Pennsylvania Department of Health
JEFFERSON HILLS HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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JEFFERSON HILLS HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  169 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.
JEFFERSON HILLS HEALTHCARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated Survey in response to a complaint completed on 2/1/24, at Jefferson Hills Healthcare and Rehabilitation Center, it was determined that there were no federal deficiencies, related to the Health portion of the survey process, identified 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, the facility was not in compliance with 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 facility provided staffing and staff interview it was determined the facility administrative staff failed to meet the minimum full time equivalent hours, that could affect resident health and safety, for nurse aides on two of 24 days (1/26 and 1/27.)

Findings Include:

Review of facility staffing for the period of 1/7/24, through 1/30/24, revealed the facility did not meet the minimum full time equivalent (FTE - a unit of time measurement used to determine the full time hours worked by an employee) hours for Nurse Aides (NA) on the following days and shifts:

1/26/24: Facility census was 42. The day shift needed 16.80 NA hours, the facility had scheduled
16.00 NA hours.
1/27/24: Facility census was 43. The day shift needed 28.67 NA hours, the facility had scheduled 25
NA hours.
The night shift needed 17.20 NA hours, the facility had scheduled 15.75 NA hours.

During an interview on 2/1/24, the Nursing Home Administrator confirmed that facility failed to meet the FTE hours, that could affect resident health and safety, for nurse aides.


 Plan of Correction - To be completed: 02/23/2024

Facility Scheduler resigned without notice on 01/24/2024.
New Scheudler has been hired with start date of 02/13/2024.
NHA will educate Scheudler on staffing ratio regulations and forms that was posted January 2024.
NHA/Director of Nursing will meet twice daily to review staffing schedule for a period of 2 weeks to ensure CNA ratios are being met.
NHA/Scheduler will continue to monitor CNA ratios throughout the day to ensure facility has sufficient staff.
Findings will be reported to QAA for further review and monitoring.


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