Pennsylvania Department of Health
GREENWOOD CENTER FOR REHABILITATION AND NURSING
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GREENWOOD CENTER FOR REHABILITATION AND NURSING
Inspection Results For:

There are 108 surveys for this facility. Please select a date to view the survey results.

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GREENWOOD CENTER FOR REHABILITATION AND NURSING - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Survey in response three Complaint Investigations, completed on May 29, 2024, it was determined that Greenwood Center for Rehabilitation and Nursing 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 Regulationsas it relates to the Health survey.

Plan of Correction:

483.25 REQUIREMENT Quality of Care:

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.

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered vital signs for one of six residents reviewed (Resident 1).

Findings include:

Clinical record review for Resident 1 revealed a physician's order dated May 2, 2024, for vital signs (measurements of the body's most basic functions to include body temperature, pulse rate, respiration rate, and blood pressure) to be completed every eight hours for three days.

Review of Resident 1's clinical documentation revealed that the facility only obtained his vital signs on May 2, 2024, at 6:00 PM, during the three days that they were to be obtained, from May 2-5, 2024.

The Director of Nursing confirmed the above noted findings during an interview on May 29, 2024, at 11:25 AM.

28 Pa. Code 211.10(c) Resident care policies

28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 06/18/2024

1. Vital signs were obtained for resident #1 on 5/7/24 and results were reported to the physician.
2. The DON/Designee conducted an audit of current facility residents with physician orders for vital signs to ensure that they have been obtained as ordered. Any identified deficiencies were corrected immediately.
3. Licensed nursing staff will be educated by the DON/Designee on the components of this regulation with an emphasis on following physician orders related to obtaining and reporting vital signs.
4.The DON/Designee will conduct random audits of 5 residents electronic medical records to ensure that physician ordered vital signs have been obtained and documented weekly for four weeks and then monthly for two months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met.
5. Date of completion will be June 18, 2024.

§ 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 staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide per 12 residents during the day shift on two of 14 days reviewed, a minimum of one nurse aide per 12 residents on four of 14 evening shifts reviewed, and a minimum of one nurse aide per 20 residents on two of 14 night shifts reviewed.

Findings include:

A review of nursing staff care hours provided by the facility revealed the following nurse aides (NA) scheduled for the resident census:

Day shift:

May 25, 2024, 8.50 NAs for a census of 118, required 9.83.
May 25, 2024, 8.50 NAs for a census of 118, required 9.83.

Evening shift:

May 15, 2024, 9.50 NAs for a census of 121, required 10.08.
May 21, 2024, 9.50 NAs for a census of 116, required 9.67.
May 25, 2024, 8.00 NAs for a census of 118, required 9.83.
May 28, 2024, 9.00 NAs for a census of 118, required 9.83.

Night shift:

May 17, 2024, 6.00 NAs for a census of 122, required 6.10.
May 23, 2024, 5.50 NAs for a census of 117, required 5.85.

The Director of Nursing was made aware of and confirmed the above noted findings related to the nurse aide staffing ratios on May 30, 2024, at 12:30 PM during an interview.

Plan of Correction - To be completed: 06/18/2024

1. The facility cannot retroactively correct the identified days the facility did not ensure the correct staffing ration.
2. There were no residents affected by the facilities alleged deficient practice related to staffing.
3. The facility continues to recruit and hire Certified Nursing Assistants. The facility will continue to implement emergency staffing strategies that include the use of nursing management providing direct resident care. The DON/Designee will monitor the staffing schedule, including ratios, daily with the scheduling department.
4. The Director of Nursing/Designee will monitor the staffing ratios and PPD daily to ensure the correct staffing ratio requirements have been met. Audits will occur weekly for four weeks and then monthly for two months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met.
5. Date of compliance will be June 18, 2024.

§ 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 staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one licensed practical nurse per 25 residents during the day shift on two of 14 days reviewed, a minimum of one Licensed practical nurse per 30 residents on one of 14 evening shifts reviewed, and a minimum of one Licensed Practical Nurse per 40 residents on one of 14 night shifts reviewed.

Findings include:

A review of nursing staff care hours provided by the facility revealed the following Licensed Practical Nurses (LPN) scheduled for the resident census:

Day shift:

May 25, 2024, 4.50 LPNs for a census of 118, required 4.72.
.May 25, 2024, 4.50 LPNs for a census of 118, required 4.72.

Evening shift:

May 26, 2024, 3.50 LPNs for a census of 118, required 3.93.

Night shift:

May 22, 2024, 2.84 LPNs for a census of 117, required 2.93.

The Director of Nursing was made aware of concerns with the facility staffing ratios, and confirmed the above noted findings during an interview on May 30, 2024, at 12:30 PM.

Plan of Correction - To be completed: 06/18/2024

1. The facility cannot retroactively correct the identified days the facility did not ensure the correct staffing ration.
2. There were no residents affected by the facilities alleged deficient practice related to staffing.
3. The facility continues to recruit and hire Licensed Practical Nurses. The facility will continue to implement emergency staffing strategies that include the use of nursing management providing direct resident care. The DON/Designee will monitor the staffing schedule, including ratios, daily with the scheduling department.
4. The Director of Nursing/Designee will monitor the staffing ratios and PPD daily to ensure the correct staffing ratio requirements have been met. Audits will occur weekly for four weeks and then monthly for two months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly and/or until substantial compliance is met.
5. Date of compliance will be June 18, 2024.

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