care hours per resident
Monday, March 25, 2024, 2.79 care hours per resident
Sunday, March 31, 2024, 2.61 care hours per resident
Thursday, April 4, 2024, 2.75 care hours per resident
Friday, April 5, 2024, 2.86 care hours per resident
Sunday, April 7, 2024, 2.83 care hours per resident

During an interview on April 8, 2024, at 2:45 p.m., the Nursing Home Administrator confirmed that the facility did not meet the minimum required nursing care hours.


 Plan of Correction - To be completed: 05/10/2024

Staffing Manager or designee will staff the daily nursing staff to meet the minimum nursing staff to resident ratios and maintain a minimum of 2.87 hours of direct care for each resident.

Nursing staff ratio audits will be conducted by DON or designee daily as well as running the actual hours worked report from timeclock software.

Reports will be reviewed at monthly QAPI meetings.


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