Pennsylvania Department of Health
THIRD AVENUE HEALTH & REHAB CENTER
Patient Care Inspection Results

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THIRD AVENUE HEALTH & REHAB CENTER
Inspection Results For:

There are  103 surveys for this facility. Please select a date to view the survey results.

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THIRD AVENUE HEALTH & REHAB CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a revisit survey completed on February 21, 2024, it was determined that Third Avenue Health & Rehabilitation Center corrected the federal deficiencies cited during the survey of January 23, 2024, but was not in compliance with the following requirements of the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


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 aides (NA) staff to resident ratio was provided on the day, and evening shifts for 5 shifts out of 21 reviewed.

Findings include:

A review of the facility's weekly staffing records from February 14, 2024, through February 20, 2024, revealed that on the following dates the facility failed to provide minimum nurse aide staff of 1:12 on the day shifts, and 1:12 on the evening shifts, based on the facility's census.

Review of facility census data indicated that on February 15, 2024, the facility census was 49, which required 32.67 hours of nurse aides during evening shift.

Review of the nursing time schedules revealed 4.00 nurse aides provided care on the evening shift on February 15, 2024, for a total of 32.00 hours. No additional excess higher-level staff were used to compensate this deficiency.

Review of facility census data indicated that on February 16, 2024, the facility census was 49, which required 32.67 hours of nurse aides during day shift.

Review of the nursing time schedules revealed 3.88 nurse aides provided care on the day shift on February 16, 2024, for a total of 31.00 hours. No additional excess higher-level staff were used to compensate this deficiency.

Review of facility census data indicated that on February 16, 2024, the facility census was 49, which required 32.67 hours of nurse aides during evening shift.

Review of the nursing time schedules revealed 4.00 nurse aides provided care on the evening shift on February 16, 2024, for a total of 32.00 hours. No additional excess higher-level staff were used to compensate this deficiency.

Review of facility census data indicated that on February 17, 2024, the facility census was 49, which required 32.67 hours of nurse aides during day shift.

Review of the nursing time schedules revealed 4.06 nurse aides provided care on the day shift on February 17, 2024, for a total of 32.50 hours. No additional excess higher-level staff were used to compensate this deficiency.

Review of facility census data indicated that on February 17, 2024, the facility census was 49, which required 32.67 hours of nurse aides during evening shift.

Review of the nursing time schedules revealed 4.00 nurse aides provided care on the evening shift on February 17, 2024, for a total of 32.00 hours. No additional excess higher-level staff were used to compensate this deficiency.

An interview with the Nursing Home Administrator on February 21, 2024, at approximately 12:35 PM, confirmed the facility had not met the required minimum nurse aides to resident ratios on the day, and evening shifts on the above dates.



 Plan of Correction - To be completed: 03/12/2024

1.The facility cannot retroactively correct the past CNA staffing ratio deficiency.


2.Moving forward, the facility will continue to schedule staff in accordance with the mandated CNA ratio requirements. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios.


3.To prevent this from reoccurring, the RDCS reeducated the NHA; DON and Scheduler on the updated staffing regulations in relation specifically to the CNA staff/resident ratios.


4.To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility is staffed in accordance with the CNA mandated requirements. Audits will be completed 5x weekly x4 weeks; 3x weekly x1 month and weekly x1 month. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

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 (LPN) staff to resident ratio was provided on the day, evening, and night shifts for 4 shifts out of 21 reviewed.

Findings include:

A review of the facility's weekly staffing records from February 14, 2024, through February 20, 2024, revealed that on the following dates the facility failed to provide minimum LPN staff of 1:25 on the day shifts, 1:30 on the evening shifts, and 1:40 on the night shifts based on the facility's census.

Review of facility census data indicated that on February 14, 2024, the facility census was 51, which required 16.32 hours of LPN's during day shift.

Review of the nursing time schedules revealed 2.04 LPNs provided care on the day shift on February 14, 2024, for a total of 16.30 hours. No additional excess higher-level staff were used to compensate this deficiency.

Review of facility census data indicated that on February 14, 2024, the facility census was 50, which required 13.33 hours of LPNs during evening shift.

Review of the nursing time schedules revealed 1.64 LPNs provided care on the evening shift on February 14, 2024, for a total of 13.13 hours. No additional excess higher-level staff were used to compensate this deficiency.

Review of facility census data indicated that on February 17, 2024, the facility census was 49, which required 9.80 hours of LPNs during night shift.

Review of the nursing time schedules revealed 1.13 LPNs provided care on the night shift on February 17, 2024, for a total of 9.00 hours. No additional excess higher-level staff were used to compensate this deficiency.

Review of facility census data indicated that on February 20, 2024, the facility census was 47, which required 12.53 hours of LPNs during evening shift.

Review of the nursing time schedules revealed 1.00 LPNs provided care on the evening shift on February 20, 2024, for a total of 8.00 hours. No additional excess higher-level staff were used to compensate this deficiency.

An interview with the Nursing Home Administrator on February 21, 2024, at approximately 12:35 PM, confirmed the facility had not met the required minimum licensed practical nurse (LPN) to resident ratios on the day, evening, and night shifts on the above dates.



 Plan of Correction - To be completed: 03/12/2024

1.The facility cannot retroactively correct the past LPN staffing ratio deficiency.


2.Moving forward, the facility will continue to schedule staff in accordance with the mandated LPN ratio requirements. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios.


3.To prevent this from reoccurring, the RDCS reeducated the NHA; DON and Scheduler on the updated staffing regulations in relation specifically to the LPN staff/resident ratios.


4.To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility is staffed in accordance with the LPN mandated requirements. Audits will be completed 5x weekly x4 weeks; 3x weekly x1 month and weekly x1 month. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.


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