Pennsylvania Department of Health
GROVE AT LATROBE, THE
Patient Care Inspection Results

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GROVE AT LATROBE, THE
Inspection Results For:

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GROVE AT LATROBE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a complaint survey completed on March 19, 2024, it was determined that The Grove at Latrobe was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.60(a)(3)(b) REQUIREMENT Sufficient Dietary Support Personnel: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(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e).

483.60(a)(3) Support staff.
The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

483.60(b) A member of the Food and Nutrition Services staff must participate on the interdisciplinary team as required in 483.21(b)(2)(ii).
Observations:


Based on resident and staff interviews and dietary schedules, it was determined that the facility failed to have sufficient dietary staff to perform essential kitchen duties.

Findings include:

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated February 15, 2024, revealed that the resident was cognitively intact, was understood, could understand, and was independent with eating after set up.

Interview with Resident 9 on March 19, 2024, at 10:52 a.m. revealed that the meals are served on styrofoam, mainly on the weekends, and he prefers to eat in his room.

A dietary schedule indicated that meals were served on styrofoam on February 25, 2024, with management's permission.

Interview with Dietary Staff 2 on March 19, 2024, at 12:07 p.m. revealed that meals are served on styrofoam when there is approval from management.

Interview with the Dietitian on March 19, 2024, at 12:07 and 12:39 p.m. confirmed that the main entrees were served on styrofoam plates due to low staffing in the kitchen; there was not enough time to wash all of the dishes. The Dietitian indicated that the facility did not have a dietary manager at this time and that she has been overseeing the kitchen until the position is filled.

28 Pa. Code 211.6(c) Dietary Services.







 Plan of Correction - To be completed: 04/19/2024

Dietary schedules/hours have been adjusted to include dietary aides through 8:00 PM and dietary cook through 7:30 PM to allow enough time to do dishes. Employee job postings have been posted and signed by 2 employees per union contract.
Dietary staff have been educated regarding staffing and hour changes.
Dietician/Designee will complete audit 3 times per week for 2 weeks then weekly for 2 weeks to ensure sufficient dietary staff is available to perform dietary duties.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:


Based on review of facility policies and observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items at palatable temperatures.

Findings include:

A facility policy regarding food temperature recordings, dated January 3, 2024, indicated that all hot food will be held at 135 Fahrenheit (F) and cold foods will be held at 41 F or below. Food will be served at a preferable temperature for the resident, as hot foods were to be served hot and cold food were served cold and in accordance with the resident preference.

Observations of the lunch meal service in the main kitchen on March 19, 2024, revealed that the West Wing cart containing a test tray left the main kitchen at 12:19 p.m. and arrived on West Wing at 12:21 p.m. Trays were passed to the residents that were in their rooms. The last resident was served at 12:32 p.m. The test tray was removed from the cart at 12:33 p.m. and the temperature of the iced tea was 46 degrees F, the mixed fruit was 47 degrees F, the coffee was 144 degrees F, the peas and carrots were 131 degrees F, the mashed potatoes and gravy was 114 degrees F, and the meatloaf with gravy was 125 degrees F. The mashed potatoes with gravy and the meatloaf with gravy were lukewarm and not at a palatable or appetizing temperature.

Interview with the Dietitian on March 19, 2024, at 12:39 p.m. confirmed that the food should have been served at the required temperatures and in accordance with the resident preferences.

28 Pa. Code 211.6(b) Dietary Services.


 Plan of Correction - To be completed: 04/19/2024

Dietician/Designee will educate dietary staff on use of hot pallets for meals.
Hot pallets will be used under meal plates to assist in keeping foods at proper temperature.
Additional insulated food cart has been ordered. Additional dinnerware (bowls, cups, silverware) has been ordered.
Dietician/Designee to audit food temperatures through test trays daily for 2 weeks, then every other week.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

483.10(i)(3) Clean bed and bath linens that are in good condition;

483.10(i)(4) Private closet space in each resident room, as specified in 483.90 (e)(2)(iv);

483.10(i)(5) Adequate and comfortable lighting levels in all areas;

483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and

483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:


Based on clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to provide a safe, clean and homelike environment in residents' shared shower rooms (East and West).

Findings include:

The facility's policy regarding Resident Environment, dated January 3, 2024, revealed that the facility will provide an environment that is safe, clean, comfortable and homelike, while allowing the residents to use their personal belongings to the extent possible.

The facility's infection control policy concerning cleaning and disinfecting, dated January 3, 2024, revealed that cleaning and disinfecting of resident care items and environment will be conducted based on risk of infection involved. Staff were to clean all foreign materials such as blood, feces, dust, or dirt from a surface before disinfecting. Cleaning environmental surfaces such as floors, walls, and furniture should be done according to the schedule and as needed.

Observations on March 19, 2024, at 10:17 a.m. and 2:48 p.m. in the East Hall shared shower room revealed a large area of a black, removable substance on the tile grout in the shower from the floor to approximately one and one-half feet up the wall.

Observations on March 19, 2024, at 10:21 a.m. and 2:52 p.m. of the West Hall revealed a strong odor of sewage in the West Hall shower room (near room one).

Interview with Nurse Aide 1 on March 19, 2024, at 10:44 a.m. confirmed that there was a sewage odor in the West shower room and that it has been there for a very long time. The West shower drain has had plumbing issues and back ups.

Interview with the Nursing Home Administrator on March 19, 2024, at 2:48, 2:52 and 4:02 p.m. during a tour of the shower rooms confirmed that there was an area of a black, removable substance on the tile grout in a shower in the East Hall shower room that should have been cleaned, and confirmed that there was an odor of sewage in the West Hall shower room. The Nursing Home Administrator also stated that the facility has contacted plumbing services, but they have not yet been in the building. There was no documented evidence of any communications to contract plumbing services provided to the survey team.

28 Pa. Code 201.18(e) Management.

28 Pa. Code 201.24(e)(4) Admission Policy.







 Plan of Correction - To be completed: 04/19/2024

Facility will provide a clean and homelike environment within the facility.
Concerns identified in the East Hall Shower Room has been addressed and the removable substance has been removed.
Concerns of a strong odor of sewage in the West Hall shower room has been addressed. Heating, Ventilation, and Air Conditioning (HVAC) has been onsite and drains are in the process of being fixed.
Nursing staff to clean shower rooms after each resident use and as needed for soilage. Environmental Service staff to clean shower rooms daily and as needed for soilage.
Nursing Home Administrator (NHA)/Designee will educate staff on providing a clean and homelike environment. Staff will be educated on reporting environmental concerns through the facility's electronic work order system.
NHA/Designee complete audits of shower rooms to ensure a clean and homelike environment is maintained 3 days a week for 2 weeks then weekly for 2 weeks.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:


Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to develop and implement an ongoing infection prevention and control program in two shower rooms (East and West Hall) that are shared by residents.

Findings include:

The facility's infection control policy regarding cleaning and disinfecting, dated January 3, 2024, revealed that cleaning and disinfecting of resident care items and the environment will be conducted based on risk of infection involved. Staff were to remove all foreign materials such as blood, feces, dust, or dirt from surfaces before disinfecting. The cleaning of environmental surfaces, such as floors, walls, and furniture, should be done according to the schedule and as needed.

Observations on March 19, 2024, at 10:17 a.m. and 2:48 p.m. in the East Hall shower room revealed a black substance on the wall above the showers near the ceiling and crown molding.

Observations on March 19, 2024, at 10:21 a.m. and 2:52 p.m. revealed that the shower room on the West Hall near Room 1 had a brown, removable substance of the shower floor. Interview with Nurse Aide 1 on March 19, 2024, at 10:44 a.m. confirmed that there was a brown, removable substance on the floor of the shower and the shower should be cleaned after every use. The log next to the shower indicated that the last shower was provided on March 16, 2024, at 7:00 a.m.

Interview with the Nursing Home Administrator on March 19, 2024, 4:02 p.m. confirmed that there was an unknown black substance on the crown molding in the East Hall shower room, and confirmed that there was a brown substance on the floor in the West Hall shower that appeared to be feces, and that the shower rooms on East and West Halls needed to be cleaned. There was no documented evidence that the facility had conducted mold testing, and there was no evidence of cleaning schedules or of when the shower rooms were last cleaned.

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




 Plan of Correction - To be completed: 04/19/2024

Concerns identified in the Shower Rooms has been addressed and the removable substances has been removed.
Nursing Home Administrator (NHA)/Designee will educate staff on providing a clean and homelike environment. Staff will be educated on reporting environmental concerns through the facilities electronic work order system.
Nursing staff to clean shower rooms after each resident use and as needed for soilage. Environmental Service staff to clean shower rooms daily and as needed for soilage.
NHA/Designee complete audits of shower rooms to ensure a clean and homelike environment is maintained 3 days a week for 2 weeks then weekly for 2 weeks.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

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 on review of policies, clinical records, and investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that one of 14 residents reviewed (Resident 4) was free from physical and verbal abuse.

Findings include:

The facility's abuse policy, dated January 3, 2024, revealed that each resident has the right to be free from abuse and neglect and are not to be subjected to abuse by anyone, including other residents.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated November 4, 2023, revealed that the resident was confused, did not have behaviors that put himself or others at risk for injury during the seven-day look-back period, and had diagnoses that included non-traumatic brain dysfunction, Alzheimer's, dementia, and violent behavior. The current behavior care plan for Resident 4 revealed that staff were to supervise the resident while in the hallways and redirect as needed, be direct with intrusive behavior, establish appropriate boundaries, and educate Resident 4 on maintaining an appropriate distance during socialization to respect others personal space.

Review of an investigation report for Resident 5, dated March 10, 2024, revealed that Resident 5 was touched inappropriately by Resident 4, and as a result, all nurse aides were to ensure that Resident 4 stayed in the men's hall.

There was no documented evidence in Resident 4's clinical record to indicate that prior to or at the time of the incident that his care-planned interventions, such as supervising the resident, were implemented, and no documented evidence that following the incident of March 10, 2024, Resident 4's behaviors were assessed or that new interventions were implemented to prevent further incidents.

An interview with Resident 5's son on March 19, 2024, at 1:28 p.m. revealed that he was not made aware that Resident 4 had touched his mother inappropriately. He revealed that during a visit with his mother on March 10, 2024, Resident 4 had entered her room but was able to be re-directed at that time.

An interview with the Assistant Director of Nursing on March 19, 2024, at 12:21 p.m. confirmed that care-planned interventions for Resident 4's behaviors should have been implemented prior to the incident with Resident 5.

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





 Plan of Correction - To be completed: 04/19/2024

The accusation made by an agency licensed practical nurse stated that resident 5's son had made an accusation that resident 4 had touched his mother inappropriately. Per conversation by the assistant director of nursing with resident 5's son on March 11, 2024 denied that he made that statement.
Multiple residents and staff were interviewed during the investigation and denied any issues relating to abuse.
Assistant Director of Nursing (ADON)/Designee will educate staff on facility's policy for Abuse Reporting and Investigation.
ADON/Designee will audit progress notes 3 times per week for 2 weeks then weekly for 2 weeks for accusations of abuse, notification of family and MD of accusations of abuse.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

483.90(d)(2) REQUIREMENT Essential Equipment, Safe Operating Condition: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.
483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.
Observations:


Based on observations and staff interviews, it was determined that the facility failed to ensure essential equipment was in safe operating condition in resident bathrooms.

Findings include:

Observations on March 19, 2024, at 10:36 a.m. and 2:56 p.m. revealed that the shared bathroom between Rooms 23 and 25 did not have a sink and the wall and plumbing were exposed.

Observations on March 19, 2024, at 2:56 p.m. revealed that the shared bathroom between Rooms 17 and 19 did not have a functioning toilet. The toilet was wrapped in a black garbage bag.

Interview with the Nursing Home Administrator on March 19, 2024, at 2:56 p.m. confirmed that the bathroom between Rooms 23 and 25 did not have a sink and that it was removed sometime last week, and a new counter was ordered. She also confirmed that the bathroom between Rooms 17 and 19 did not have a functioning toilet and that the pipes needed to be fixed. The Nursing Home Administrator revealed that the Maintenance Director was on leave, and that she did not have access to any records or repair documents.

28 Pa. Code 201.18(e)(6) Management.



 Plan of Correction - To be completed: 04/19/2024

The counter for the bathroom between rooms 23 and 25 has been ordered.
Heating, Ventilation, and Air Conditioning (HVAC) has been onsite and pipes are in the process of being fixed.
Nursing Home Administrator (NHA)/Designee will educate environmental services staff on safe operation of equipment. Staff will be educated on reporting environmental concerns through the facility's electronic work order system.
Environmental Services/Designee will complete house audit of facility to ensure equipment is in working order.
Environmental Services/Designee will audit the facility's electronic work order system 5 days per week for 2 weeks then weekly for 2 weeks for concerns of un-operational equipment.
Routine preventative maintenance is scheduled on the electronic work order system. Maintenance Department will monitor the electronic work order system 5 days per week ongoing.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

483.90(i)(4) REQUIREMENT Maintains Effective Pest Control Program: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.
483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.
Observations:


Based on observations, a review of clinical records, as well as staff and resident interviews, it was determined that the facility failed to maintain an effective pest control program.

Findings include:

Resident Council Meeting Minutes, dated December 28, 2023, revealed that the residents voiced concerns about continued gnats in the building.

Observations on March 19, 2024, at 2:56 p.m. around the doorway of Room 23 revealed small flying insects in the hallway.

Interview with the Nursing Home Administrator on March 19, 2024, at 2:56 p.m. revealed that the pest control company has been providing services every two months; however, the only pest control records for the facility revealed service dates of February 7, 2024, and March 13, 2024. The facility was inspected and treated for pest activity by servicing fly lights and traps. There was no evidence of pest service before February 7, 2024.

There was no evidence that the pest control treatments in February and March 2024 were effective in keeping the facility free from gnats.

Interview with the Nursing Home Administrator on March 19, 2024, at 2:56 p.m. confirmed that the pest control documents were the only documentation that she had.

28 Pa. Code 201.18(e)(2)(3) Management.



 Plan of Correction - To be completed: 04/19/2024

It is the practice of this facility to maintain an effective pest control program so the facility is free of pests.
Pest Control Company has been providing services every two months and as needed. No further gnats have been noticed in the facility. No further complaints of gnats by the residents of the facility.
Facility Environmental Services/Designee will complete audits of the facility weekly for 4 weeks to help ensure that pests are identified and disposed of timely.
Facility Environmental Services/Designee will keep a record of the pest control company's visits to ensure services are provided every two months.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

201.14(d) LICENSURE Responsibility of licensee.:State only Deficiency.
[Reserved]
Observations:


Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to notify the Department of Health of an incident that had the potential for serious harm to a resident.

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated November 4, 2023, revealed that the resident was confused, did not have behaviors that put himself or others at risk for injury during the seven-day look-back period, and had diagnoses that included non-traumatic brain dysfunction, Alzheimer's, dementia, and violent behavior. The current behavior care plan for Resident 4 revealed that staff were to supervise the resident while in the hallways and redirect as needed, be direct with intrusive behavior, establish appropriate boundaries, and educate Resident 4 on maintaining an appropriate distance during socialization to respect others personal space.

Review of an investigation report for Resident 5, dated March 10, 2024, revealed that Resident 5 was touched inappropriately by Resident 4, and as a result, all nurse aides were to ensure that Resident 4 stayed in the men's hall.

There was no documentation to indicate that the incident involving Resident 4 was reported to the Department of Health.

Interview with the Assistant Director of nursing on March 19, 2024, at 12:21 a.m. confirmed that the Department of Health was not notified of this incident.

Chapter 51.3(f) Notification.





 Plan of Correction - To be completed: 04/19/2024

The accusation made by an agency licensed practical nurse stated that resident 5's son had made an accusation that resident 4 had touched his mother inappropriately. Per conversation by the assistant director of nursing with resident 5's son on March 11, 2024 denied that he made that statement.
Director of Nursing (DON)/Designee will educate Assistant Director of Nursing on Electronic Event Reporting (ERS) of suspected abuse allegations.
ADON/Designee will audit progress notes 3 times per week for 2 weeks then weekly for 2 weeks for accusations of abuse, notification of family and MD of accusations of abuse.
DON/Designee will audit ERS system to ensure that all allegations of abuse are reported in the ERS within 2 hours.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.

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 schedules, staffing information provided by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one nurse aide (NA) per 12 residents on the day shift for two of 21 days.

Findings Include:

Review of facility census data indicated that on March 7, 2024, the facility census was 80, which required 6.67 (80 residents divided by 12) NA's during the day shift. Review of the nursing time schedules revealed 5.09 NA's provided care on the day shift on March 7, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 15, 2024, the facility census was 79, which required 6.58 NA's during the day shift. Review of the nursing time schedules revealed 6.31 NA's provided care on the day shift on March 15, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Interview with the Nursing Home Administrator on March 19, 2024, at 4:15 p.m. confirmed that the facility did not meet the required nurse aide-to-resident staffing ratios for the days listed above and that all of the staffing hours were provided.







 Plan of Correction - To be completed: 04/19/2024

The facility cannot correct that nurse aide staffing ratios were not met on 3/7/2024 and 3/15/2024. There were no adverse effects to the residents on the identified dates.
The facility will ensure that staffing ratios are met every shift.
If staffing ratios are not able to be met then admissions will be halted.
Nursing scheduler will be re-educated by the Nursing Home Administrator/Designee on ensuring staffing ratios are met each shift.
Daily shift staffing ratios will be reviewed at Standup. The nursing supervisors will review shift staffing ratios on the weekends.
If the facility projects not to meet staffing ratios on a shift, the scheduler/designee will be responsible to call off duty personnel or extra support staff to assist, department heads, bonuses will be offered if needed, corporate clinical staff will be contacted, as well as agencies for assistance.
The Nursing Home Administrator/Designee will audit staffing daily for 4 weeks to ensure staffing ratios are being met.
Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.


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