Pennsylvania Department of Health
 GROVE AT GREENVILLE, THE
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GROVE AT GREENVILLE, THE
Inspection Results For:

There are  131 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.
GROVE AT GREENVILLE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey and an Abbreviated Complaint Survey completed on July 18, 2024, at The Grove at Greenville, it was determined there were no federal deficiencies identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities as it relates 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)(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 review of facility nursing staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide (NA) per 12 residents on the evening shift for one of seven days reviewed from 1/6/24 through 1/12/24, for staffing ratio (1/6/24).

Findings include:

Review of seven days of nursing staffing documentation from 1/6/24, through 1/12/24, for the evening shift revealed:

1/6/24,facility census of 88 residents,7.00 NA's worked and 7.33 were required.

Therefore, not meeting the required minimum number of one NA per 12 residents on the evening shift.

During an interview on 7/18/24, at approximately 11:30 a.m. the Nursing Home Administrator confirmed the accuracy of the facility provided staffing information and confirmed the facility failed to meet the minimum NA to resident ratio on the above date and shift.





 Plan of Correction - To be completed: 08/26/2024

1. The facility cannot correct that nurse aide staffing ratios were not met 1/6/24. There were no adverse effects to residents on the identified dates.

2. The facility will ensure that staffing ratios are met every shift.

3. Nursing administration and the nursing scheduler will be re-educated by the Nursing Home Administrator/designee on ensuring staffing ratios are meet each shift. A Daily staffing meeting will be held by administration to monitor staffing ratios. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing ratios the scheduler/or designee will call off duty facility staff, and will utilize external staffing support resources.

4. The Nursing Home Administrator/designee will audit staffing daily for three weeks and monthly for three months to ensure staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.

Re-education will take place 8/8/2024.
§ 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 facility nursing staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide (NA) per 10 residents on day shift for eight of 14 days reviewed (7/1/24, 7/7/24, 7/11/24 - 7/15/24, and 7/17/24), one NA per 10 residents on evening shift for 14 of 14 days reviewed (7/1/24 - 7/7/24, 7/11/24 - 7/17/24), and one NA per 15 residents on overnight shift for nine of 14 days reviewed (7/1/24 - 7/5/24, 7/11/24 - 7/13/24, and 7/17/24) from 7/1/24 through 7/7/24, and 7/11/24 through 7/17/24, for staffing ratios.

Findings include:

Review of 14 days of nursing staffing documentation from 7/1/24 through 7/7/24, and from 7/11/24 through 7/17/24, for the day shift revealed:

7/1/24,facility census of 86 residents 8.0 NA's worked and 8.60 were required.
7/7/24, facility census of 90 residents 8.0 NA's worked and 9.00 were required.
7/11/24,facility census of 92 residents 8.0 NA's worked and 9.20 were required.
7/12/24,facility census of 92 residents 9.0 NA's worked and 9.20 were required.
7/13/24,facility census of 92 residents 9.0 NA's worked and 9.20 were required.
7/14/24,facility census of 90 residents 7.20 NA's worked and 9.00 were required.
7/15/24,facility census of 90 residents 8.0 NA's worked and 9.00 were required.
7/17/24,facility census of 91 residents 9.0 NA's worked and 9.10 were required.

Therefore, not meeting the required minimum number of one nurse aide (NA) per 10 residents on the day shift.

Review of 14 days of nursing staffing documentation from 7/1/24 through 7/7/24, and from 7/11/24 through 7/17/24, for the evening shift revealed:

7/1/24, facility census of 86 residents 7.47 NA's worked and 7.82 were required.
7/2/24,facility census of 88 residents 6.50 NA's worked and 8.00 were required.
7/3/24,facility census of 88 residents 7.0 NA's worked and 8.0 were required.
7/4/24,facility census of 88 residents 7.5 NA's worked and 8.0 were required.
7/5/24,facility census of 89 residents 7.0 NA's worked and 8.09 were required.
7/6/24,facility census of 90 residents 7.0 NA's worked and 8.18 were required.
7/7/24,facility census of 90 residents 7.0 NA's worked and 8.18 were required.
7/11/24,facility census of 92 residents 7.50 NA's worked and 8.36 were required.
7/12/24,facility census of 92 residents 7.50 NA's worked and 8.36 were required.
7/13/24,facility census of 92 residents 8.0 NA's worked and 8.36 were required.
7/14/24,facility census of 90 residents 7.0 NA's worked and 8.18 were required.
7/15/24,facility census of 90 residents 7.50 NA's worked and 8.18 were required.
7/16/24,facility census of 90 residents 7.50 NA's worked and 8.18 were required.
7/17/24,facility census of 91 residents 8.0 NA's worked and 8.27 were required.

Therefore, not meeting the required minimum number of one nurse aide (NA) per 10 residents on the evening shift.

Review of 14 days of nursing staffing documentation from 7/1/24 through 7/7/24, and from 7/11/24 through 7/17/24, for the overnight shift revealed:

7/1/24, facility census of 86 residents 5.00 NA's worked and 5.73 were required.
7/2/24,facility census of 88 residents 5.00 NA's worked and 5.87 were required.
7/3/24,facility census of 88 residents 5.00 NA's worked and 5.87 were required.
7/4/24,facility census of 88 residents 5.00 NA's worked and 5.87 were required.
7/5/24,facility census of 89 residents 5.00 NA's worked and 5.93 were required.
7/11/24,facility census of 92 residents 6.0 NA's worked and 6.13 were required.
7/12/24,facility census of 92 residents 6.0 NA's worked and 6.13 were required.
7/13/24,facility census of 92 residents 6.0 NA's worked and 6.13 were required.
7/17/24,facility census of 91 residents 6.0 NA's worked and 6.07 were required.

Therefore, not meeting the required minimum number of one nurse aide (NA) per 15 residents on the night shift.

During an interview on 7/18/24, at approximately 11:30 a.m. the Nursing Home Administrator confirmed the accuracy of the facility provided staffing information and confirmed the facility failed to meet the minimum NA to resident ratio on the above dates and shifts.








 Plan of Correction - To be completed: 08/26/2024

1. The facility cannot correct that nurse aide staffing ratios were not met dayshift on 7/1/24, 7/7/24, 7/11/24 - 7/15/24, and 7/17/24, evening shift 7/1/24 - 7/7/24, 7/11/24 - 7/17/24, and overnight shit 7/1/24 - 7/5/24, 7/11/24 - 7/13/24, and 7/17/24.

2. The facility will ensure that staffing ratios are met every shift

3. Nursing administration and the nursing scheduler will be re-educated by the Nursing Home Administrator/designee on ensuring staffing ratios are meet each shift. A Daily staffing meeting will be held by administration to monitor staffing ratios. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing ratios the scheduler/or designee will call off duty facility staff, and will utilize external staffing support resources

4. The Nursing Home Administrator/designee will audit staffing daily for three weeks and monthly for three months to ensure staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations

Education will occur on 8/8/2024
§ 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 review of facility nursing staffing documents and staff interview, it was determined that the facility failed to ensure the total number of nursing care hours provided in each 24-hour period met the required minimum of 3.20 hours of direct care per resident beginning July 1, 2024, for nine of 14 days reviewed (7/1/24, 7/2/24, 7/3/24, 7/6/24, 7/7/24, 7/11/24, 7/13/24, 7/14/24, and 7/17/24).

Findings include:

Review of nursing staffing documents for the time period of 7/1/24 through 7/7/24, and 7/11/24 through 7/17/24, revealed the following per patient day (PPD) hours:

7/1/24 3.18 PPD
7/2/24 3.11 PPD
7/3/24 3.15 PPD
7/6/24 3.17 PPD
7/7/24 3.19 PPD
7/11/24 3.19 PPD
7/13/24 3.18 PPD
7/14/24 3.02 PPD
7/17/24 3.17 PPD

During an interview on 7/18/24, at approximately 11:30 a.m. the Nursing Home Administrator confirmed the accuracy of the facility provided staffing information and confirmed the facility failed to meet the required hours of direct resident care on the above dates.



 Plan of Correction - To be completed: 08/26/2024

1. The facility cannot correct the PPD staffing requirements that were not met 7/1/24, 7/2/24, 7/3/24, 7/6/24, 7/7/24, 7/11/24, 7/13/24, 7/14/23, 7/17/24. There were no adverse effects to residents on the identified dates.

2. The facility will ensure that staffing PPD requirements are met on a daily baiss.

3. Nursing administration and the nursing scheduler will be re-educated by the Nursing Home Administrator/designee on ensuring PPD (per patient day) requirement is met everyday. A Daily staffing meeting will be held by administration to monitor staffing. Nursing supervisors will monitor on weekends. If the facility is projected to not meet 3.2 PPD, the scheduler/or designee will call off duty facility staff, and will utilize external staffing support resources.

4. The Nursing Home Administrator/designee will audit staffing daily for three weeks and monthly for three months to ensure staffing PPD requirements are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.

Education will take place on 8/8/24.

Yes, agency and off duty staff will be utilized in the event of unexpected call offs.

Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance


Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement
Visit the PA Power Port