Pennsylvania Department of Health
AVENTURA AT CREEKSIDE
Patient Care Inspection Results

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AVENTURA AT CREEKSIDE
Inspection Results For:

There are  112 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.
AVENTURA AT CREEKSIDE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a revisit and abbreviated complaint survey completed on January 24, 2024, it was determined that Aventura at Creekside failed to correct federal deficiencies cited during the survey of November 20, 2023, and continued to be out of 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(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and the resident pantry.

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).

A tour of the facility's kitchen conducted on January 24, 2024, at approximately 10 AM, in the presence of the Director of Nursing, revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness:

There were seven thawed four-ounce nutritional shakes on in a square metal container on a shelf in the refrigerator which were not dated. Per the manufacturer label the shakes should be used within 14 days of thawing.

Multiple dead bugs were observed in the overhead light fixtures.

Observation of the resident pantry on the unit revealed that the resident refrigerator contained numerous containers of food that were labeled with a room number, but lacked the date when they item was placed in the refrigerator.

The bottom of the refrigerator was heavily soiled with food debris and a sticky substance.

The floor of the resident pantry was heavily soiled with dirt and debris.

During an interview with the Nursing Home Administrator (NHA) on January 24, 2024, at 2:30 AM confirmed that the dietary department and resident pantry area were to be maintained in a sanitary manner to prevent potential contamination of food and storage items.


28 Pa. Code 201.18 (e)(2.1) Management





 Plan of Correction - To be completed: 02/12/2024

1. The 7 thawed four-ounce nutritional shakes were discarded. The items in the resident refrigerator that lacked a date, where discarded. The bottom of the refrigerator and the floor in the resident pantry was cleaned the day of the survey.

2. The Administrator/designee will conduct an audit of thawing practices of items with expiration dates. The Administrator/designee will conduct a general audit of the resident pantry for dated food in the resident refrigerator and general cleanliness of the refrigerator and floor.

3. Food Service Director and dietary staff will be re-educated on open dates. Housekeeping will be educated on daily cleaning checklists for resident pantry, and the supervisor will sign off after verification of cleaning.

4. Nursing home Administrator/designee will conduct random audits of kitchen area and resident pantry, two times a day 5x a week for two weeks and then weekly times two months. Results will be reviewed by QA committee for 2 months and then reevaluated.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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.
§483.10(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 81°F; and

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

Based on observation and staff interview it was determined that the facility failed to provide housekeeping services to maintain a clean and orderly environment and resident care equipment in one resident room out of 34 (Room 116) and as observed for one resident on the one resident unit in the facility.


Findings include:


Observations of resident room 116 revealed that just inside the door there blankets were observed laying on the floor. The overbed table was soiled with food debris. Dirty resident laundry, and tissues were observed on the floor and a plastic medicine cup containing a moist substance on the floor under the center resident bed in the room.

Observation of room 116's resident bathroom revealed moist towels hanging on the assist bars of the toilet. A soiled brief was observed on the floor next to the garbage can. The trash can in the bathroom was overflowing with garbage. A bedpan was placed on the top of the toilet assist/grab bar.

Observation in the hallway of the resident unit revealed that the inside arm panels of Resident 4's wheelchair were heavily soiled with dried stuck-on food debris.

Interview with the Nursing Home Administrator on January 24, 2024, at approximately 2:30 PM confirmed the facility is to be maintained daily to provide a clean and sanitary living environment for the residents.


28 Pa. Code 201.18 (e)(2.1) Management




 Plan of Correction - To be completed: 02/12/2024

1. Blankets that were observed laying on the floor were immediately picked up. The overbed table was cleaned. Dirty resident laundry and trash that was on the floor was cleaned up. Towels hanging on the assist bars of the toilet were placed in the laundry. The brief was disposed of. The bathroom trash was emptied. The bedpan was removed and stored appropriately. Resident 4's wheelchair was cleaned.

2. The Administrator/designee conducted an audit of resident rooms and bathrooms to identify any others with the potential to be affected. All cleanliness issues were addressed.
An audit of the cleanliness of all residents utilizing wheelchairs will be conducted. Any chairs needing to be cleaned will be cleaned, and any needing to be replaced will be.

3. All nursing staff will be educated on maintaining a clean environment with includes handling of soiled linen and disposing of incontinent products.

All housekeeping staff will be educated on general cleanliness expectations of resident rooms and the frequency of emptying trash in resident bathrooms.

Housekeeping staff will implement a wheelchair cleaning schedule to ensure all wheelchairs are being cleaned. Any resident identified as needing more frequent wheelchair cleaning will be added to the cleaning schedule as appropriate.

Any resident identified as needing more frequent cleaning of bathrooms will be added to housekeeping schedule as appropriate.

4. To monitor and maintain ongoing compliance, Nursing home Administrator/designee will conduct random audits of kitchen area and resident pantry, two times a day 5x a week for two weeks and then weekly times two months. Results will be reviewed by QA committee for 2 months and then reevaluated.

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 observations and staff and resident interview it was determined that the facility failed to maintain an environment free of potential accident hazards on one of one nursing unit

Findings include:


Observations conducted during a tour of resident rooms on January 24, 2024, at 11:25 AM revealed in occupied resident room 116 two bottles of Nystatin powder (antifungal powder), one container of calmoseptine ointment, and one bottle of antifungal cream were observed on Resident 1's nightstand.

Additional observations of the resident rooms on January 24, 2024, at 12:35 PM revealed that the above noted creams and powders remained on the nightstand in Resident 1's room. Resident 1 was present in the room at the time of the observation and the resident care supplies and personal care products were within the resident's reach.

An observation of occupied room 115 revealed two containers of hydrogel wound ointment and one bottle of nystatin powder on Resident 2's nightstand within reach of the resident.

An observation of occupied room 139 revealed one bottle of isopropyl alcohol on top of the Resident 3's dresser. The resident was seated next to his dresser at the time of the observation and the bottle within his reach.

Interviews with the above residents at the time of these observations revealed that the residents did not use these products independently without staff assistance.

These personal care and resident care supplies were labeled for external use only and were potentially hazardous if ingested or mishandled by residents.

An interview with the Nursing Home Administrator on January 24, 2024, at 2:15 PM verified that residents' treatment and care supplies should not be left out at the bedside and confirmed the facility failed to maintain the residents' environment free of potential accident hazards.


28 Pa. Code 201.18 (e)(2.1) Management

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



 Plan of Correction - To be completed: 02/12/2024

1. The two bottles of Nystatin powder (antifungal powder), one container of calmoseptine ointment, and one bottle of antifungal cream were immediately removed from the resident #1's room and locked in the Medication Cart. Two containers of hydrogel wound ointment and one bottle of nystatin powder were immediately removed from Resident #2's room and secured in the Medication Cart as well. The bottle of Isopropyl Alcohol was also immediately removed and disposed of.

2. To identify others with the potential to be affected, the facility completed a sweep of resident rooms to determine if powder, ointment, cream or other hazardous items were left at bedside. Items removed as necessary.

3. To prevent this from reoccurring, the ADON/designee educated staff on the regulatory requirements of F689 Free of Accident Hazard/Supervision/Devices and that the resident environment should remain as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents. (i.e., no treatments should be left at bedside.)

4. To monitor and maintain ongoing compliance, the DON/designee will complete room rounds to ensure there are no treatments/or other hazardous items left at bedside 5x weekly for 4 weeks, 2x weekly x1 month then weekly x1 month. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

483.10(i)(4), 483.90(e)(2)(3) REQUIREMENT Resident Room Bed/Furniture/Closet: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.
§483.10(i)(4) Private closet space in each resident room, as specified in §483.90
(e)(2)(iv)

§483.90(e)(2) -The facility must provide each resident with--
(i) A separate bed of proper size and height for the safety and convenience of the resident;
(ii) A clean, comfortable mattress;
(iii) Bedding, appropriate to the weather and climate; and
(iv) Functional furniture appropriate to the resident's needs, and individual closet space in the resident's bedroom with clothes racks and shelves accessible to the resident.

§483.90(e)(3) CMS, or in the case of a nursing facility the survey agency, may permit variations in requirements specified in paragraphs (e)(1) (i) and (ii) of this section relating to rooms in individual cases when the facility demonstrates in writing that the variations
(i) Are in accordance with the special needs of the residents; and
(ii) Will not adversely affect residents' health and safety.
Observations:

Based on observations and staff interview it was determined that the facility failed to provide each resident with a clean mattress on one bed out of 81 available in the facility (Resident room 114).


Findings revealed:

Observations of resident room 114 on January 24, 2024, at 11:25 AM revealed that the resident bed located by the door was stripped of its bottom fitted sheet.

Further observation of the exposed mattress on the bed revealed that there were distinct dirty shoe footprints visible on top of the mattress.

Interview with the Nursing Home Administrator on January 24, 2024, at approximately 2:30 PM confirmed the facility is to provide a clean and sanitary mattress for each resident.


28 Pa. Code (e)(2.1) Management



 Plan of Correction - To be completed: 02/12/2024

1. No resident was occupying the bed closest to the door in resident room 114.

2. The Administrator/designee conducted an audit of all mattress' in empty resident rooms, to ensure they are clean and in good condition.

3. All housekeeping staff was educated on ensuring each mattress placed on a resident bed is clean and sanitary.

4. To monitor and maintain ongoing compliance, the DON/designee will complete daily room rounds 5x a week to ensure mattress' are clean and sanitary.

§ 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 nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 36 shifts out of 63 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse aide staff of 1:12 on the day and evening shift and 1:20 on the night shift based on the facility's census.

January 3, 2024 - 5.88 nurse aides on the day shift, versus the required 6.17 for a census of 74.
January 3, 2024 - 5 nurse aides on the evening shift, versus the required 6.17 for a census of 74.
January 3, 2024 - 3.63 nurse aides on the night shift, versus the required 3.7 for a census of 74.
January 4, 2024 - 5.13 nurse aides on the day shift, versus the required 6.33 for a census of 76.
January 4, 2024 - 6 nurse aides on the evening shift, versus the required 6.33 for a census of 76.
January 5, 2024 - 5.88 nurse aides on the day shift, versus the required 6.33 for a census of 76.
January 5, 2024 - 5.13 nurse aides on the evening shift, versus the required 6.33 for a census of 76.
January 5, 2024 - 3.63 nurse aides on the night shift, versus the required 3.80 for a census of 76.
January 6, 2024 - 5.63 nurse aides on the day shift, versus the required 6.33 for a census of 76.
January 6, 2024 - 4.75 nurse aides on the evening shift, versus the required 6.33 for a census of 76.
January 7, 2024 - 4.38 nurse aides on the day shift, versus the required 6.33 for a census of 76.
January 7, 2024 - 4 nurse aides on the evening shift, versus the required 6.33 for a census of 76.
January 7, 2024 - 3.75 nurse aides on the night shift, versus the required 3.80 for a census of 76.
January 8, 2024 - 5.63 nurse aides on the day shift, versus the required 6.33 for a census of 76.
January 8, 2024 - 5.75 nurse aides on the evening shift, versus the required 6.33 for a census of 76.
January 9, 2024 - 5.75 nurse aides on the day shift, versus the required 6.33 for a census of 76.
January 9, 2024 - 5.25 nurse aides on the evening shift, versus the required 6.33 for a census of 76.
January 9, 2024 - 3.63 nurse aides on the night shift, versus the required 3.80 for a census of 76.
January 10, 2024 - 5 nurse aides on the evening shift, versus the required 6.33 for a census of 76.
January 11, 2024 - 5.63 nurse aides on the day shift, versus the required 6.08 for a census of 73.
January 11, 2024 - 5.25 nurse aides on the evening shift, versus the required 6.08 for a census of 73.
January 12, 2024 - 5.13 nurse aides on the evening shift, versus the required 6.08 for a census of 73.
January 12, 2024 - 3.63 nurse aides on the night shift, versus the required 3.65 for a census of 73.
January 13, 2024 - 4.75 nurse aides on the day shift, versus the required 6 for a census of 72.
January 13, 2024 - 4.75 nurse aides on the evening shift, versus the required 6 for a census of 72.
January 14, 2024 - 4 nurse aides on the evening shift, versus the required 6 for a census of 72.
January 15, 2024 - 5.50 nurse aides on the evening shift, versus the required 6.08 for a census of 73.
January 16, 2024 - 5.63 nurse aides on the day shift, versus the required 6.25 for a census of 75.
January 16, 2024 - 4.25 nurse aides on the evening shift, versus the required 6.25 for a census of 75.
January 19, 2024 - 5 nurse aides on the evening shift, versus the required 6.33 for a census of 76.
January 20, 2024 - 5.75 nurse aides on the day shift, versus the required 6.42 for a census of 77.
January 20, 2024 - 4.38 nurse aides on the evening shift, versus the required 6.42 for a census of 77.
January 21, 2024 - 5.63 nurse aides on the evening shift, versus the required 6.42 for a census of 77.
January 22, 2024 - 4.75 nurse aides on the evening shift, versus the required 6.25 for a census of 75.
January 23, 2024 - 6 nurse aides on the day shift, versus the required 6.25 for a census of 75.
January 23, 2024 - 5.63 nurse aides on the evening shift, versus the required 6.25 for a census of 75.

An interview with the Nursing Home Administrator on January 24, 20024, at approximately 2:15 PM, confirmed the facility had not met the required nurse aide to resident ratios on the shifts and dates above.




 Plan of Correction - To be completed: 02/12/2024

1. Facility is unable to correct past deficiency.

2. The facility has an active recruitment/retention plan to fill open positions which includes supplemental staffing bonuses to cover vacancies. The facility will ensure that shift ratios are met on every shift.

3. Agency will be utilized for open shifts as needed and available. 

Calculation of daily shift ratios will be completed and reviewed daily for accuracy by the scheduler and DON. All efforts will be made to meet the staffing ratio. 

If call offs occur, all efforts will be made to attempt to fill that position with CNA's that are working in ancillary departments.

4.The DON or designee will conduct an audit of the CNA ratios to ensure ratios are being met weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and re-evaluation.
§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum licensed practical nurse staff to resident ratio was provided on each shift for 23 shifts out of 63 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:25 on the day shift, 1:30 on the evening shift, and 1:40 on the night shift based on the facility's census.

January 4, 2024 - 3 LPNs on the day shift, versus the required 3.04 for a census of 76.
January 4, 2024 - 2.38 LPNs on the evening shift, versus the required 2.53 for a census of 76.
January 5, 2024 - 3 LPNs on the day shift, versus the required 3.04 for a census of 76.
January 5, 2024 - 2.25 LPNs on the evening shift, versus the required 2.53 for a census of 76.
January 5, 2024 - 1.75 LPNs on the night shift, versus the required 1.90 for a census of 76.
January 6, 2024 - 3 LPNs on the day shift, versus the required 3.04 for a census of 76.
January 6, 2024 - 2.25 LPNs on the evening shift, versus the required 2.53 for a census of 76.
January 6, 2024 - 1.63 LPNs on the night shift, versus the required 1.90 for a census of 76.
January 7, 2024 - 3 LPNs on the day shift, versus the required 3.04 for a census of 76.
January 8, 2024 - 3 LPNs on the day shift, versus the required 3.04 for a census of 76.
January 9, 2024 - 3 LPNs on the day shift, versus the required 3.04 for a census of 76.
January 10, 2024 - 3 LPNs on the day shift, versus the required 3.04 for a census of 76.
January 11, 2024 - 1.75 LPNs on the night shift, versus the required 1.83 for a census of 73.
January 12, 2024 - 1.75 LPNs on the night shift, versus the required 1.83 for a census of 73.
January 14, 2024 - 2.25 LPNs on the evening shift, versus the required 2.40 for a census of 72.
January 15, 2024 - 2 LPNs on the evening shift, versus the required 2.43 for a census of 73.
January 15, 2024 - 1.38 LPNs on the night shift, versus the required 1.83 for a census of 73.
January 17, 2024 - 3 LPNs on the day shift, versus the required 3.04 for a census of 76.
January 18, 2024 - 3 LPNs on the day shift, versus the required 3.16 for a census of 79.
January 19, 2024 - 3 LPNs on the day shift, versus the required 3.04 for a census of 76.
January 19, 2024 - 1.5 LPNs on the night shift, versus the required 1.90 for a census of 76.
January 21, 2024 - 3 LPNs on the day shift, versus the required 3.08 for a census of 77.
January 21, 2024 - 1.63 LPNs on the night shift, versus the required 1.93 for a census of 77.

An interview with the Nursing Home Administrator on January 24, 2024, approximately 2:15 PM, confirmed the facility had not met the required LPN to resident ratios on the above dates.




 Plan of Correction - To be completed: 02/12/2024

1. Facility is unable to correct past deficiency.

2. The facility has an active recruitment/retention plan to fill open positions which includes supplemental staffing bonuses to cover vacancies. The facility will ensure that general nursing hours are being met for each shift.

3. Staff Scheduler, DON, HR will be educated on the importance of meeting LPN ratios, and that the facility is actively recruiting LPNs.

Agency will be utilized for open shifts as needed and available. 

Calculation of daily shift ratios will be completed and reviewed daily for accuracy by the scheduler and DON. All efforts will be made to meet the staffing ratio. 

If call offs occur, all efforts will be made to attempt to fill that position with LPN's that are working in ancillary departments.

4.The DON or designee will conduct an audit of the LPN ratios to ensure ratios are being met weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and re-evaluation.
§ 211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:

Based on a review of nurse staffing and resident census and staff interview, it was determined that the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Findings include:

A review of the facility's staffing levels revealed that on the following dates the facility failed to provide minimum nurse staffing of 2.87 hours of general nursing care to each resident:

January 3, 2024 -2.75 direct care nursing hours per resident
January 4, 2024 -2.75 direct care nursing hours per resident
January 5, 2024 -2.59 direct care nursing hours per resident
January 6, 2024 -2.60 direct care nursing hours per resident
January 7, 2024 - 2.43 direct care nursing hours per resident
January 9, 2024 - 2.80 direct care nursing hours per resident
January 11, 2024 - 2.78 direct care nursing hours per resident
January 13, 2024 - 2.75 direct care nursing hours per resident
January 14, 2024 - 2.79 direct care nursing hours per resident
January 16, 2024 - 2.86 direct care nursing hours per resident

An interview with the Nursing Home Administrator on January 24, 2024, at approximately 2:15 PM confirmed the facility failed to consistently provide minimum general nursing care hours to each resident daily.



 Plan of Correction - To be completed: 02/12/2024

1. Facility is unable to correct past deficiency.

2. A facility wide audit was completed to ensure the minimum PPD of 2.87 hours are met daily for each resident.

3. Staff Scheduler, DON, HR will be educated on the importance of meeting general nursing hours, and that the facility is actively recruiting nursing staff.

Agency will be utilized for open shifts as needed and available. 

Calculation of daily shift ratios will be completed and reviewed daily for accuracy by the scheduler and DON. All efforts will be made to meet general nursing hours requirement. 

If call offs occur, all efforts will be made to attempt to fill that position with CNA's/LPN's/RN's that are working in other capacities.

4.The DON or designee will conduct an audit of the general nursing hours are being met weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and re-evaluation.

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