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

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GREENE HEALTH & REHAB CENTER
Inspection Results For:

There are  111 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.
GREENE HEALTH & REHAB CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a complaint survey completed on March 15, 2024, it was determined that Greensburg Health and Rehab Center was not in 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:


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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.
483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:


Based on review of policies, clinical records, and grievance/complaint investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of four residents reviewed (Resident 1).

Findings include:

The facility's policy regarding abuse, dated August 29, 2023, indicated that the facility would not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property. The facility would investigate all alleged, suspicions, and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property, and injuries of unknown source. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Mental abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated December 20, 2023, revealed that the resident could understand and was understood. A care plan for an Activities of Daily Living (ADL) self-care deficit, dated February 12, 2024, indicated that staff was to encourage the resident to use the call bell to call for assistance as needed. That the resident was at risk for falls and staff was to always keep the call light in reach and to keep personal items and frequently used items within reach.

An interview with Resident 1, completed by Registered Nurse 1, dated January 24, 2024, revealed that on January 24, 2024, at shift change, Agency Nurse Aide 2 (on the 400-unit) asked the registered nurse to go speak with Resident 1 regarding an incident that happened in the evening, and she did not want to be inadvertently associated with it. Agency Nurse Aide 3 from an unknown agency was working the first assignment on the 400 unit. Per Resident 1's report, Agency Nurse Aide 3 was rough with him during evening care, which he did not think too much of. Afterwards, Nurse Aide 3 did not place the bed remote and call light within his reach, to which Resident 1 asked her for these items. Resident 1 claims that Nurse Aide 3 stated she would give him back the call bell only if he agrees to not ring out until 10:00 p.m. Resident 1 stated he does not utilize the call bell except for emergencies and continued to ask for the call light back. At this time, Resident 1 stated that Nurse Aide 3 began to offer and retract the call light to him in a game-like manner that was upsetting to him. Resident 1 stated he then told Nurse Aide 3 to "give him his damn call light," to which Nurse Aide 3 then refused because the resident was swearing. Nurse Aide 3 then dropped the call light in the resident's trash can and left the room, closing the door behind her. Resident 1 stated that the heat was turned on in the room, making it very hot, and that he was unable to utilize the call bell, and that his door was closed. Resident 1 stated that he does not want to be at this facility and spends too much money to be here and to be treated in this manner. Resident 1 asked the writer to have Nurse Aide 3 terminated. The writer explained that Nurse Aide 3 was an outside agency staff, but that this matter would be addressed in a formal grievance to be handled by the appropriate management. Resident 1 seemed pleased with this outcome.

Interview with the Resident 1 on March 13, 2024, at 2:45 p.m. revealed that he had asked Nurse Aide 3 to do something for him but he could not recall what it was. He indicated that she became rude, so he became rude right back. That is when she took his call light off him and placed it in the garbage can where he could not reach it. He indicated that she then left the room and shut the door. He indicated that it was concerning to him because he was not able to reach the call bell if needed, and since the door was closed, he would not be able to yell out for assistance because no one would be able to hear him. He indicated that even his roommate at the time was ringing his call bell and no one would come. He indicated that it was not until the next shift when they finally came into his room.

Interview with Registered Nurse 1 on March 13, 2024, at 4:19 p.m. revealed that Resident 1 stated that Nurse Aide 3 came into his room and was rude. He had asked her for his call bell and Nurse Aide 3 would act as if she was going to give the call bell to him and then she would pull the call bell away, so he swore at her. Nurse Aide 3 made the resident mad by placing the call bell away from him, so that he could not use it. She indicated that at the time of her interview with the resident, she was not thinking it was abuse.

Interview with the Nursing Home Administrator on March 15, 2024, at 11:08 a.m. confirmed that the incident between Resident 1 and Nurse Aide 3 was considered abuse per their policy.

28 Pa. Code 201.14(a) Responsibility of Licensee.

28 Pa. Code 201.18(b)(1)(e)(1) Management.

28 Pa. Code 201.29(a)(j) Resident Rights.

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






 Plan of Correction - To be completed: 04/11/2024

The submission of this plan of correction does not constitute admission or agreement on the part of the provider with the deficiencies or conclusions contained in the Statement of Deficiencies. This plan of correction is prepared and executed solely to respond to the allegation of non-compliance cited during the annual re-licensure survey ended on March 15, 2024.


F600 Free from Abuse and Neglect


1. Actions taken for the situation identified:
Observations and assessments revealed no ill effects or injuries Resident 1.
A full investigation was completed, and Nurse Aide 3 has been placed on the Do Not Return list due to poor work performance; however, the facility was unable to substantiate the allegation of abuse. An event report will be filed, including a PB-22 report.

2. How the facility will act to protect residents in similar situations:
The facility recognizes that all residents have the potential to be affected. Facility staff, as well as agency staff, will be re-educated on the facility's policy on abuse and neglect, residents' rights, and the facility policy for following the individualized care plans in place for each resident.

3. System changes and measures to be taken:
The Regional Clinical Nurse Consultant will educate facility managers on properly identifying and investigating allegations of abuse. The Director of Nursing will educate facility staff, including agency staff, on how to properly report concerns, incidents, and allegations timely so that a thorough investigation can be initiated. Concern forms will be reviewed at both Clinical Morning Meeting and the afternoon Stand Down Meeting until resolved. All allegations of abuse will be investigated and reported to the Department of Health per facility policy through the electronic Event Reporting System, and other entities will be notified as required.

4. Monitoring mechanisms to assure compliance:
The Administrator/designee will be responsible for randomly monitoring 24-hour nursing reports, incident reports, and resident concerns (3) times a week for two (2) weeks and once (1) a week for four (4) weeks to ensure allegations of abuse are investigated and reported appropriately. Noted areas of non-compliance will be addressed upon discovery. Audit results will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings, and further action plans and audits will continue until substantial compliance is achieved. Ongoing self-monitoring will help to ensure quality standards continue to be met.


5. Date Corrective Action will be completed:
Substantial compliance is expected by April 11, 2024.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to thoroughly investigate potential abuse for one of four residents reviewed (Resident 1).

Findings include:

The facility's policy regarding abuse, dated August 29, 2023, indicated that the facility would not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property. The facility would investigate all alleged, suspicions, and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property, and injuries of unknown source. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Mental abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated December 20, 2023, revealed that the resident could understand and was understood. A care plan for an Activities of Daily Living (ADL) self-care deficit, dated February 12, 2024, indicated that staff was to encourage the resident to use the call bell to call for assistance as needed. The resident was at risk for falls, and staff was to always keep the call light in reach and to keep personal items and frequently used items within reach.

An interview with Resident 1, completed by Registered Nurse 1, dated January 24, 2024, revealed that on January 24, 2024, at shift change, Agency Nurse Aide 2 (on the 400-unit) asked the registered nurse to go speak with Resident 1 regarding an incident that happened in the evening, and she did not want to be inadvertently associated with it. Agency Nurse Aide 3 from an unknown agency was working the first assignment on the 400 unit. Per Resident 1's report, Agency Nurse Aide 3 was rough with him during evening care, which he did not think too much of. Afterwards, Nurse Aide 3 did not place the bed remote and call light within his reach, to which Resident 1 asked her for these items. Resident 1 claims that Nurse Aide 3 stated she would give him back the call bell only if he agrees to not ring out until 10:00 p.m. Resident 1 stated he does not utilize the call bell except for emergencies and continued to ask for the call light back. At this time, Resident 1 stated that Nurse Aide 3 began to offer and retract the call light to him in a game-like manner that was upsetting to him. Resident 1 stated he then told Nurse Aide 3 to "give him his damn call light," to which Nurse Aide 3 then refused because the resident was swearing. Nurse Aide 3 then dropped the call light in the resident's trash can and left the room, closing the door behind her. Resident 1 stated that the heat was turned on in the room, making it very hot, and that he was unable to utilize the call bell and that his door was closed. Resident 1 stated that he does not want to be at this facility and spends too much money to be here and to be treated in this manner. Resident 1 asked the writer to have Nurse Aide 3 terminated. This writer explained that Nurse Aide 3 was an outside agency staff, but that this matter would be addressed in a formal grievance to be handled by the appropriate management. Resident 1 seemed pleased with this outcome.

Interview with the Assistant Director of Nursing on March 13, 2024, at 2:35 p.m. revealed that when she came in to work the next morning, she was advised of the situation between Resident 1 and Nurse Aide 3. She went back to speak with Resident 1 and at that time the resident did not feel it was abuse because the other nurse aide had gotten him his call light, and that he did not want Nurse Aide 3 caring for him again. She indicated that is when the facility called Nurse Aide 3's agency and told them that she was not allowed to come back to the facility.

There was no documented evidence of the interaction between the Assistant Director of Nursing and Resident 1 on the morning following the incident on January 24, 2024. There was no documented evidence that statements were obtained from Nurse Aide 2, Nurse Aide 3, and/or Resident 1's roommate.

Interview with the Resident 1 on March 13, 2024, at 2:45 p.m. revealed that he had asked Nurse Aide 3 to do something for him but he could not recall what it was. He indicated that she became rude, so he became rude right back. That is when she took his call light off him and placed it in the garbage can where he could not reach it. He indicated that she then left the room and shut the door. He indicated that it was concerning to him because he was not able to reach the call bell if needed, and since the door was closed, he would not be able to yell out for assistance because no one would be able to hear him. He indicated that even his roommate at the time was ringing his call bell and no one would come. He indicated that it was not until the next shift when they finally came into his room.

Interview with the Director of Nursing on March 13, 2024, at 3:35 p.m. confirmed that there was no documented evidence of the interaction between the Assistant Director of Nursing and Resident 1 the following morning after the incident on January 24, 2024.

Interview with Registered Nurse 1 on March 13, 2024, at 4:19 p.m. revealed that Resident 1 stated that Nurse Aide 3 came into his room and was rude. He had asked her for his call bell and Nurse Aide 3 would act as if she was going to give the call bell to him and then she would pull the call bell away, so he swore at her. Nurse Aide 3 made the resident mad by placing the call bell away from him, so that he could not use it. She indicated that at the time of her interview with the resident, she was not thinking it was abuse and confirmed that she did not obtain statements from Nurse Aide 2, Nurse Aide 3, and/or Resident 1's roommate.

Interview with the Nursing Home Administrator on March 15, 2024, at 11:08 a.m. confirmed that the incident between Resident 1 and Nurse Aide 3 on January 24, 2024, was not thoroughly investigated as per their policy.

28 Pa. Code 201.18(e)(1) Management.

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




 Plan of Correction - To be completed: 04/11/2024

F610 Investigate/Prevent/Correct Alleged Violation


1. Actions taken for the situation identified:
Observations and assessments revealed no ill effects or injuries Resident 1.
A full investigation was completed, including staff and resident interviews, and an event report, including a PB-22 (Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property), was submitted. The investigation did not substantiate abuse; however, Nurse Aide 3 has been placed on the Do Not Return List from the agency.

2. How the facility will act to protect residents in similar situations:
The facility recognizes that all residents have the potential to be affected.
In response to any allegation of abuse, neglect, exploitation, or mistreatment, the Administrator will ensure that all alleged violations are thoroughly investigated and addressed appropriately, including reporting the results of such investigations to designated officials, as required.

3. System changes and measures to be taken:
The Regional Clinical Nurse Consultant will educate the facility managers on properly identifying and investigating allegations of abuse. The Director of Nursing will educate the facility staff, including agency staff, on the types of abuse and how to properly report incidents and allegations timely so that an investigation, including resident and staff interviews, can be initiated. Concern forms will be reviewed at both Clinical Morning Meeting and the afternoon Stand Down Meeting until resolved. All allegations of abuse will be investigated and reported to the Department of Health per facility policy through the electronic Event Reporting System, and other entities will be notified as required.

4. Monitoring mechanisms to assure compliance:
The Administrator/designee will be responsible for randomly monitoring incident reports and resident concerns (3) times a week for two (2) weeks and once (1) a week for four (4) weeks to ensure incidents have been investigated as necessary. Noted areas of non-compliance will be addressed upon discovery. Audit results will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings, and further action plans and audits will continue until substantial compliance is achieved. Ongoing self-monitoring will help to ensure quality standards continue to be met.

5. Date Corrective Action will be completed:
Substantial compliance is expected by April 11, 2024.

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 nursing schedules, review of staffing information furnished by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one nurse aide per 12 residents on the day shift for nine of 21 days, failed to ensure a minimum of one nurse aide per 12 residents on the evening shift for three of 21 days, and failed to ensure a minimum of one nurse aide per 20 residents on the overnight shifts for six of 21 days (24-hour periods) reviewed.

Findings Include:

Review of facility census data indicated that on February 12, 2024, the facility census was 89, which required 7.42 nurse aides (NA's) during the day shift. Review of the nursing time schedules revealed 6.50 NA's provided care on the day shift on February 12, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 15, 2024, the facility census was 92, which required 7.67 NA's during the day shift. Review of the nursing time schedules revealed 7.47 NA's provided care on the day shift on February 15, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 17, 2024, the facility census was 91, which required 7.58 NA's during the day shift. Review of the nursing time schedules revealed 6.53 NA's provided care on the day shift on February 17, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 18, 2024, the facility census was 91, which required 7.58 NA's during the day shift. Review of the nursing time schedules revealed 7.47 NA's provided care on the day shift on February 18, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 19, 2024, the facility census was 91, which required 7.58 NA's during the day shift. Review of the nursing time schedules revealed 7.33 NA's provided care on the day shift on February 19, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 22, 2024, the facility census was 92, which required 7.67 NA's during the day shift. Review of the nursing time schedules revealed 7.47 NA's provided care on the day shift on February 22, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 24, 2024, the facility census was 91, which required 7.58 NA's during the day shift. Review of the nursing time schedules revealed 7.20 NA's provided care on the day shift on February 12, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on March 3, 2024, the facility census was 91, which required 7.58 NA's during the day shift. Review of the nursing time schedules revealed 7.47 NA's provided care on the day shift on March 3, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on March 4, 2024, the facility census was 90, which required 7.50 NA's during the day shift. Review of the nursing time schedules revealed 7.33 NA's provided care on the day shift on March 3, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 16, 2024, the facility census was 92, which required 7.67 NA's during the evening shift. Review of the nursing time schedules revealed 7.47 NA's provided care on the evening shift on February 16, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 23, 2024, the facility census was 92, which required 7.67 NA's during the evening shift. Review of the nursing time schedules revealed 6.07 NA's provided care on the evening shift on February 23, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on March 8, 2024, the facility census was 86, which required 7.17 NA's during the evening shift. Review of the nursing time schedules revealed 6.93 NA's provided care on the evening shift on February 16, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 11, 2024, the facility census was 89, which required 4.45 NA's during the night shift. Review of the nursing time schedules revealed 3.20 NA's provided care on the night shift on February 11, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 16, 2024, the facility census was 92, which required 4.60 NA's during the night shift. Review of the nursing time schedules revealed 3.20 NA's provided care on the night shift on February 16, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 23, 2024, the facility census was 92, which required 4.60 NA's during the night shift. Review of the nursing time schedules revealed 4.37 NA's provided care on the night shift on February 23, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 24, 2024, the facility census was 91, which required 4.55 NA's during the night shift. Review of the nursing time schedules revealed 4.27 NA's provided care on the night shift on February 24, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on March 8, 2024, the facility census was 86, which required 4.30 NA's during the night shift. Review of the nursing time schedules revealed 4.27 NA's provided care on the night shift on March 8, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on March 9, 2024, the facility census was 85, which required 4.25 NA's during the night shift. Review of the nursing time schedules revealed 3.87 NA's provided care on the night shift on March 8, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Interview with the Nursing Home Administrator on March 15, 2024, at 11:08 a.m. confirmed that the facility did not meet the required nurse aide-to-resident staffing ratios for the days listed above.





 Plan of Correction - To be completed: 04/11/2024

P5510 Nursing Services - Nurse Aide


1. Actions taken for the situation identified:
The facility cannot retroactively address the incidents. No residents were adversely affected.

2. How the facility will act to protect residents in similar situations:
The facility will schedule, monitor and manage the nursing staff ratios to meet the requirements

3. System changes and measures to be taken:
The Nursing Home Administrator has reviewed the required ratios with the Director of Nursing and other staff responsible for nursing staff scheduling to ensure that the facility meets the requirement.

4. Monitoring mechanisms to assure compliance:
The Nursing Home Administrator/designee will conduct audits of the nursing staff ratios to determine compliance weekly for four (4) weeks then monthly for two (2) months. Noted areas of non-compliance will be addressed upon discovery. Audit results will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings, and further action plans and audits will continue until substantial compliance is achieved. Ongoing self-monitoring will help to ensure quality standards continue to be met.

5. Date Corrective Action will be completed:
Substantial compliance is expected by April 11, 2024.

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 review of nursing schedules, review of staffing information furnished by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 25 residents during the day on the day shift for one of 21 days, failed to ensure a minimum of one LPN per 30 residents during the evening shift for one of 21 days, and failed to ensure a minimum of one LPN per 40 residents on the overnight shifts for one of 21 days (24-hour periods) reviewed.

Findings Include:

Review of facility census data indicated that on March 5, 2024, the facility census was 89, which required 3.56 LPN's during the day shift. Review of the nursing time schedules revealed 3.00 LPNs worked on the day shift on March 5, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 18, 2024, the facility census was 91, which required 3.03 LPN's during the evening shift. Review of the nursing time schedules revealed 3.00 LPN's worked on the evening shift on February 18, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on February 16, 2024, the facility census was 92, which required 2.30 LPN's during the night shift. Review of the nursing time schedules revealed 2.00 LPN's worked on the night shift on February 16, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Interview with the Nursing Home Administrator on March 15, 2024, at 11:08 a.m. confirmed that the facility did not meet the required LPN-to-resident staffing ratios for the days listed above.





 Plan of Correction - To be completed: 04/11/2024

P5530 Nursing Services Licensed Practical Nurse


1. Actions taken for the situation identified:
The facility cannot retroactively address the incidents. No residents were adversely affected.

2. How the facility will act to protect residents in similar situations:
The facility will schedule, monitor and manage the nursing staff ratios to meet the requirements

3. System changes and measures to be taken:
The Nursing Home Administrator has reviewed the required ratios with the Director of Nursing and other staff responsible for nursing staff scheduling to ensure that the facility meets the requirement.

4. Monitoring mechanisms to assure compliance:
The Nursing Home Administrator/designee will conduct audits of the nursing staff ratios to determine compliance weekly for four (4) weeks then monthly for two (2) months. Noted areas of non-compliance will be addressed upon discovery. Audit results will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings, and further action plans and audits will continue until substantial compliance is achieved. Ongoing self-monitoring will help to ensure quality standards continue to be met.

5. Date Corrective Action will be completed:
Substantial compliance is expected by April 11, 2024.

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 review of nursing schedules and staff interviews, it was determined that the facility failed to provide 2.87 hours of direct resident care for each resident for three of 21 days (24-hour periods) reviewed.

Findings include:

Nursing time schedules provided by the facility for the days of February 11 through 24, 2024, and March 3 through 9, 2024, revealed that the facility provided only 2.68 hours of direct care for each resident on February 16, 2024; 2.86 hours of direct care for each resident on February 18, 2024; and 2.69 hours of direct care for each resident on February 23, 2024.

Interview with the Nursing Home Administrator on March 15, 2024, at 11:08 a.m. confirmed that the facility did not meet the required direct resident care hours on the days listed above.



 Plan of Correction - To be completed: 04/11/2024

P5630 Nursing Services Direct Care Hours


1. Actions taken for the situation identified:
The facility cannot retroactively address the incidents. No residents were adversely affected.

2. How the facility will act to protect residents in similar situations:
The facility will schedule, monitor and manage the nursing direct care hours to meet the requirements

3. System changes and measures to be taken:
The Nursing Home Administrator has reviewed the required number of direct care hours with the Director of Nursing and other staff responsible for nursing staff scheduling to ensure that the facility meets the requirement.

4. Monitoring mechanisms to assure compliance:
The Nursing Home Administrator/designee will conduct audits of the nursing staff direct care hours to determine compliance weekly for four (4) weeks then monthly for two (2) months. Noted areas of non-compliance will be addressed upon discovery. Audit results will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings, and further action plans and audits will continue until substantial compliance is achieved. Ongoing self-monitoring will help to ensure quality standards continue to be met.

5. Date Corrective Action will be completed:
Substantial compliance is expected by April 11, 2024.


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