Pennsylvania Department of Health
CORNER VIEW NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CORNER VIEW NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 329 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.


CORNER VIEW NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an abbreviated survey in response to three complaints completed on July 25, 2024, it was determined that Corner View Nursing and Rehabilitation Center 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 a review of facility documents it was determined that the facility failed to ensure sufficient nursing staff to comply with state laws regarding mandated minimum staffing requirements.

Findings include:

Review of "28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, dated 7/1/23, indicated the following subsections.

(f.1) In addition to the director of nursing services, a facility shall provide all of the following:
(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.
(3) Effective July 1, 2024, a minimum of 1 NA per 10 resident during the day, 1 NA per 11 residents during the evening, and 1 NA per 15 residents overnight.
(i) A minimum number of general nursing care hours shall be provided for each 24-hour period
as follows:
(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.
(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 3.20 hours of direct resident care for each resident.

Review of facility surveys completed since 7/25/24, revealed the following:

Survey of 7/25/23:
-Failed to provide one Nurse Aide (NA) per 12 residents on the daylight shifts for three out of 15 days (6/16/24, 6/29/24 and 6/30/24) and failed to provide the State required minimum of one NA per 12 residents on twelve out of 15 evening shifts (6/16/24, 6/18/24, 6/19/24, 6/20/24, and 6/22/24) and one Nurse Aide (NA) per 10 residents on the daylight shifts for two out of 7 days (7/5/24 and 7/7/24) and failed to provide the State required minimum of one NA per 10 residents on four out of 7 evening shifts (7/2/24, 7/5/24, 7/6/24 and 7/7/24).

-Failed to provide one licensed practical nurse (LPN) per 25 residents during daylight shifts for six out of 15 days (6/16/24, 6/17/24, 6/21/24, 6/22/24, 6/28/24 and 6/30/24) and failed to provide a minimum of one Licensed Practical Nurse (LPN) per 30 residents during the evening shift for five out of 15 days (6/19/24, 6/20/24, 6/24/24, 6/25/24 and 6/28/24) and one licensed practical nurse (LPN) per 25 residents during daylight shifts for two out of 7 days (7/5/24 and 7/7/24).

-Failed to provide a minimum of 2.87 PPD (per patient daily) hours of direct care for each resident for fifteen out of 15 days reviewed (6/16/24, 6/17/24, 6/18/24, 6/19/24, 6/20/24, 6/21/24, 6/22/24, 6/23/24, 6/24/24, 6/25/24, 6/26/24, 6/27/24, 6/28/24, 6/29/24 and 6/30/24) and the facility failed to provide a minimum of 3.20 PPD (per patient daily) hours of direct care for each resident for six out of seven days reviewed (7/1/24, 7/2/24, 7/3/24, 7/5/24, 7/6/24 and 7/7/24).

During an inteview on 4/8/24, at approximately 11:15 a.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to ensure sufficient nursing staff to comply with state laws regarding mandated minimum staffing requirements.

28 Pa. Code 201.14(g) Responsibility of licensee.

28 Pa. Code 201.18(e)(1)(2) Management.

Plan of Correction - To be completed: 09/04/2024

No residents were affected during the days identified in the 2567. The Administrator, Director of Nursing and Staffing Coordinator were re-educated regarding minimum staffing PPD (per patient day) by the Corporate Clinical Director.
The facility has previously reviewed the staffing plan and has assessed wages, provided extra shift pick up bonuses to qualified staff, provided for flexible scheduling, and has advertised in several ways for staff including on online help wanted sites.
Staff that are trained and capable to assisting with any care tasks such as passing linens, making beds, nail care, hair care, passing trays to residents that do not require assistance or observation with meals will be utilized. The facility will send representatives to local job fairs, partnered with local businesses such as job corps, each morning the administration staff meets to review the staffing for the day and any critical days in the future, weekly staffing meetings, staffing to include increased employees to cover for any call offs, progressive disciplinary action if necessary and weekly review of new staff that has been hired and will be joining the facility team in the future and any staff that has resigned or has been terminated. Corporate leadership included on strategies and any needs of the facility.
The Nursing Home Administrator, Director of Nursing, and Staffing Coordinator, or designees, will review the ratios daily and look ahead in the upcoming week schedule.
The Director of Nursing or designee will monitor the staffing ratios for nurse aides, LPN, and PPD 5 times a week for 4 weeks then weekly X4.
Results of audits will be reviewed at the facilities quality assurance performance improvement meeting.

483.15(a)(1)-(7) REQUIREMENT Admissions Policy:

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.

�483.15(a) Admissions policy.
�483.15(a)(1) The facility must establish and implement an admissions policy.

�483.15(a)(2) The facility must-
(i) Not request or require residents or potential residents to waive their rights as set forth in this subpart and in applicable state, federal or local licensing or certification laws, including but not limited to their rights to Medicare or Medicaid; and
(ii) Not request or require oral or written assurance that residents or potential residents are not eligible for, or will not apply for, Medicare or Medicaid benefits.
(iii) Not request or require residents or potential residents to waive potential facility liability for losses of personal property.

�483.15(a)(3) The facility must not request or require a third party guarantee of payment to the facility as a condition of admission or expedited admission, or continued stay in the facility. However, the facility may request and require a resident representative who has legal access to a resident's income or resources available to pay for facility care to sign a contract, without incurring personal financial liability, to provide facility payment from the resident's income or resources.

�483.15(a)(4) In the case of a person eligible for Medicaid, a nursing facility must not charge, solicit, accept, or receive, in addition to any amount otherwise required to be paid under the State plan, any gift, money, donation, or other consideration as a precondition of admission, expedited admission or continued stay in the facility. However,-
(i) A nursing facility may charge a resident who is eligible for Medicaid for items and services the resident has requested and received, and that are not specified in the State plan as included in the term ''nursing facility services'' so long as the facility gives proper notice of the availability and cost of these services to residents and does not condition the resident's admission or continued stay on the request for and receipt of such additional services; and
(ii) A nursing facility may solicit, accept, or receive a charitable, religious, or philanthropic contribution from an organization or from a person unrelated to a Medicaid eligible resident or potential resident, but only to the extent that the contribution is not a condition of admission, expedited admission, or continued stay in the facility for a Medicaid eligible resident.

�483.15(a)(5) States or political subdivisions may apply stricter admissions standards under State or local laws than are specified in this section, to prohibit discrimination against individuals entitled to Medicaid.

�483.15(a)(6) A nursing facility must disclose and provide to a resident or potential resident prior to time of admission, notice of special characteristics or service limitations of the facility.

�483.15(a)(7) A nursing facility that is a composite distinct part as defined in �483.5 must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under paragraph (c)(9) of this section.

Observations:

Based on review of resident records, admission documentation and staff interview, it was determined that the facility failed to maintain admission documentation for two of seven residents (Resident R1, R7).

Findings include:

Review of Resident R1 was admitted 6/18/24 with diagnoses that include dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), anemia and COPD (COPD, or chronic obstructive pulmonary disease, is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe).

Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:
13-15: cognitively intact
8-12: moderately impaired
0-7: severe impairment

Review of Resident R1 Admission MDS assessment ( Minimum Data Set assessment MDS- a periodic assessment of resident care needs) dated 6/25/24 indicated the resident was assessed as having a BIMS score of 10, which indicates moderately impaired.

Review of Resident R1's admission packet dated 6/20/24 indicated a signature from R1.

Review of Resident R6 was admitted 3/6/24 with diagnoses that include catatonic disorder (group of symptoms that usually involve a lack of movement and communication, and also can include agitation, confusion) and schizophrenia.

Review of Resident R6's admission packet dated 3/12/24 indicated a no signature from resident or POA (power of Attorney).

During an interview with Nursing Home Administrator on 7/26/24 at 11:30 a.m. confirmed Resident R1 was cognitivly impaired and should not have signed facility paperwork and R6 never had his admission paper work completed as required.

28 Pa Code: 201.18(b)(2) Management

28 Pa Code: 201.24(a) Admission policy

28 Pa Code: 201.19(i) Residents rights

Plan of Correction - To be completed: 09/04/2024

Residents R1 admission agreement will be reviewed with resident as well as a family member and re-signed. Admission director/designee will make every effort to review and obtain a signature on R7's admission agreement.
All current residents' admission agreements will be reviewed for resident ability to sign and for completion of the document.
Prior to getting admission agreements signed by new residents, the staff completing admissions paperwork will review the residents Brief Interview for Mental Status (BIMS) score.
Education will be provided on F620 with the admission director/designee with a focus on maintaining admission documentation.
Audits of new admission paperwork will be completed by the Director of Nursing/designee weekly x 8 weeks.
Results of audits will be reviewed at the facilities quality assurance performance improvement meeting. The facility Administrator will ensure compliance.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

�483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

�483.70(i) Medical records.
�483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

�483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

�483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

�483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

�483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under �483.50.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that clinical records were complete and accurate for four of seven residents reviewed (Residents R1, R2, R3 and R4).

Review of Resident R1's admission record indicated the resident was admitted to the facility 6/18/24, with the diagnoses of dementia(a general term for loss of memory, language, problem solving that are severe enough to interfere with daily life), anemia and COPD (chronic obstructive pulmonary disease, is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe).

Review of Resident R1's EMR (electronic medical record) and paper file indicated no Inventory Sheet( form used to log resident belongings on admission).

Review of Resident R2's admission record indicated the resident was admitted to the facility 7/1/24, with diagnoses of bipolar disorder, end stage renal disease and renal dialysis dependence.

Review of Resident R2's EMR (electronic medical record) and paper file indicated no Inventory Sheet( form used to log resident belongings on admission).

Review of Resident R3's admission record indicated the resident was admitted to the facility 7/27/20, with the diagnoses of dementia (a general term for loss of memory, language, problem solving that are severe enough to interfere with daily life), depression and schizoaffective disorder.

Review of Resident R3's EMR (electronic medical record) and paper file indicated no Inventory Sheet( form used to log resident belongings on admission).

Review of Resident R4's admission record indicated the resident was admitted to the facility 10/27/23, with diagnoses of dementia (a general term for loss of memory, language, problem solving that are severe enough to interfere with daily life) and malignant neoplasm of the lung.

Review of Resident R4's EMR (electronic medical record) and paper file indicated no Inventory Sheet( form used to log resident belongings on admission).

During an interview on 7/25/24, at 11:30 a.m. the Nursing Home Administrator confirmed the Resident R1, R2, R3 and R4 medical records were incomplete and not accurate for four of seven reviewed.

28 Pa. Code 111.5(f) Clinical records
28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 09/04/2024

Resident's (R1, R2, R3 and R4) belongings (if noted with any) have been recorded on an inventory sheet and are in the resident records.
A review of current resident's medical record completed to ensure an inventory sheet has been completed and uploaded into the resident's medical record.
Chart reviews to be completed following the resident's admission to verify that an inventory sheet has been completed and uploaded in to the resident's medical record.
Education with nursing staff on F842 by the Director of Nursing/designee with a focus on ensuring that clinical records are complete and accurate to include an inventory sheet.
Audits for new admission's inventory sheets to be completed weekly X4 weeks then monthly X2.
Results of audits will be reviewed at the facilities quality assurance performance improvement meeting.

483.90(i)(4) REQUIREMENT Maintains Effective Pest Control Program:

�483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.

Observations:

Based on pest control service logs, observations, and staff interview it was determined that the facility failed to maintain an effective pest control program for one out of two nurses stations (2nd floor) and two out of three rooms (2nd floor).

Findings include:

Review of records of invoices from pest control provider dated May-July 2024 , indicated that mouse traps were laid out; however, the record did not include evidence of efforts to eradicate mice on the 2nd floor nursing unit in July 2024.

During observation on 7/25/24, the 2nd floor was observed with the following:
At 10 a.m. observations of three glue traps beside the unit refrigerator.
Rooms 2020 and 2021 glue traps in rooms under the heating units.

During an interview on 7/25/24 at 10:30 a.m. Resident R5 indicated he has "seen mice and cockroaches on the nursing unit". Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 6/27/24, indicated Resident R5 has a BIMS (Interview for Mental Status), cognitively intact.

During an interview on 7/25/24 at 1:30 p.m. Nursing Home Administrator confirmed the facily failed to maintain an effective pest control program as required.

28 Pa. Code.18(e)(2) Management

28 Pa. Code 207.20(a) Administrator's responsibility

Plan of Correction - To be completed: 09/04/2024

The facility removed the mouse traps from behind the nurses' station on 2nd floor as well as from room 2020 and 2021.
Terminix will follow up and treat affected areas as needed.
Education with maintenance by the administrator on F925 with a focus on maintaining an effective pest control program.
Unit inspection to ensure that the environment is free from mice will be completed weekly X4 weeks then monthly X2.
Results of audits will be reviewed at the facilities quality assurance performance improvement meeting.

� 211.12(f.1)(3) LICENSURE Nursing services. :

(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.

Plan of Correction - To be completed: 09/04/2024

No residents were affected during the days identified in the 2567. The Administrator, Director of Nursing and Staffing Coordinator were educated regarding minimum staffing ratios for Nurse Aides by the Corporate Clinical Director.
The facility has previously reviewed the staffing plan and has assessed wages, provided extra shift pick up bonuses to qualified staff, provided for flexible scheduling, and has advertised in several ways for staff including on online help wanted sites.
The facility will send representatives to local job fairs, partnered with local businesses such as job corps, each morning the administration staff meets to review the staffing for the day and any critical days in the future, weekly staffing meetings, staffing to include increased employees to cover for any call offs, progressive disciplinary action if necessary and weekly review of new staff that has been hired and will be joining the facility team in the future and any staff that has resigned or has been terminated. Corporate leadership included on strategies and any needs of the facility.
The Nursing Home Administrator, Director of Nursing, and Staffing Coordinator, or designees, will review the ratios daily and look ahead in the upcoming week schedule.
The Director of Nursing or designee will monitor the staffing ratios for nurse aides 5 times a week for 4 weeks then weekly X4.
Results of audits will be reviewed at the facilities quality assurance performance improvement meeting.

� 211.12(f.1)(4) LICENSURE Nursing services. :

(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 review of nursing time schedule documents, and staff interview, it was determined that the facility to provide a minimum of one licensed practical nurse (LPN) per 25 residents during daylight shifts for six out of 15 days (6/16/24, 6/17/24, 6/21/24, 6/22/24, 6/28/24 and 6/30/24) and failed to provide a minimum of one Licensed Practical Nurse (LPN) per 30 residents during the evening shift for five out of 15 days (6/19/24, 6/20/24, 6/24/24, 6/25/24 and 6/28/24) and one licensed practical nurse (LPN) per 25 residents during daylight shifts for two out of 7 days (7/5/24 and 7/7/24).

Findings include:

A review of 3-week nurse staffing schedules (6/16/24-6/30/24) did not include one Licensed Practical Nurse (LPN) per 25 residents during the day shift on the following dates: 6/16/24, 6/17/24, 6/21/24, 6/22/24, 6/28/24 and 6/30/24.

A review of 3-week nurse staffing schedules (6/16/24-6/30/24) did not include one Licensed Practical Nurse (LPN) per 30 residents during the evening shift on the following dates: 6/19/24, 6/20/24, 6/24/24, 6/25/24 and 6/28/24.

A review of 3-week nurse staffing schedules (7/1/24-7/7/24) did not include one Licensed Practical Nurse (LPN) per 25 residents during the day shift on the following dates: 7/5/24 and 7/7/24.

During an interview on 7/25/24, at 1:20 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during daylight shifts for six out of 15 days (6/16/24, 6/17/24, 6/21/24, 6/22/24, 6/28/24 and 6/30/24) and failed to provide a minimum of one Licensed Practical Nurse (LPN) per 30 residents during the evening shift for five out of 15 days (6/19/24, 6/20/24, 6/24/24, 6/25/24 and 6/28/24) and one licensed practical nurse (LPN) per 25 residents during daylight shifts for two out of 7 days (7/5/24 and 7/7/24) as required.

Plan of Correction - To be completed: 09/04/2024

No residents were affected during the days identified in the 2567. The Administrator, Director of Nursing and Staffing Coordinator were re-educated regarding minimum staffing ratios for Licensed Practical Nurses by the Corporate Clinical Director.
The facility has previously reviewed the staffing plan and has assessed wages, provided extra shift pick up bonuses to qualified staff, provided for flexible scheduling, and has advertised in several ways for staff including on online help wanted sites.
The facility will send representatives to local job fairs, partnered with local businesses such as job corps, each morning the administration staff meets to review the staffing for the day and any critical days in the future, weekly staffing meetings, staffing to include increased employees to cover for any call offs, progressive disciplinary action if necessary and weekly review of new staff that has been hired and will be joining the facility team in the future and any staff that has resigned or has been terminated. Corporate leadership included on strategies and any needs of the facility.

The Nursing Home Administrator, Director of Nursing, and Staffing Coordinator, or designees, will review the ratios daily and look ahead in the upcoming week schedule.
The Director of Nursing or designee will monitor the staffing ratios for LPN 5 times a week for 4 weeks then weekly X4.
Results of audits will be reviewed at the facilities quality assurance performance improvement meeting.

� 211.12(i)(2) LICENSURE Nursing services.:

(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 2.87 PPD (per patient daily) hours of direct care for each resident for fifteen out of 15 days reviewed (6/16/24, 6/17/24, 6/18/24, 6/19/24, 6/20/24, 6/21/24, 6/22/24, 6/23/24, 6/24/24, 6/25/24, 6/26/24, 6/27/24, 6/28/24, 6/29/24 and 6/30/24) and the facility failed to provide a minimum of 3.20 PPD (per patient daily) hours of direct care for each resident for six out of seven days reviewed (7/1/24, 7/2/24, 7/3/24, 7/5/24, 7/6/24 and 7/7/24).

Findings include:

Review of staffing documents and nurse schedules for 3 weeks (6/16/24-7/7/24) indicated that State required PPD (per patient daily) minimum hours of 2.87 was not met on the following days:
6/16/24= 2.56 PPD
6/17/24= 2.81 PPD
6/18/24= 2.77 PPD
6/19/24= 2.66 PPD
6/20/24= 2.81 PPD
6/21/24= 2.71 PPD
6/22/24= 2.52 PPD
6/23/24= 2.62 PPD
6/24/24= 2.51 PPD
6/25/24= 2.81 PPD
6/26/24= 2.61 PPD
6/27/24= 2.77 PPD
6/28/24= 2.72 PPD
6/29/24= 2.33 PPD
6/30/24= 2.54 PPD

State required PPD (per patient daily) minimum hours of 3.20 was not met on the following days:
7/1/24= 2.95 PPD
7/2/24= 2.99 PPD
7/3/34= 3.18 PPD
7/5/24= 2.73 PPD
7/6/24= 2.73 PPD
7/7/24= 2.56 PPD

During an interview on 7/25/24, at 1:20 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a minimum of 2.87 PPD (per patient daily) hours of direct care for each resident for fifteen out of 15 days reviewed (6/16/24, 6/17/24, 6/18/24, 6/19/24, 6/20/24, 6/21/24, 6/22/24, 6/23/24, 6/24/24, 6/25/24, 6/26/24, 6/27/24, 6/28/24, 6/29/24 and 6/30/24) and the facility failed to provide a minimum of 3.20 PPD (per patient daily) hours of direct care for each resident for six out of seven days reviewed (7/1/24, 7/2/24, 7/3/24, 7/5/24, 7/6/24 and 7/7/24).

Plan of Correction - To be completed: 09/04/2024

No residents were affected during the days identified in the 2567. The Administrator, Director of Nursing and Staffing Coordinator were re-educated regarding minimum staffing PPD (per patient day) by the Corporate Clinical Director.
The facility has previously reviewed the staffing plan and has assessed wages, provided extra shift pick up bonuses to qualified staff, provided for flexible scheduling, and has advertised in several ways for staff including on online help wanted sites.
The facility will send representatives to local job fairs, partnered with local businesses such as job corps, each morning the administration staff meets to review the staffing for the day and any critical days in the future, weekly staffing meetings, staffing to include increased employees to cover for any call offs, progressive disciplinary action if necessary and weekly review of new staff that has been hired and will be joining the facility team in the future and any staff that has resigned or has been terminated. Corporate leadership included on strategies and any needs of the facility.
The Nursing Home Administrator, Director of Nursing, and Staffing Coordinator, or designees, will review the ratios daily and look ahead in the upcoming week schedule.
The Director of Nursing or designee will monitor the PPD 5 times a week for 4 weeks then weekly X4.
Results of audits will be reviewed at the facilities quality assurance performance improvement meeting.

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