Pennsylvania Department of Health
PETERS TOWNSHIP POST ACUTE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

PETERS TOWNSHIP POST ACUTE
Inspection Results For:

There are 155 surveys for this facility. Please select a date to view the survey results.

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PETERS TOWNSHIP POST ACUTE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a revisit survey completed on April 21, 2025, it was determined that Peters Township Post Acute failed to correct the deficiencies cited during the survey of February 25, 2025, under the requirements of the 28 Pa, Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(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 a review of staffing documents provided by the facility and staff interview it was determined that the facility failed to provide one nurse assistant (NA) per 10 residents on the daylight shift on one of seven days (4/20/25) and one NA per 11 residents on the second shift on one of seven days (4/18/25) as required.

Findings include:

A review of facility staffing documents provided by the facility from 4/14/25 through 4/20/25, revealed the facility failed to provide NA on the following shifts as required:

Daylight shift:

DateCensusActual hours Hours required

4/20/2510970.0581.75

Evening shift:

DateCensusActual hoursHours required

4/18/2511062.8875.00

During an interview on 4/21/25 at 4:10 p.m., the Operation Manager confirmed that the facility failed to provide NA's in the facility on the above shifts as required.

Plan of Correction - To be completed: 06/09/2025

The Director of Nursing, Human Resources, and the Scheduler will be re-educated by the Nursing Home Administrator or designee on the updated nurse aide-to-resident ratios effective July 1, as outlined by state regulations.

To ensure ongoing compliance with required staffing ratios, daily staffing huddles (Monday through Friday) will continue to be held to review current and projected CNA coverage for both the current day and upcoming week. We will check in regularly on the weekends. When anticipated staffing falls below the mandated minimums, the facility will proactively reach out to existing staff and agency partners to secure coverage. We have also established new contracts with additional staffing agencies, including Shift Key, to broaden our available pool of nurse aides and enhance staffing flexibility.

To monitor compliance, the Nursing Home Administrator or designee will conduct weekly audits of nurse aide staffing ratios for four consecutive weeks. The findings from these audits will be presented at monthly QAPI meetings for review, discussion, and further recommendations.

§ 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 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 40 residents during the night shift on one of seven days (4/19/25) as required.

Findings include:

Review of facility census data, nursing time schedules from 4/14/25 through 4/20/25, revealed the following LPN staffing shortages.

Night Shift: Census Actual Hours Hours Required

4/19/2510818.2821.60

During an interview on 4/21/25, at 4:10 p.m. the Operations Manager confirmed that the facility failed to provide LPN's on the above day as required.

Plan of Correction - To be completed: 06/09/2025

The Director of Nursing, Human Resources, and the Scheduler will be re-educated by the Nursing Home Administrator or designee on the updated nurse-to-resident ratios effective July 1, as outlined by state regulations.

To ensure ongoing compliance with required staffing ratios, daily staffing huddles (Monday through Friday) will continue to be held to review current and projected LPN coverage for both the current day and upcoming week. We will check in regularly on the weekends. When anticipated staffing falls below the mandated minimums, the facility will proactively reach out to existing staff and agency partners to secure coverage. We have also established new contracts with additional staffing agencies, including Shift Key, to broaden our available pool of LPNs and enhance staffing flexibility.

To monitor compliance, the Nursing Home Administrator or designee will conduct weekly audits of LPN staffing ratios for four consecutive weeks. The findings from these audits will be presented at monthly QAPI meetings for review, discussion, and further recommendations.

§ 211.12(i)(2) LICENSURE Nursing services.:

(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 a review of nursing time schedules and staff interview, it was determined that the facility failed to provide a minimum of 3.20 PPD (per patient daily) hours of direct care for each resident on two of seven days (4/18/25 and 4/20/25).

Findings include:

Review of staffing documents and nursing staff schedules from 4/14/25 through 4/20/25, indicated that the State required PPD minimum hours of 3.20 was not met on the following days:

4/18/25= 3.11 PPD.
4/20/25= 2.91 PPD.

During an interview on 4/21/25 at 4:10 p.m. the Operations Manager confirmed that the facility failed to provide a minimum of 3.20 PPD hours of direct care on the above dates as required.

Plan of Correction - To be completed: 06/09/2025

To ensure compliance with the state-required minimum of 3.2 HPPD, staffing meetings will be conducted five days a week to review the previous day's actual HPPD and evaluate projected staffing for the current and upcoming week. If projections indicate staffing will fall below the 3.2 minimum, the facility will immediately reach out to current employees and contracted staffing agencies to secure additional coverage.

The facility continues to actively recruit nursing staff through multiple platforms, including online job postings, local outreach, and employee referral programs. We have had meetings with new agencies to give us more potential staff to reach out to.

To monitor compliance, the Nursing Home Administrator or designee will perform HPPD audits five days per week for four consecutive weeks. Findings will be reviewed during monthly QAPI meetings to assess staffing trends and implement further recommendations as needed.

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