Pennsylvania Department of Health
FREDERICK LIVING - CEDARWOOD
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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FREDERICK LIVING - CEDARWOOD - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and a Civil Rights survey completed on September 4, 2024, at Frederick Living - Cedarwood, it was determined there were no deficiencies identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities as it related to the Health portion of the survey process; however, the facility was not in compliance with the following requirements of 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 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 a review of nursing time schedules, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for three of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from August 14 through September 3, 2024, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on night shift (11:00 p.m. to 7:00 a.m.) on August 18, 20, and 21, 2024.

Plan of Correction - To be completed: 09/18/2024

The 11:00 p.m. – 7:00 a.m. schedule has been altered to add team member hours to this shift. On call nursing team members have been re-educated on decision-making priorities regarding staffing levels, particularly LPN staffing.

Daily scheduling meetings have been instituted to review upcoming shift schedules and strategies for call-offs/cancellations. These meetings are also an opportunity to monitor the previous days' staffing outcomes. System issues will be reported to the QAPI team for review and improvement.

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