Pennsylvania Department of Health
SUNSET RIDGE REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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SUNSET RIDGE REHABILITATION AND NURSING CENTER
Inspection Results For:

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SUNSET RIDGE REHABILITATION AND NURSING CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on November 15, 2023, at Sunset Ridge Healthcare and Rehabilitation Center identified no federal deficiencies related to the reported complaint allegations under the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities, but the facility was not in compliance with the following requirements of 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the health portion of the survey process.



 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 interviews, it was determined that the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for four shifts out of 63 reviewed shifts.

Findings include:

A review of the facility's daily staffing records revealed that the facility did not meet the required minimum nurse aide-to-resident ratios on the following dates:

On October 15, 2023, four nurse aides working on the evening shift, which failed to meet the minimum requirement of five nurse aides for a census of 60 residents.

On October 21, 2023, four nurse aides working on the day shift, which failed to meet the minimum requirement of five nurse aides for a census of 60 residents.

On November 13, 2023, five nurse aides working on the day shift, which failed to meet the minimum requirement of six nurse aides for a census of 61 residents.

On November 13, 2023, five (5) nurse aides working on the evening shift, which failed to meet the minimum requirement of six nurse aides for a census of 61 residents.

An interview with the Nursing Home Administrator and Director of Nursing on November 15, 2023, at approximately 1:30 PM confirmed the facility had not met the required nurse aide-to-resident ratios on the above shifts.



 Plan of Correction - To be completed: 01/02/2024

1.The facility cannot retroactively correct past Nursing Aide ratios.

2.The facility will continue to take measures to adequately provide nurse-aid staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff with the required nurse aide to resident ratios. These measures include, continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign on bonuses.

3.The Director of Nursing/designee will continue to educate minimum staffing ratios to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios.

4.The Director of Nursing/designee will audit the daily schedules to ensure that the minimum number of nurse aide staff to resident ratios have been scheduled. The results of the audits will be reviewed at the facilities QAPI meeting for 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 interviews, it was determined that the facility failed to ensure the minimum licensed practical nurse to resident ratio was provided on each shift on 33 shifts out 63 reviewed shifts.

Findings include:

A review of the facility's daily staffing records revealed that the facility did not meet the required minimum LPN-to-resident ratios on the following dates:

On October 15, 2023, the facility had two (2) LPNs working on the dayshift, which failed to meet the minimum requirement of three (3) LPNs for a census of sixty (60) residents.

On October 18, 2023, the facility had two (2) LPNs working on the dayshift, which failed to meet the minimum requirement of three (3) LPNs for a census of fifty-nine (59) residents.

On October 19, 2023, the facility had two (2) LPNs working on the dayshift, which failed to meet the minimum requirement of three (3) LPNs for a census of fifty-eight (58) residents.

On October 20, 2023, the facility had two (2) LPNs working on the dayshift, which failed to meet the minimum requirement of three (3) LPNs for a census of fifty-nine (59) residents.

On October 22, 2023, the facility had two (2) LPNs working on the dayshift, which failed to meet the minimum requirement of three (3) LPNs for a census of fifty-eight (58) residents.

On October 23, 2023, the facility had two (2) LPNs working on the dayshift, which failed to meet the minimum requirement of three (3) LPNs for a census of fifty-nine (59) residents.

On October 24, 2023, the facility had one (1) LPN and one registered nurse (1) working as an LPN on the dayshift, which failed to meet the minimum requirement of three (3) LPNs for a census of sixty (60) residents.

On October 25, 2023, the facility had two (2) LPNs on the dayshift, which failed to meet the minimum requirement of three (3) LPNs for a census of sixty (60) residents.

On October 28, 2023, the facility had two (2) LPNs on the dayshift, which failed to meet the minimum requirement of three (3) LPNs for a census of sixty (60) residents.

On November 9, 2023, the facility had two (2) LPNs on the dayshift, which failed to meet the minimum requirement of three (3) LPNs for a census of sixty-three (63) residents.

On November 10, 2023, the facility had two (2) LPNs on the dayshift, which failed to meet the minimum requirement of three (3) LPNs for a census of sixty-one (61) residents.

On November 11, 2023, the facility had two (2) LPNs on the dayshift, which failed to meet the minimum requirement of three (3) LPNs for a census of sixty-two (62) residents.

On November 12, 2023, the facility had two (2) LPNs on the dayshift, which failed to meet the minimum requirement of three (3) LPNs for a census of sixty-two (62) residents.

On November 13, 2023, the facility had two (2) LPNs on the dayshift, which failed to meet the minimum requirement of three (3) LPNs for a census of sixty-one (61) residents.

On November 14, 2023, the facility had two (2) LPNs on the dayshift, which failed to meet the minimum requirement of three (3) LPNs for a census of sixty (60) residents.

The minimum required ratio on the evening shift is one licensed practical nurse (LPN) for every thirty residents (1:30). A review of the facility's daily staffing records revealed that the facility did not meet the required minimum LPN-to-resident ratios on the following dates:

On November 8, 2023, the facility had two (2) LPNs on the evening shift, which failed to meet the minimum requirement of three (3) LPNs for a census of sixty-three (63) residents.

On November 9, 2023, the facility had two (2) LPNs on the evening shift, which failed to meet the minimum requirement of three (3) LPNs for a census of sixty-three (63) residents.

On November 10, 2023, the facility had two (2) LPNs on the evening shift, which failed to meet the minimum requirement of three (3) LPNs for a census of sixty-one (61) residents.

On November 11, 2023, the facility had two (2) LPNs on the evening shift, which failed to meet the minimum requirement of three (3) LPNs for a census of sixty-two (62) residents.

On November 12, 2023, the facility had two (2) LPNs on the evening shift, which failed to meet the minimum requirement of three (3) LPNs for a census of sixty-two (62) residents.

On November 13, 2023, the facility had two (2) LPNs on the evening shift, which failed to meet the minimum requirement of three (3) LPNs for a census of sixty-one (61) residents.

The minimum required ratio on the overnight shift is one licensed practical nurse (LPN) for every forty residents (1:40). A review of the facility's daily staffing records revealed that the facility did not meet the required minimum LPN-to-resident ratios on the following dates:

On October 16, 2023, the facility had one (1) LPN on the overnight shift, which failed to meet the minimum requirement of two (2) LPNs for a census of sixty (60) residents.

On October 17, 2023, the facility had one (1) LPN on the overnight shift, which failed to meet the minimum requirement of two (2) LPNs for a census of fifty-nine (59) residents.

On October 18, 2023, the facility had one (1) LPN on the overnight shift, which failed to meet the minimum requirement of two (2) LPNs for a census of fifty-nine (59) residents.

On October 20, 2023, the facility had one (1) LPN on the overnight shift, which failed to meet the minimum requirement of two (2) LPNs for a census of fifty-nine (59) residents.

On October 21, 2023, the facility had one (1) LPN on the overnight shift, which failed to meet the minimum requirement of two (2) LPNs for a census of sixty (60) residents.

On October 22, 2023, the facility had one (1) LPN on the overnight shift, which failed to meet the minimum requirement of two (2) LPNs for a census of fifty-eight (58) residents.

On October 23, 2023, the facility had one (1) LPN on the overnight shift, which failed to meet the minimum requirement of two (2) LPNs for a census of fifty-nine (59) residents.

On October 24, 2023, the facility had one (1) LPN on the overnight shift, which failed to meet the minimum requirement of two (2) LPNs for a census of sixty (60) residents.

On October 25, 2023, the facility had one (1) LPN on the overnight shift, which failed to meet the minimum requirement of two (2) LPNs for a census of sixty (60) residents.

On October 28, 2023, the facility had one (1) LPN on the overnight shift, which failed to meet the minimum requirement of two (2) LPNs for a census of sixty (60) residents.

On November 9, 2023, the facility had one (1) LPN on the overnight shift, which failed to meet the minimum requirement of two (2) LPNs for a census of sixty-three (63) residents.

On November 12, 2023, the facility had one (1) LPN on the overnight shift, which failed to meet the minimum requirement of two (2) LPNs for a census of sixty-two (62) residents.

During an interview on November 15, 2023, at approximately 1:30 PM, the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to meet the required licensed practical nurse to resident ratios on the above shifts.



 Plan of Correction - To be completed: 01/02/2024

1.The facility cannot retroactively correct past LPN ratios.

2.The facility will continue to take measures to adequately provide LPN staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff with the required LPN to resident ratios. These measures include, continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign on bonuses.

3.The Director of Nursing/designee will continue to educate minimum staffing ratios to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios.

4.The Director of Nursing/designee will audit the daily schedules to ensure that the minimum number of nurse aide staff to resident ratios have been scheduled. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations


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