Pennsylvania Department of Health
 QUALITY LIFE SERVICES - SARVER
Patient Care Inspection Results

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QUALITY LIFE SERVICES - SARVER
Inspection Results For:

There are  78 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
QUALITY LIFE SERVICES - SARVER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated survey in response to a facility submitted event completed on August 6, 2024, it was determined that Quality Life Services - Sarver 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:


483.70(a)-(c) REQUIREMENT License/Comply w/ Fed/State/Locl Law/Prof Std: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.
§483.70(a) Licensure.
A facility must be licensed under applicable State and local law.

§483.70(b) Compliance with Federal, State, and Local Laws and Professional Standards.
The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility.

§483.70(c) Relationship to Other HHS Regulations.
In addition to compliance with the regulations set forth in this subpart, facilities are obliged to meet the applicable provisions of other HHS regulations, including but not limited to those pertaining to nondiscrimination on the basis of race, color, or national origin (45 CFR part 80); nondiscrimination on the basis of disability (45 CFR part 84); nondiscrimination on the basis of age (45 CFR part 91); nondiscrimination on the basis of race, color, national origin, sex, age, or disability (45 CFR part 92); protection of human subjects of research (45 CFR part 46); and fraud and abuse (42 CFR part 455) and protection of individually identifiable health information (45 CFR parts 160 and 164). Violations of such other provisions may result in a finding of non-compliance with this paragraph.
Observations:

Based on review of facility provided documents it was determined that the facility failed to ensure sufficient nursing staff to comply with state laws regarding mandated minimum staffing requirements (Time Period 7/15/24 -8/5/24).

Findings include:

Review of "28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, dated 7/1/24, indicated the following subsections:
(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.
(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.

Review of facility provided documents it was determined that the facility failed to provide the State required minimum of one Nurse Aide (NA) per 10 residents on the daylight shift for 21 out of 21 days.
-Daylight shift:
7/15/24 Census 55 Needed 5.4 Had 4.5
7/16/24 Census 55 Needed 5.5 Had 5.0
7/17/24 Census 55 Needed 5.5 Had 5.0
7/18/24 Census 56 Needed 5.6 Had 5.0
7/19/24 Census 55 Needed 5.5 Had 4.66
7/20/24 Census 54 Needed 5.4 Had 5.0
7/21/24 Census 54 Needed 5.4 Had 5.0
7/22/24 Census 54 Needed 5.4 Had 5.03
7/23/24 Census 56 Needed 5.6 Had 5.0
7/24/24 Census 57 Needed 5.7 Had 5.0
7/25/24 Census 57 Needed 5.7 Had 5.0
7/26/24 Census 57 Needed 5.7 Had 5.0
7/27/24 Census 58 Needed 5.8 Had 4.84
7/28/24 Census 57 Needed 5.7 Had 5.66
7/29/24 Census 57 Needed 5.7 Had 4.84
7/30/24 Census 57 Needed 5.7 Had 5.0
7/31/24 Census 57 Needed 5.7 Had 5.0
8/1/24 Census 57 Needed 5.7 Had 5.0
8/2/24 Census 57 Needed 5.7 Had 4.97
8/3/24 Census 57 Needed 5.7 Had 5.0
8/4/24 Census 57 Needed 5.7 Had 5.0

Failed to provide the State required minimum of one NA per 11 residents on 18 out of 21 evening shifts.
-Evening shift:
7/15/24 Census 54 Needed 4.91 Had 4.84
7/16/24 Census 55 Needed 5.0 Had 4.66
7/17/24 Census 55 Needed 5.0 Had 4.63
7/18/24 Census 56 Needed 5.09 Had 4.75
7/19/24 Census 55 Needed 5.0 Had 4.50
7/22/24 Census 54 Needed 4.91 Had 4.63
7/23/24 Census 56 Needed 5.09 Had 4.72
7/24/24 Census 57 Needed 5.18 Had 5.06
7/25/24 Census 57 Needed 5.18 Had 4.75
7/26/24 Census 57 Needed 5.18 Had 4.78
7/27/24 Census 58 Needed 5.27 Had 4.31
7/28/24 Census 57 Needed 5.18 Had 5.03
7/29/24 Census 57 Needed 5.18 Had 4.84
7/30/24 Census 57 Needed 5.18 Had 4.94
7/31/24 Census 57 Needed 5.18 Had 5.0
8/1/24 Census 57 Needed 5.18 Had 4.97
8/2/24 Census 57 Needed 5.18 Had 5.03
8/3/24 Census 57 Needed 5.18 Had 5.03

Failed to provide the State required minimum of one NA per 15 residents on 20 of 21 midnight shifts.

-Night Shift:
7/16/24 Census 55 Needed 3.67 Had 3.03
7/17/24 Census 55 Needed 3.67 Had 2.94
7/18/24 Census 56 Needed 3.73 Had 2.97
7/19/24 Census 55 Needed 3.67 Had 3.0
7/20/24 Census 54 Needed 3.6 Had 3.0
7/21/24 Census 54 Needed 3.6 Had 3.0
7/22/24 Census 54 Needed 3.6 Had 3.16
7/23/24 Census 56 Needed 3.73 Had 3.0
7/24/24 Census 57 Needed 3.80 Had 3.0
7/25/24 Census 57 Needed 3.8 Had 3.0
7/26/24 Census 57 Needed 3.8 Had 3.06
7/27/24 Census 58 Needed 3.87 Had 3.0
7/28/24 Census 57 Needed 3.8 Had 3.0
7/29/24 Census 57 Needed 3.8 Had 3.0
7/30/24 Census 57 Needed 3.8 Had 3.0
7/31/24 Census 57 Needed 3.8 Had 3.0
8/1/24 Census 57 Needed 3.8 Had 3.09
8/2/24 Census 57 Needed 3.8 Had 3.06
8/3/24 Census 57 Needed 3.8 Had 3.0
8/4/24 Census 57 Needed 3.8 Had 3.09

Failed to provide a minimum of 3.20 PPD (per patient daily) hours of direct care for each resident for 11 out of 21 days reviewed.
7/16/24 - PPD 3.1
7/19/24 - PPD 3.07
7/25/24 - PPD 3.13
7/26/24 - PPD 3.11
7/27/24 - PPD 2.84
7/30/24 - PPD 3.15
7/31/24 - PPD 3.09
8/1/24 - PPD 3.13
8/2/24 - PPD 3.17
8/3/24 - PPD 3.17
8/4/24 - PPD 3.18

Telephonic interview on 8/6/24, at 11:10 a.m. the Nursing Home Administrator confirmed the facility failed to ensure sufficient nursing staff to comply with state laws regarding mandated minimum staffing requirements (Time Period 7/15/24 -8/5/24).

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code: 201.29(b)(d)(j) Resident rights.


 Plan of Correction - To be completed: 09/10/2024

1. The facility was unable to make corrective action for the (nurse aide ratio / ppd) for identified days that have already passed. All residents received care in accordance with their care plans and physician orders.
2. DON or designee will re-educate the labor manager and the RN supervisors on the 7/1/2024 requirements.
3. Facility continues to offer incentives, competitive wages, and several other benefits in an effort to hire for all open positions.
4. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. Facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff.
5. DON or designee will audit daily staffing ratios and ppd along with all steps taken to fill vacancies 5 days a week and ongoing.
6. Results of the audits will be reviewed and recorded in the monthly QAPI meeting.
7. Date certain 9/10/24

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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.
§483.21(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 review of facility policy and clinical records and staff interview, it was determined that the facility failed to update a care plan for one of four residents (Resident R1) to accurately reflect the current status of the resident.

Findings include:

Review of the facility policy "Comprehensive Care Plan" dated 12/1/23, indicated an interdisciplinary plan of care will be established for every resident and updated in accordance with state and federal regulatory requirements and on as needed basis with changes.

Review of the facility policy "Elopement Prevention" dated 12/1/23, indicated should the resident's behavior warrant elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) prevention measures, a comprehensive elopement prevention plan will be documented as part of the care plan. Staff observations will be noted during the resident's stay and modifications will be made to the care plan and prevention techniques.

Review of the admission record indicated Resident R1 was admitted to the facility on 4/1/24.

Review of the Minimum Data Set (MDS- a periodic assessment of care needs) dated 7/8/24, indicated the diagnoses of Non-Alzheimer's Dementia (dementia caused by other diseases with symptoms forgetfulness, limited social skills, and impaired thinking abilities that interfere with daily functioning), renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids), high blood pressure, and anxiety. Section C0500 indicated a Brief Interview for Mental Status (BIMS - is a screening test that aides in detecting cognitive impairment) as a three - severe cognitive impairment.

Review of Resident R1's physician order dated 4/1/24, indicated safety device - Wanderguard (right wrist - a bracelet that alarms when resident goes beyond supervised area) check placement and function every shift.

Review of Resident R1's Nursing Review short form dated 4/1/24, indicated Elopement - resident is at risk and requires a wanderguard bracelet.

Review of Resident R1's care plan dated 4/1/24, indicated "I am an elopement risk. Distract me from wandering by offering me pleasant diversions, structured activities, food, conversation, television, books etc., and to issue me a wanderguard.

Review of Resident R1's progress notes dated 7/14/24, at 9:21 p.m. indicated Resident R1 was ramming his wheelchair into the baseboard heater repeatedly and refused to stop when asked.

Review of Resident R1's progress notes dated 7/15/24, at 6:44 a.m. indicated Resident R1 woke at 3:30 a.m. and has been wandering. Found in another resident's room, went off to Personal Care unit twice, finding his wife and woke her up. Wheeling around threatening to burn the place down. He was given Ativan (anxiety medication) 1 mg (milligram).

Review of Resident R1's progress notes dated 7/21/24, at 1:31 p.m. indicated Resident R1 was talking about how he's in the military and he wants to escape here and steal a car but if he goes outside, he's going to get shot. Proceeded to say it's easy to steal a car wander guard on and functioning. Registered Nurse (RN) Supervisor notified.

Review of Resident R1's progress notes dated 7/22/24, at 3:11 a.m. indicated physician on call called for an order of intramuscular injection (IM) Haldol (antipsychotic medication) due to resident becoming violent after waking up agitated while looking for his wife and children. Resident was reminded his wife was sleeping and his children were at home. He was asked to go back to his room then he began threatening staff and attempting to punch nursing staff.

Review of Resident R1's progress notes dated 7/22/24, at 11:46 a.m. indicated social services spoke with family regarding Dementia Unit placement.

Review of Resident R1's progress notes dated 7/22/24, at 9:06 p.m. indicated resident opened front doors, wanderguard alarm sounding. Redirected. Then went up ramp in Personal Care, alarm sounding again, made it all the way up the ramp and opened fire tower doors as staff was approaching. Resident was walking without walker or wheelchair. When asked what he was looking for he stated, "I'm sorry".

Review of Resident R1's Psychiatric Provider note dated 7/23/24 at 1:00 a.m. indicated short term memory poor, concentration/attention poor- distracted. Insight - poor, lack of insight concerning matters of self. Judgement poor, lacks judgement regarding everyday activities. The patient misses his wife, and he often wanders through the facility looking for her. He is easily agitated and can be hard to redirect. Becomes anxious when told that this wife and truck are not here. Often awake at night.

Review of Resident R1's progress notes dated 7/24/24, at 3:30 p.m. indicated resident up in his wheelchair self-propelling looking for the place that you eat - dining area and at 8:09 p.m. nurse aide reported observing Resident R1 urinating in the shower stall of shower room.

Review of Resident R1's progress notes dated 7/25/24, at 6:03 a.m. indicated resident was exit seeking and opened the front doors, activating the wanderguard alarm. He was walking without a walker or wheelchair. Every 15-minute checks were ordered.

Review of Resident R1's progress notes dated 7/26/24, at 12:56 a.m. Indicated resident was verbally aggressive and yelling at staff. Staff were able to calm resident, get him to his room and into bed.

Review of Resident R1's progress notes dated 7/27/24, at 1:28 p.m. indicated staff notified the family and physician about the elopement.

Review of Resident R1's progress notes dated 7/27/24, at 1:57 p.m. Staff heard the wanderguard alarm going off. Noted it was for the Lincoln Hall and went down to the Personal Care to investigate. I found the Personal Care Aide who stated she didn't see anyone, and I could not locate anyone. When I went back upstairs, I saw Resident R1 upstairs eating lunch. Staff informed me somehow, he got downstairs.

Review of Resident R1's care plan failed to include new interventions or revisions aftre each behavior displayed above to prevent elopement despite multiple behaviors of exit seeking, confusion, agitation, and wandering.

Interview on 8/5/24, at 2:00 p.m. the Nursing Home Administrator confirmed the facility failed to update the care plan for one of four residents reviewed to accurately reflect the current status of the resident.

28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code: 201.29(b)(d)(j) Resident rights.
28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing Services.


 Plan of Correction - To be completed: 09/10/2024

1. R1, care plan has been updated to reflect current orders.
2. All residents care plans will be updated with new orders, during AM Clinical meeting.
3. Education will be provided to IDT by DON or designee regarding care plan updates.
4. Audits will be completed 2 times per week for 3 weeks on 5 residents by DON or designee to ensure that resident care plans reflect the current resident orders.
5. Results of the audits will be reviewed at the monthly QAPI meeting.
6. Date certain 9/10/24.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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.
§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on review of facility policy, clinical records, observations, and staff interviews it was determined that the facility failed to make certain each resident received adequate supervision that resulted in one elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of four residents (Resident R1).

Findings include:

Review of the facility's policy "Elopement Prevention" dated 12/1/23, indicated the receptionist will maintain the list of all residents at risk for elopement, including name and room number. This list will be distributed to the management team of the care community with staff members who may be in contact with those residents. Departments include nursing, therapeutic recreation, housekeeping, and maintenance.

Review of the facility's policy "Accidents and Incidents" dated 12/1/23, indicated the purpose of the policy is to promote a safe environment for all residents.

Review of the admission record indicated Resident R1 was admitted to the facility on 4/1/24.

Review of the Minimum Data Set (MDS- a periodic assessment of care needs) dated 7/8/24, indicated the diagnoses of Non-Alzheimer ' s Dementia (dementia caused by other diseases with symptoms forgetfulness, limited social skills, and impaired thinking abilities that interfere with daily functioning), renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids), high blood pressure, and anxiety. Section C0500 indicated a Brief Interview for Mental Status (BIMS - is a screening test that aides in detecting cognitive impairment) as a three - severe cognitive impairment.

Review of Resident R1's physician order dated 4/1/24, indicated safety device - Wanderguard (right wrist - a bracelet that alarms when resident goes beyond supervised area) check placement and function every shift.

Review of Resident R1's care plan dated 4/1/24, indicated distract me from wandering by offering me pleasant diversions, structured activities, food, conversation, television, books etc.

Further review of Resident R1's care plan dated 4/3/24, indicated "I enjoy one on one visitation with my wife in PC (personal care - the PC wife's room is the last room in the skilled nursing hallway) I ambulate independently to her personal care home".

Review of Resident R1's Nursing Review short form dated 4/1/24, indicated Elopement - resident is at risk and requires a wanderguard bracelet.

Review of Resident R1's progress notes dated 7/14/24, at 9:21 p.m. indicated Resident R1 was ramming his wheelchair into the baseboard heater repeatedly and refused to stop when asked.

Review of Resident R1's progress notes dated 7/15/24, at 6:44 a.m. indicated Resident R1 woke at 3:30 a.m. and has been wandering. Found in another resident's room, went off to Personal Care unit twice, finding his wife and woke her up. Wheeling around threatening to burn the place down. He was given Ativan (anxiety medication) 1 mg (milligram).

Review of Resident R1's progress notes dated 7/21/24, at 1:31 p.m. indicated Resident R1 was talking about how he's in the military and he wants to escape here and steal a car but if he goes outside, he's going to get shot. Proceeded to say it's easy to steal a car wander guard on and functioning. Registered Nurse (RN) supervisor notified.

Review of Resident R1's progress notes dated 7/22/24, at 3:11 a.m. indicated physician on call called for an order of intramuscular injection (IM) Haldol (antipsychotic medication) due to resident becoming violent after waking up agitated while looking for his wife and children. Resident was reminded his wife was sleeping and his children were at home. He was asked to go back to his room then he began threatening staff and attempting to punch nursing staff.

Review of Resident R1's progress notes dated 7/22/24, at 11:46 a.m. indicated social services spoke with family regarding Dementia Unit placement.

Review of Resident R1's progress notes dated 7/22/24, at 9:06 p.m. indicated resident opened front doors, wanderguard alarm sounding. Redirected. Then went up ramp in Personal Care, alarm sounding again, made it all the way up the ramp and opened fire tower doors as staff was approaching. Resident was walking without walker or wheelchair . When asked what he was looking for he stated, "I'm sorry".

Review of Resident R1' Psychiatric Provider note dated 7/23/24 at 1:00 a.m. indicated short term memory poor, concentration/attention poor- distracted. Insight - poor, lack of insight concerning matters of self. Judgement poor, lacks judgement regarding everyday activities. The patient misses his wife, and he often wanders through the facility looking for her. He is easily agitated and can be hard to redirect. Becomes anxious when told that this wife and truck are not here. Often awake at night.

Review of Resident R1's progress notes dated 7/24/24, at 3:30 p.m. indicated resident up in his wheelchair self-propelling looking for the place that you eat - dining area and at 8:09 p.m. nurse aide reported observing Resident R1 urinating in the shower stall of shower room.

Review of Resident R1's progress notes dated 7/25/24, at 6:03 a.m. indicated resident was exit seeking and opened the front doors, activating the wanderguard alarm. He was walking without a walker or wheelchair. Every 15-minute checks were ordered.

Review of Resident R1's progress notes dated 7/26/24, at 12:56 a.m. Indicated resident was verbally aggressive and yelling at staff. Staff were able to calm resident, get him to his room and into bed.

Review of Resident R1's progress notes dated 7/27/24, at 1:28 p.m. indicated staff notified the family and physician about the elopement.

Review of Resident R1's progress notes dated 7/27/24, at 1:57 p.m. Staff heard the wanderguard alarm going off. Noted it was for the Lincoln Hall and went down to the Personal Care to investigate. I found the Personal Care Aide who stated she didn't see anyone, and I could not locate anyone. When I went back upstairs, I saw Resident R1 upstairs eating lunch. Staff informed me somehow, he got downstairs.

Review of the facility provided investigation dated 7/27/24, indicated that Maintenance Employee E1's witness statement "I went to get on the elevator and another one of the residents was also waiting. I got on, as well as Resident R1 did. Went down one floor and we both got off".

Review of the Nursing Home Administrators interview with Maintenance Employee E1's witness statement dated 7/29/24, indicated "Maintenance Employee E1 indicated he was not paying attention to alarms, but did accompany resident down elevator, unaware that he wasn't supposed to be on it".

Interview on 8/5/24, at 2:00 p.m. the Nursing Home Administrator confirmed the facility failed to make certain each resident received adequate supervision that resulted in one elopement for one of four residents (Resident R1).

28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code: 201.29(b)(d)(j) Resident rights.
28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing Services.



 Plan of Correction - To be completed: 09/10/2024

1. On 7/28/24 R1 was transferred to a locked unit for safety.
2. Residents that are elopement risk evaluated to make sure they have adequate supervision processes in place. All residents are evaluated for risk of elopement on admission, quarterly and with any significant change.
3. Education will be provided to nursing staff by DON or designee on elopement policy and procedures.
4. Audit of current residents that are an elopement risk to ensure adequate supervision is in place. Audit new admissions daily for elopement risk on admission for 3 weeks.
5. Result of audits will be reviewed at monthly QAPI meeting.
6. Date certain 09/10/24.

§ 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 schedules, nursing staffing documents and staff interview, it was determined that the facility failed to provide the State required minimum of one Nurse Aide (NA) per 10 residents on the daylight shift for 21 out of 21 days, and failed to provide the State required minimum of one NA per 11 residents on 18 out of 21 evening shifts, and failed to provide the State required minimum of one NA per 15 residents on 20 of 21 midnight shifts (Time period reviewed 7/15/24 - 8/4/24).

Findings include:

Review of the facility's 3-week nurse staffing schedules (7/15/24-8/4/24) did not include the State required minimum of Nurse Aides (NA) on:
-Daylight shift:
7/15/24 Census 55 Needed 5.4 Had 4.5
7/16/24 Census 55 Needed 5.5 Had 5.0
7/17/24 Census 55 Needed 5.5 Had 5.0
7/18/24 Census 56 Needed 5.6 Had 5.0
7/19/24 Census 55 Needed 5.5 Had 4.66
7/20/24 Census 54 Needed 5.4 Had 5.0
7/21/24 Census 54 Needed 5.4 Had 5.0
7/22/24 Census 54 Needed 5.4 Had 5.03
7/23/24 Census 56 Needed 5.6 Had 5.0
7/24/24 Census 57 Needed 5.7 Had 5.0
7/25/24 Census 57 Needed 5.7 Had 5.0
7/26/24 Census 57 Needed 5.7 Had 5.0
7/27/24 Census 58 Needed 5.8 Had 4.84
7/28/24 Census 57 Needed 5.7 Had 5.66
7/29/24 Census 57 Needed 5.7 Had 4.84
7/30/24 Census 57 Needed 5.7 Had 5.0
7/31/24 Census 57 Needed 5.7 Had 5.0
8/1/24 Census 57 Needed 5.7 Had 5.0
8/2/24 Census 57 Needed 5.7 Had 4.97
8/3/24 Census 57 Needed 5.7 Had 5.0
8/4/24 Census 57 Needed 5.7 Had 5.0

-Evening shift:
7/15/24 Census 54 Needed 4.91 Had 4.84
7/16/24 Census 55 Needed 5.0 Had 4.66
7/17/24 Census 55 Needed 5.0 Had 4.63
7/18/24 Census 56 Needed 5.09 Had 4.75
7/19/24 Census 55 Needed 5.0 Had 4.50
7/22/24 Census 54 Needed 4.91 Had 4.63
7/23/24 Census 56 Needed 5.09 Had 4.72
7/24/24 Census 57 Needed 5.18 Had 5.06
7/25/24 Census 57 Needed 5.18 Had 4.75
7/26/24 Census 57 Needed 5.18 Had 4.78
7/27/24 Census 58 Needed 5.27 Had 4.31
7/28/24 Census 57 Needed 5.18 Had 5.03
7/29/24 Census 57 Needed 5.18 Had 4.84
7/30/24 Census 57 Needed 5.18 Had 4.94
7/31/24 Census 57 Needed 5.18 Had 5.0
8/1/24 Census 57 Needed 5.18 Had 4.97
8/2/24 Census 57 Needed 5.18 Had 5.03
8/3/24 Census 57 Needed 5.18 Had 5.03

-Night Shift:
7/16/24 Census 55 Needed 3.67 Had 3.03
7/17/24 Census 55 Needed 3.67 Had 2.94
7/18/24 Census 56 Needed 3.73 Had 2.97
7/19/24 Census 55 Needed 3.67 Had 3.0
7/20/24 Census 54 Needed 3.6 Had 3.0
7/21/24 Census 54 Needed 3.6 Had 3.0
7/22/24 Census 54 Needed 3.6 Had 3.16
7/23/24 Census 56 Needed 3.73 Had 3.0
7/24/24 Census 57 Needed 3.80 Had 3.0
7/25/24 Census 57 Needed 3.8 Had 3.0
7/26/24 Census 57 Needed 3.8 Had 3.06
7/27/24 Census 58 Needed 3.87 Had 3.0
7/28/24 Census 57 Needed 3.8 Had 3.0
7/29/24 Census 57 Needed 3.8 Had 3.0
7/30/24 Census 57 Needed 3.8 Had 3.0
7/31/24 Census 57 Needed 3.8 Had 3.0
8/1/24 Census 57 Needed 3.8 Had 3.09
8/2/24 Census 57 Needed 3.8 Had 3.06
8/3/24 Census 57 Needed 3.8 Had 3.0
8/4/24 Census 57 Needed 3.8 Had 3.09

Telephonic interview on 8/6/24, at 11:10 a.m. the Nursing Home Administrator confirmed the facility failed to provide the State required minimum of one Nurse Aide (NA) per 10 residents on the daylight shift for 21 out of 21 days, and failed to provide the State required minimum of one NA per 11 residents on 18 out of 21 evening shifts, and failed to provide the State required minimum of one NA per 15 residents on 20 of 21 midnight shifts (Time period reviewed 7/15/24 - 8/4/24).


 Plan of Correction - To be completed: 09/10/2024

1. The facility was unable to make corrective action for the (nurse aide ratio / ppd) for identified days that have already passed. All residents received care in accordance with their care plans and physician orders.
2. DON or designee will re-educate the labor manager and the RN supervisors on the 7/1/2024 requirements.
3. Facility continues to offer incentives, competitive wages, and several other benefits in an effort to hire for all open positions.
4. Admin, DON, and Labor manager will conduct daily staffing meetings Monday – Friday to review (ratios / ppd) throughout the day, the following day, and the weekend. In the event of vacancies the facility will follow staffing policies including offering open shifts to internal staff, contracted agency staff, and offering current staff to stay extra or start earlier.
5. DON or designee will audit daily staffing ratios and ppd along with all steps taken to fill vacancies 5 days a week and ongoing.
6. Results of the audits will be reviewed and recorded in the monthly QAPI meeting.
7. Date certain 9/10/24

§ 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 nursing time schedules and staff interview it was determined that the facility failed to provide a minimum of 3.20 PPD (per patient daily) hours of direct care for each resident for 11 out of 21 days reviewed (7/15/24 - 8/4/24) as required.

Findings include:

Review of staffing documents and nurse schedules for 3 weeks (7/15/24 - 8/4/24) indicated that required PPD minimum hours of 3.20 was not met on the following days:
7/16/24 - PPD 3.1
7/19/24 - PPD 3.07
7/25/24 - PPD 3.13
7/26/24 - PPD 3.11
7/27/24 - PPD 2.84
7/30/24 - PPD 3.15
7/31/24 - PPD 3.09
8/1/24 - PPD 3.13
8/2/24 - PPD 3.17
8/3/24 - PPD 3.17
8/4/24 - PPD 3.18

Telephonic interview on 8/6/24, at 11:10 a.m. the Nursing Home Administrator confirmed the facility failed to provide a minimum of 3.20 PPD hours of direct care for each resident for 11 out of 21 days reviewed (7/15/24 - 8/4/24) as required.


 Plan of Correction - To be completed: 09/10/2024

1. The facility was unable to make corrective action for the (nurse aide ratio / ppd) for identified days that have already passed. All residents received care in accordance with their care plans and physician orders.
2. DON or designee will re-educate the labor manager and the RN supervisors on the 7/1/2024 requirements.
3. Facility continues to offer incentives, competitive wages, and several other benefits in an effort to hire for all open positions.
4. Admin, DON, and Labor manager will conduct daily staffing meetings Monday – Friday to review (ratios / ppd) throughout the day, the following day, and the weekend. In the event of vacancies the facility will follow staffing policies including offering open shifts to internal staff, contracted agency staff, and offering current staff to stay extra or start earlier.
5. DON or designee will audit daily staffing ratios and ppd along with all steps taken to fill vacancies 5 days a week and ongoing.
6. Results of the audits will be reviewed and recorded in the monthly QAPI meeting.
7. Date certain 9/10/24


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