Pennsylvania Department of Health
MOUNTAIN CITY NURSING & REHAB CTR
Patient Care Inspection Results

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MOUNTAIN CITY NURSING & REHAB CTR
Inspection Results For:

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MOUNTAIN CITY NURSING & REHAB CTR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a revisit completed on January 23, 2024, it was determined that Mountain City Nursing & Rehabilitation Center corrected the federal deficiencies cited during the survey of November 21, 2023, under the requirements of 42 CFR Part 483 Subpart B 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)(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 time schedules and the resident census and staff interviews, it was determined that the facility failed to provide a minimum one nurse aide per 12 residents during the evening shift on three of seven days reviewed (1/15/2024, 1/16/2024, and 1/21/2024) and the minimum of one nurse aide per 20 residents during the night shift on three of seven days reviewed (1/16/2024, 1/19/2024, and 1/20/2024).

Findings include:

Review of facility census data revealed that on 1/15/2024, the resident census 230, which required 19.17 nurse aides during the evening shift. Review of the nursing time schedules revealed only 17.57 nurse aides on the evening shift on 1/15/2024.

The facility census on 1/16/2024, was 230 residents, which required 19.17 nurse aides during the evening shift. Review of the nursing time schedules revealed only 18.67 nurse aides on the evening shift on 1/16/2024.

The facility census on 1/16/2024, was 230 residents, which required 11.50 nurse aides during the night shift. Review of the nursing time schedules revealed only 11.20 nurse aides on the night shift on 1/16/2024.

The facility census on 1/19/2024, was 230 residents, which required 11.50 nurse aides during the evening shift. Review of the nursing time schedules revealed only 11.07 nurse aides on the night shift on 1/19/2024.

The facility census on 1/20/2024, was 228 residents, which required 11.40 nurse aides during the night shift. Review of the nursing time schedules revealed only 10.40 nurse aides on the night shift on 1/20/2024.

The facility census on 1/21/2024, was 228 residents, which required 19.0 nurse aides during the evening shift. Review of the nursing time schedules revealed only 18.87 nurse aides on the evening shift on 1/21/2024.

During an interview on January 23, 2023, at 2:30 p.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a minimum nurse aide staffing ratios on the above shifts.




 Plan of Correction - To be completed: 02/13/2024

1. Facility can't retroactively correct
2. To identify other areas of concern the facility reviewed 1 weeks' worth of schedules to review CNA staffing ratios.

3. To prevent this from reoccurring, the DON/designee will educate staff responsible for the nursing schedule on required CNA ratios. Nursing staff incentives, alternative scheduling, and nursing agency staff will also be considered for compliance.

4. To monitor and maintain ongoing compliance the NHA/designee will audit the nursing schedule related to CNA staffing ratios 5x's/week for 2 weeks and then weekly for 4 weeks, and monthly for 3 months. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

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