Pennsylvania Department of Health
SUMMIT AT BLUE MOUNTAIN NURSING AND REHABILITATION CENTER, T
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SUMMIT AT BLUE MOUNTAIN NURSING AND REHABILITATION CENTER, T
Inspection Results For:

There are 74 surveys for this facility. Please select a date to view the survey results.

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SUMMIT AT BLUE MOUNTAIN NURSING AND REHABILITATION CENTER, T - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a revisit survey completed on April 4, 2024, it was determined that The Summit at Blue Mountain Nursing and Rehabilitation Center corrected the federal deficiencies identified during the survey of January 25, 2024, under the requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care but continued to be out of 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)(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 schedules and staff interviews, it was determined that the facility failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift, 1 LPN per 30 residents on the evening shifts, and one LPN per 40 residents during the night shift on one of 7 days (March 30, 2024).

Findings include:

Review of facility census data indicated that on March 30, 2024, the facility census was 36, which required 1 LPNs during the night shift.

Review of the nursing time schedules and time punch card documentation revealed 0 LPNs provided care on March 30, 2024, on the night shift.

No additional excess higher-level staff were available to compensate this deficiency.

An interview April 4, 2024 at 11 A.M., the Nursing Home Administrator confirmed that the facility did not meet the state minimum nursing ratios for LPNs

Plan of Correction - To be completed: 04/23/2024

Staffing ratios cannot be retroactively corrected for previous date noted out of ratio compliance.

Education provided to facility staff responsible for ratios regarding regulations and ratios for night shift. DON and/or NHA to confirm proper PPD and ratios per shift.

Facility designee to monitor for correct nursing rations weekly x 4, monthly x 2 to ensure compliance for staffing ratios. Findings to be reported to QAPI.

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