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

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YARDLEY REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

There are 162 surveys for this facility. Please select a date to view the survey results.

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YARDLEY REHABILITATION AND HEALTHCARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and an Abbreviated survey in response to a complaint completed February 22, 2024, it was determined that Yardley Rehabilitation and Healthcare Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

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.

§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations:

Based on clinical record review, observation and resident and staff interview, it was determined that the facility failed to ensure that a resident had the call bell accessible for one of 33 sampled residents. (Resident 139)

Findings include:

Clinical record review revealed that Resident 139 had diagnoses of Parkinson's disease, dysphagia, (difficulty swallowing) and history of mild protein and calorie malnutrition. The Minimum Data Set assessment dated February 5, 2024, indicated that the resident was alert and oriented, was frequently incontinent of bowel and bladder and had limitations in his upper and lower extremities on both sides. The care plan identified that the resident was at risk for falls due to Parkinson's disease. There was an intervention for staff to ensure that the resident had his call bell within reach.

On February 20, 2024, at 10:29 a.m., 11:00 a.m., and 12:18 p.m., the resident was observed in bed. His touch pad call bell had been placed near the top of his pillow, completely out of his reach. At 10:29 a.m., the resident stated that he was thirsty and that he needed fresh water in his cup that was on his over the bed table. The cup of water was on the table and was out of his reach.

On February 21, 2024, at 9:55 a.m., the resident was observed in bed. The call bell had been placed on his upper right shoulder, but it was upside down. At that time, the resident stated that he could not reach the call bell and that the cord needed to be about four to five inches longer so that he could utilize it to call for assistance from staff.

In an interview on February 22, 2024, at 9:56 a.m., the Registered Nurse (RN 2 ) stated that the cord had not been long enough for the resident to reach the call bell and that he was capable of utilizing the call bell to call for assistance from staff.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 03/13/2024

1. The facility administrator inspected R 139's touchpad call bell on 2/22/2024. The call light cord was corrected and clipped within the resident's reach.
2. Current residents were evaluated by the Administrator/designee to validate that call bell cords were the correct length and clipped within the residents' reach. Variances have been addressed.
3. Facility staff will be re-educated on the facility call light policy which includes but is not limited to validating that call lights are the correct length and notifying maintenance with variances and maintaining call bells within the residents' reach by the DON/designee.
4. Audits will be completed by the IDT twice weekly x 2 weeks; then weekly x 4 weeks, to validate that call bell cords are the correct length and being clipped within resident reach. The QAA Committee will review audits for trends and appropriate follow-up as needed.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs identified in the comprehensive assessment for two of 33 sampled residents. (Resident 39, 42)

Findings include:

Clinical record review revealed that Resident 39 was admitted to the facility on February 2, 2024, and had diagnoses that included muscle weakness and history of a traumatic brain injury. The Minimum Data Set (MDS) assessment dated February 8, 2024, identified that Resident 39 was frequently incontinent of urine and the Care Area Assessment (CAA) summary indicated that it was to be addressed in the care plan. There was no evidence that interventions to address Resident 39's urinary incontinence were included in the current care plan.

Clinical record review revealed that Resident 42 was admitted to the facility on January 22, 2024, and had diagnoses that included Parkinson's disease and dementia. The MDS assessment dated January 27, 2024, indicated that Resident 42 was always incontinent of urine and the CAA summary indicated that it was to be addressed in the care plan. There was no evidence that interventions to address Resident 42's urinary incontinence were included in the current care plan.

In an interview on February 22, 2024, at 11:35 a.m., the Director of Nursing confirmed that the identified care areas were not addressed in the residents' care plans.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 03/13/2024

1. Resident 39 and resident 42 had their urinary evaluations reviewed by the clinical team. R 39 and R 42 had their care plan updated to include urinary incontinence with interventions initiated to reflect urinary and incontinence care needs.

Resident 39 and resident 42 had their urinary evaluations reviewed by the clinical team. R 39 and R42 had their care plan updated to include urinary incontinence with interventions initiated to reflect urinary and incontinence care needs.

2. Current residents who triggered for incontinence care needs were reviewed by the Clinical team to validate that the care plans to include interventions were in place to accurately reflect the resident's status and needs. Variances have been addressed.
3. Licensed nurses will be re-educated to the facility policy for Incontinence Care including formulating care plans for residents with urinary incontinence by the DON/designee.
4. Audits will be completed by the DON/Designee, twice weekly x 2 weeks; then weekly x 4 weeks to ensure urinary incontinence interventions have been care- planned for residents who triggered for urinary incontinence. The QAA Committee will review audits for trends and appropriate follow-up as needed.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:

§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Observations:

Based on clinical record review, observation, and resident interview, it was determined that the facility failed to ensure that appropriate assistance with eating was provided to one of four sampled residents who required assistance with activities of daily living, including eating. (Resident 139)

Findings include:

Clinical record review revealed that Resident 139 had diagnoses that included Parkinson's disease, cognitive communication deficit, and history of mild protein malnutrition. The Minimum Data Set assesment dated February 5, 2024, indicated that the resident was alert and oriented and had limitations in range of motion of his upper and lower extremities on both sides. The care plan identified that the resident had a self-care deficit in activities of daily living, including eating. There was an intervention that indicated he required hands-on assistance for eating and drinking.

Review of a speech language pathology discharge summary dated January 24, 2024, revealed a therapist documented that the resident was totally dependent for feeding assistance. Further review of the summary revealed that the therapist recommended close supervision and feeding assistance as he was totally dependent for eating.

Review of a nutrition note dated February 16, 2024, revealed that the resident needed to be fed by staff because of tremors that he had from Parkinson's disease.

Observation on February 21, 2024, at 12:20 p.m., revealed that the resident was in his room in bed and a staff member brought in his food tray and placed it on his over the bed table. At 12:40 p.m., the resident was still not eating and had not touched any of the food or drinks on his food tray. He stated that staff usually assisted him with eating his meals; however, today no one had assisted him with eating his meal. He further stated that he was hungry and thirsty. It was not until 12:45 p.m., 25 minutes after receiving his meal, that a staff member went in to the room and sat down to assist him with eating his meal.

CFR 483.254(a)(2) ADL Care Provided for Dependent Residents.
Previously cited 3/10/23

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 03/13/2024

1. Resident 139 was interviewed by the Unit Manager, following the noon meal, to validate that he had no further complaints of thirst or hunger. Resident 139 reported he was assisted with the meal and reported no issues.
2. Current residents identified as requiring feeding assistance will be evaluated via rounds and/or interviews to validate they are receiving timely meal assistance. Variances will be addressed.
3. Clinical staff will be re-educated by the ADON/designee on providing timely meal assistance per the resident's plan of care upon the resident receiving their meal tray.
4. Audits will be completed by the DON/Designee, twice weekly x 2 weeks; then weekly x 4 weeks to validate that the residents requiring meal assistance are being provided timely assistance as required upon receiving their meal tray. The QAA Committee will review audits for trends and appropriate follow-up as needed.

483.25(k) REQUIREMENT Pain Management:

§483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for four of 33 sampled residents. (Resident 22, 64, 116, 121)

Findings include:

Review of the facility policy entitled, "Pain Management," last reviewed February 1, 2024, revealed that the facility was to provide adequate pain control for the residents. Pain was to be managed through non-pharmacological and pharmacological interventions.

Clinical record review revealed that Resident 22 had diagnoses that included neuropathy (nerve pain). A physician's order dated November 2, 2023 directed staff to administer the narcotic pain medication, oxycodone, every four hours as needed for moderate to severe pain. Review of the care plan revealed the resident had pain and interventions included that staff offer relaxation therapy, heat and cold application, muscle simulation, or positioning to assist with pain control. Review of the Medication Administration Records (MARs), revealed that the resident received the oxycodone six times in January and twice in February, 2024, without evidence to support that non-pharmacological interventions were offered prior to the administration of the as needed pain medication.

Clinical record review revealed that Resident 64 had diagnoses that included fibromyalgia and muscle wasting and atrophy (shrinking of muscles). A physician's order dated November 17, 2023, directed staff to administer the narcotic pain medication, oxycodone, every six hours as needed for pain. Review of the care plan revealed the resident had chronic pain and interventions included that staff offer relaxation therapy, bathing, heat and cold application, or muscle stimulation to assist with pain control. Review of the MARs, revealed that the resident received the oxycodone 65 times in January and 36 times in February, 2024, without evidence to support that non-pharmacological interventions were offered prior to the administration of the as needed pain medication.

Clinical record review revealed that Resident 116 had diagnoses that included lumbago with sciatica (low back pain) and muscle weakness. A physician's order dated July 14, 2023, directed staff to administer the narcotic pain medication, oxycodone, every six hours as needed for pain. Review of the care plan revealed the resident had chronic pain and interventions included that staff offer relaxation therapy, heat and cold application, muscle stimulation, or positioning to assist with pain control. Review of the MARs, revealed that the resident received the oxycodone 54 times in January and 37 times in February, 2024, without evidence to support that non-pharmacological interventions were offered prior to the administration of the as needed pain medication.

Clinical record review revealed that Resident 121 had diagnoses that included hemiparesis (weakness one one side of the body), neuropathy, and depression. A physician's order dated August 3, 2022, directed staff to administer the narcotic pain medication, oxycodone, every four hours as needed for severe pain. Review of the care plan revealed the resident had pain and interventions included that staff offer relaxation therapy, heat and cold application, muscle stimulation, or positioning to assist with pain control. Review of the MARs, revealed that the resident received the oxycodone 25 times in January and 20 times in February, 2024, without evidence to support that non-pharmacological interventions were offered prior to the administration of the as needed pain medication.

In an interview on February 22, 2024, at 10:42 a.m., the Director of Nursing confirmed that there was no documented evidence that staff offered non-pharmacological interventions prior to the administration of the as needed pain medication.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 03/13/2024

1. Resident 22's PRN pain medications and non-pharmacological measures were reviewed by the physician to validate that those orders remained appropriate for the resident's pain management needs with no changes in orders noted.
Resident 64's PRN pain medications and non-pharmacological measures were reviewed by the physician to validate that those orders remained appropriate for the resident's pain management needs with no changes in orders noted.
Resident 116's PRN pain medications and non-pharmacological measures were reviewed by the physician to validate that those orders remained appropriate for the resident's pain management needs with no changes in orders noted.
Resident 121's PRN pain medications and non-pharmacological measures were reviewed by the physician to validate that those orders remained appropriate for the resident's pain management needs with no changes in orders noted.

2. Current residents with PRN narcotic pain medication orders have been reviewed to validate that non-pharmacological interventions are in place and attempted before the administration of PRN pain medication. Variances will be addressed.
3. Licensed nurses will be re-educated by the DON/designee on the facility policy for pain management, including documentation of attempted non-pharmacological interventions prior to the administration of PRN pain medications.
4. Audits will be conducted by the DON/Designee, twice weekly x 2 weeks; then weekly x 4 weeks on residents who have orders for PRN narcotic pain medication to validate the documentation of attempted non-pharmacological interventions before the administration of PRN pain medications. The QAA Committee will review audits for any identified trends with appropriate follow-up as needed.

483.25(l) REQUIREMENT Dialysis:

§483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on policy review, clinical record review, observation, and interview, it was determined that the facility failed to ensure that staff provided services consistent with professional standards of practice for one of three sampled dialysis residents. (Resident 147)

Findings include:

Review of the facility policy entitled, "Hemodialysis Access Emergency Care Policy," dated February 1, 2024, revealed that a smooth clamp should be kept at the bedside of residents with a dialysis catheter in place.

Clinical record review revealed that Resident 147 had diagnoses that included end stage renal disease, permacath (tunneled catheter inserted into the blood vessel in the neck or upper chest under the collarbone and into the right side of the heart for dialysis), and dependence on renal dialysis (a process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). Review of current physician's orders revealed that there was an order since January 24, 2024, for staff to keep a clamp at bedside at all times and to check for placement every shift.

Observation on February 20, 2024, at 11:23 a.m., and February 21, 2024, at 10:00 a.m., revealed there was no clamp available in Resident 147's room as ordered. On February 21, 2024, at 11:00 a.m., LPN 1 confirmed that there was no clamp at the bedside.

In an interview on February 22, 2024, at 9:40 a.m., The Director of Nursing confirmed that the facility failed to ensure the availability of necessary emergency supplies at the resident's bedside.

28 Pa. Code 211.12(c)(d)(1)(2)(5) Nursing Services.

Plan of Correction - To be completed: 03/13/2024

1. Resident 147 has had a smooth dialysis clamp placed at the bedside by the Unit Manager.
2. Current dialysis residents have been audited by the facility Unit Managers, to validate a dialysis clamp is present at the bedside. Variances have been addressed.
3. Licensed nurses will be educated by the DON/designee on the facility policy for Hemodialysis Access Emergency Care; including maintaining a smooth clamp at the bedside of residents with a dialysis catheter in place.
4. Audits will be conducted twice weekly x 2 weeks; then weekly x 4 weeks on dialysis residents by the DON/Designee to validate a dialysis clamp is present at the bedside. Variances will be addressed. The QAA Committee will review audits for any identified trends with appropriate follow-up as needed.

483.35(g)(1)-(4) REQUIREMENT Posted Nurse Staffing Information:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§483.35(g) Nurse Staffing Information.
§483.35(g)(1) Data requirements. The facility must post the following information on a daily basis:
(i) Facility name.
(ii) The current date.
(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:
(A) Registered nurses.
(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).
(C) Certified nurse aides.
(iv) Resident census.

§483.35(g)(2) Posting requirements.
(i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift.
(ii) Data must be posted as follows:
(A) Clear and readable format.
(B) In a prominent place readily accessible to residents and visitors.

§483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

§483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.

Observations:

Based on observation and interview, it was determined that the facility failed to post accurate and current nurse staffing information.

Findings include:

Observation on February 20, 2024, at 10:05 a.m., and February 21, 2024, at 9:25 a.m., revealed that nurse staffing information was posted in the lobby and had not been updated since February 16, 2024.

In an interview on February 21, 2024, at 1:00 p.m., the Nursing Home Administrator confirmed that incorrect staffing data was posted.

28 Pa Code 201.18(b)(3) Management.

Plan of Correction - To be completed: 03/13/2024

1. No specific residents were identified. On 2/21/24 the facility Administrator posted the up-to-date nurse staffing information.
2. Rounds were completed by the facility Administrator/designee with current nurse staffing information posted in designated facility areas on 2/22/2024, 2/23/24, and 2/25/24.
3. The NHA has educated staffing personnel on the facility process for posting accurate staffing information timely and keeping the postings up to date per regulatory guidelines.
4. Audits will be conducted by the NHA/Designee, daily x 2 weeks; and then weekly x 4 weeks to validate that nurse staffing information is posted in designated facility areas timely and maintained up to date. The QAA Committee will review audits for any identified trends with appropriate follow-up as needed.

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(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 nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for five of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from September 3 through September 9, 2023, December 25 through December 31, 2023, and February 15 through 21, 2024, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for 12 residents on day (7:00 a.m. to 3:00 p.m.) shift on December 26 and 31, 2023.

The facility failed to meet the minimum NA to resident ratio of one NA for 12 residents on evening (3:00 p.m. to 11:00 p.m.) shift on December 25, 29, and 31, 2023, and February 16, 2024.

In an interview conducted on February 22, 2024, at 11:00 a.m., the Regional Director of Nursing confirmed that the facility failed to meet the required staffing ratio for nurse aides on the previously mentioned dates and shifts.

Plan of Correction - To be completed: 03/13/2024

- No residents were negatively impacted by the CNA ratios.
- The facility completed an audit of staffing ratios for the past 30 days. Variances were reviewed with the staffing coordinator and recorded on the facility audit tool.
- The Administrator re-educated the staffing coordinator on the staffing ratios. The Administrator and the Regional director of operations have reviewed staff recruitment and retention initiatives and have communicated those initiatives to the facility recruitment manager.
- The Administrator / Designee will audit CNA ratios 3 times per week for 4 weeks then weekly for 2 months. Audit findings will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of the previously completed audit findings.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(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 nursing time schedules, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for three of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from September 3 through September 9, 2023, December 25 through December 31, 2023, and February 15 through 21, 2024, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on night (11:00 p.m. to 7:00 a.m.) shift on December 25, 29, and 30, 2023.

In an interview conducted on February 22, 2024, at 11:00 a.m., the Regional Director of Nursing confirmed that the facility failed to meet the required staffing ratios for licensed practical nurses on the previously mentioned dates and shifts.

Plan of Correction - To be completed: 03/13/2024

- No residents were negatively impacted by the Nurses ratios.
- The facility completed an audit of staffing ratios for the past 30 days. Variances were reviewed with the staffing coordinator and recorded on the facility audit tool.
- The Administrator re-educated the staffing coordinator on the staffing ratios. The Administrator and the Regional director of operations have reviewed staff recruitment and retention initiatives and have communicated those initiatives to the facility recruitment manager.
- The Administrator / Designee will audit nurse ratios 3 times per week for 4 weeks then weekly for 2 months. Audit findings will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of the previously completed audit findings.

§ 211.12(i)(1) LICENSURE Nursing services.:

(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 a review of nursing time schedules, it was determined that the facility failed to provide a minimum of 2.87 hours of direct care for each resident for three of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from September 3 through September 9, 2023, December 25 through December 31, 2023, and February 15 through February 21, 2024, revealed the following total nursing care hours below minimum requirements:

Friday December 29, 2023: 2.75 care hours per resident.
Saturday December 30, 2023: 2.82 care hours per resident.
Sunday December 31, 2023: 2.71 care hours per resident.

In an interview on February 22, 2024, at 11:00 a.m., the Regional Director of Nursing confirmed that the facility failed to provide the minimum hours of direct care for each resident for the days listed above.

Plan of Correction - To be completed: 03/13/2024

- No residents were negatively impacted by not meeting 2.87 PPD.
- The facility completed an audit of HPPD for the past 30 days. Variances were reviewed with the staffing coordinator and recorded on the facility audit tool.
- The Administrator re-educated the staffing coordinator on the required HPPD. The Administrator and the Regional director of operations have reviewed staff recruitment and retention initiatives and have communicated those initiatives to the facility recruitment manager.
- The Administrator / Designee will audit centers HPPD 3 times per week for 4 weeks then weekly for 2 months. Audit findings will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of the previously completed audit findings.

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