Pennsylvania Department of Health
MOSSER NURSING HOME
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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MOSSER NURSING HOME - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights survey completed on April 12, 2024, at Mosser Nursing Home, it was determined there were no deficiencies identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities as it related to the Health portion of the survey process; however, the facility was not in compliance with the following requirements of 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 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 four of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from October 15 through October 21, 2023, from December 27, 2023, through January 2, 2024, and from April 5 through April 11, 2024 revealed the following:

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

The facility failed to meet the minimum NA to resident ratio of one NA for 20 residents on night shift (11:00 p.m. to 7:00 a.m.) on December 29, 30, 31, 2023, and January 1, 2024.

Plan of Correction - To be completed: 05/10/2024

The facility will ensure the minimum Nurse Aide staff to resident ratio is provided on each shift.
The facility will perform audits to ensure the minimum Nurse Aide staff to resident ratio is provided on each shift.
The Scheduler will be re-educated to ensure the minimum Nurse Aide staff to resident ratio is provided on each shift.
Audits will be conducted 5X/week X 1 month to ensure the minimum Nurse Aide staff to resident ratio is provided on each shift.
Audits will continue until substantial compliance is achieved.

§ 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 October 15 through October 21, 2023, from December 27, 2023, through January 2, 2024, and from April 5 through April 11, 2024, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 30 residents on evening shift (3:00 p.m. to 11:00 p.m.) on December 31, 2023.

The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on night shift (11:00 p.m. to 7:00 a.m.) on December 31, 2023, January 1, 2024, and April 7, 2024.

Plan of Correction - To be completed: 05/10/2024

The facility will ensure the minimum LPN staff to resident ratio is provided on each shift.
The facility will perform audits to ensure the minimum LPN staff to resident ratio is provided on each shift.
The Scheduler will be re-educated to ensure the minimum LPN staff to resident ratio is provided on each shift.
Audits will be conducted 5X/week X 1 month to ensure the minimum LPN to resident ratio is provided on each shift. Audits will continue until substantial compliance is achieved.

§ 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 one of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from October 15 through October 21, 2023, from December 27, 2023, through January 2, 2024, and from April 5 through April 11, 2024, revealed the following total nursing care hours below minimum requirements:

Sunday, December 31, 2023: 2.68 care hours per resident.

Plan of Correction - To be completed: 05/10/2024

The facility will ensure the minimum hours of direct care is provided.
The facility will perform audits to ensure the minimum hours of direct care is provided.
The Scheduler will be re-educated to ensure the minimum hours of direct care is provided.
Audits will be performed 5X/week X 1 month to ensure the minimum hours of direct care is provided. Audits will continue until substantial compliance is achieved.

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