Pennsylvania Department of Health
 NORTH STRABANE REHABILITATION AND WELLNESS CENTER, LLC
Patient Care Inspection Results

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NORTH STRABANE REHABILITATION AND WELLNESS CENTER, LLC
Inspection Results For:

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NORTH STRABANE REHABILITATION AND WELLNESS CENTER, LLC - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Findings of an abbreviated complaint survey, in response to two complaints, completed on July 23, 2024 at North Strabane Rehabilitation and Wellness Center identified no deficient practice 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, deficient practice was identified under 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


§ 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 nursing time schedules and staff interview it was determined that the facility administrative staff failed to provide a minimum of one nurse aide (NA) per 10 residents during the day or one NA per 11 residents on the evening shift, and/or one nurse aid per 15 residents during the night shift for 19 of 21 days (7/1, 7/2, 7/3, 7/5, 7/7, 7/8, 7/9, 7/11, 7/12, 7/13, 7/14, 7/15, 7/16, 7/17, 7/18, 7/19, 7/20, and 7/21/24).

Findings include:

Review of the facility census data, nursing time schedules, and deployment sheets from 7/1/24 through 7/21/24, revealed the following nurse aide staffing shortages:

On 7/1 and 7/2/24, the census was 51, which required 5.10 NAs during the day shift. Review of the nursing time schedules revealed 4.00 NAs provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/3/24, the census was 52, which required 5.20 NAs during the day shift. Review of the nursing time schedules revealed 5.00 NAs provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/5/24, the census was 54, which required 5.40 NAs during the day shift. Review of the nursing time schedules revealed 5.00 NAs provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/7, and 7/10/24, the census was 53, which required 5.30 NAs during the day shift. Review of the nursing time schedules revealed 5.00 NAs provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/8, and 7/9/24, the census was 52, which required 5.20 NAs during the day shift. Review of the nursing time schedules revealed 4.93 and 4.87 NAs provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/11/24, the census was 54, which required 5.40 NAs during the day shift. Review of the nursing time schedules revealed 4.80 and 4.87 NAs provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/12, 7/15, and 7/16/24, the census was 56, which required 5.60 NAs during the day shift. Review of the nursing time schedules revealed 4.93, 4,00 and 5.00 NAs provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/13, and 7/14/24, the census was 55, which required 5.50 NAs during the day shift. Review of the nursing time schedules revealed 4.00 NAs provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/17, 7/19, and 7/20/24, the census was 57, which required 5.70 NAs during the day shift. Review of the nursing time schedules revealed 5.00, 5.00, and 4.00 NAs provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/18, and 7/21/24, the census was 58, which required 5.80 NAs during the day shift. Review of the nursing time schedules revealed 5.00 NAs provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/5/24, the census was 54, which required 4.91 NAs during the evening shift. Review of the nursing time schedules revealed 4.53 NAs provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/9/24, the census was 52, which required 4.73 NAs during the evening shift. Review of the nursing time schedules revealed 4.00 NAs provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/12, 7/15, and 7/16/24, the census was 56, which required 5.09 NAs during the evening shift. Review of the nursing time schedules revealed 4.47, 4.00 and 4.00 NAs provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/13, and 7/14/24, the census was 55, which required 5.00 NAs during the evening shift. Review of the nursing time schedules revealed 4.53 NAs provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/17, and 7/20/24, the census was 57, which required 5.18 NAs during the evening shift. Review of the nursing time schedules revealed 5.00 and 4.00 NAs provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/18, and 7/21/24, the census was 58, which required 5.27 NAs during the evening shift. Review of the nursing time schedules revealed 5.00 NAs provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/10/24, the census was 53, which required 3.53 NAs during the night shift. Review of the nursing time schedules revealed 3.00 NAs provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/11/24, the census was 54, which required 3.60 NAs during the night shift. Review of the nursing time schedules revealed 3.00 NAs provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/13 and 7/14/24, the census was 55, which required 3.67 NAs during the night shift. Review of the nursing time schedules revealed 3.53 and 3.00 NAs provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/12 and 7/15/24, the census was 56, which required 3.73 NAs during the night shift. Review of the nursing time schedules revealed 3.00 NAs provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/21/24, the census was 58, which required 3.87 NAs during the night shift. Review of the nursing time schedules revealed 3.67 NAs provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

During an interview on 7/23/24, at 3:30 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a minimum of one nurse aide per ten residents during the day and one nurse aide per 11 residents during the evening shift, and/or one nurse aid per 15 residents during the night shift on 19 of 21 days.


 Plan of Correction - To be completed: 08/28/2024

" The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and / or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements."

The facility has no ability to correct back citations on nursing assistant ratios.

The facility has instituted a sign on bonus for Certified Nursing Assistants of $2500.00 dollars. The facility has scheduled a job fair on 8/7/24 for the entire day to recruit Certified Nursing Assistants. Appointments will be made with HR at this time to initiate hire. The facility already uses agency and has provided agency a currents needs list for Certified Nursing assistants indicating dates and shifts.

The Regional Clinical Director will in-service the Administrator, DON, Scheduler and Human resource Director on 7/30/24 on the appropriate staffing regulations for Certified Nursing Assistants according to census and shifts worked.

The administrator will give a report to QAPI monthly on compliance with meeting staffing ratios for Certified Nursing Assistants for a period of 2 months.

§ 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 time schedules and staff interview it was determined that the facility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift for 11 of 21 days (7/2, 7/3, 7/5, 7/9, 7/10, 7/11, 7/17, 7/19, 7/20, 7/21/24) and one LPN per forty residents during the night shift for 20 of 21 days (7/1 through 7/10/24, and 7/12 through 7/21/24).

Findings include:

Review of the facility census data, nursing time schedules, and deployment sheets from 7/1/24 through 7/21/24, revealed the following nurse LPN staffing shortages:

On 7/2/24 the census was 51, which required 2.04 LPN's during the day shift. Review of the nursing time schedules revealed 2.00 LPN's provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/3 and 7/9/24 the census was 52, which required 2.08 LPN's during the day shift. Review of the nursing time schedules revealed 2.00 LPN's provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/7 and 7/10/24 the census was 53, which required 2.12 LPN's during the day shift. Review of the nursing time schedules revealed 2.00 LPN's provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/5 and 7/11/24 the census was 54, which required 2.16 LPN's during the day shift. Review of the nursing time schedules revealed 2.00 LPN's provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/17, 7/19, and 7/20/24 the census was 57, which required 2.28 LPN's during the day shift. Review of the nursing time schedules revealed 2.00 LPN's provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/21/24 the census was 58, which required 2.32 LPN's during the day shift. Review of the nursing time schedules revealed 2.00 LPN's provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/1 and 7/2/24 the census was 51, which required 1.28 LPN's during the night shift. Review of the nursing time schedules revealed 1,00 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/3, 7/8, and 7/9/24 the census was 52, which required 1.30 LPN's during the night shift. Review of the nursing time schedules revealed 1.00 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/4, 7/5, and 7/6/24 the census was 54, which required 1.35 LPN's during the night shift. Review of the nursing time schedules revealed 1.00 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/13 and 7/14/24 the census was 55, which required 1.38 LPN's during the night shift. Review of the nursing time schedules revealed 1.00 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/15, and 7/16/24 the census was 56, which required 1.40 LPN's during the night shift. Review of the nursing time schedules revealed 1.00 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.


On 7/17, 7/19, and 7/20/24 the census was 57, which required 1.43 LPN's during the night shift. Review of the nursing time schedules revealed 1.00 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 7/18, and 7/21/24 the census was 58, which required 1.45 LPN's during the night shift. Review of the nursing time schedules revealed 1.00 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

During an interview on 7/23/24, at 3:30 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a minimum of one LPN per 25 residents during the day shift on 11 of 21 days and one LPN per 40 residents during the night shift for 20 of 21 days.


 Plan of Correction - To be completed: 08/28/2024

The facility has no ability to correct back citations on Licensed nurse ratios.

The administrator/designee will complete a labor staffing tool daily to assure appropriate ratios are maintained for Licensed Practical Nurses in relation to census and shifts ongoing.

The facility has instituted a sign on bonus for Licensed Practical Nurses of $3,000.00 dollars. The facility has scheduled a job fair on 8/7/24 for the entire day to recruit Licensed Practical Nurses. Appointments will be made with HR at this time to initiate hire. The facility already uses agency and has provided agency a current needs list for all licensed nurses indicating dates and shifts.

The Regional Clinical Director will in-service the Administrator, DON, Scheduler and Human resource Director on 7/30/24 on the appropriate staffing regulations for Licensed Practical nurses, to maintain appropriate staffing ratios using correct guidelines for census and shifts.

The administrator will give a report to QAPI monthly on compliance with meeting staffing ratios for Licensed Practical nurses for a period of 2 months.
§ 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 nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on 12 of 21 days (7/5, 7/11, 7/12, 7/13, 7/14, 7/15, 7/16, 7/17, 7/18, 7/19, 7/20, and 7/21/24).

Findings include:

Review of the nursing schedules and census information for 7/1/24, through 7/21/24, revealed that the facility failed to maintain 3.20 hours of general nursing care to each resident in a 24-hour period on the following dates:

-7/5/24, Census 54. PPD 3.06.
-7/11/24, Census 54. PPD 3.11.
-7/12/24, Census 56. PPD 3.09.
-7/13/24, Census 55. PPD 2.95.
-7/14/24, Census 55. PPD 3.03.
-7/15/24, Census 56. PPD 2.90.
-7/16/24, Census 56. PPD 3.12.
-7/17/24, Census 57. PPD 3.11.
-7/18/24, Census 58. PPD 3.19.
-7/19/24, Census 57. PPD 3.13.
-7/20/24, Census 57. PPD 2.70.
-7/21/24, Census 58. PPD 2.87.

During an interview on 7/23/24, at approximately 3:30 p.m. the Nursing Home Administrator confirmed that the facility failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on 12 of 21 days.


 Plan of Correction - To be completed: 08/28/2024

The facility does not have the ability to correct back citations on Over all required PPD of 3.2.

The administrator/designee will complete a labor staffing tool daily to assure appropriate over-all nursing PPD is at least at the minimum of 3.2 nursing care hours in a 24 hour period. This tool will be done daily and ongoing. This daily staffing tool will be done daily, and includes overall PPD as well as a break- down of hours/daily by each nursing category, for Certified Nursing Assistants, Licensed Practical Nurses and Registered nurses.

The Regional Clinical Director will in-service the Administrator, DON, Scheduler and Human resources Director on 7/30/24 on the appropriate over all nursing PPD of 3.2 in a 24 hour period.
The facility has sign on bonuses for Certified Nursing Assistants for $2500.00, for Licensed Practical Nurses $3,000.00 and for Registered Nurses $10,000 dollars. A job fair has been scheduled for 8-4-24 to last all day, to recruit Nursing staff. At the time of the fair the HR Director will initiate the hiring process on all qualified interested candidates. The facility already uses agency and has provided agencies with a current needs list for Certified Nursing Assistants, Licensed Practical nurses and Registered nurses including dates and shifts.

The administrator will give a report to OAPI monthly on compliance with meeting over-all nursing PPD of 3.2 in 24 hours period. This QAPI will be completed and reviewed for a period of 2 months.









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