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 111 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 to a Complaint Investigation, completed on July 25, 2024, at Greenwood Center for Rehabilitation and Nursing, it was determined that there were no federal deficiencies, identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care as they relate 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)(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.

Plan of Correction - To be completed: 08/06/2024

1. The facility cannot retroactively correct the identified days the facility did not ensure the correct staffing ratios for nurse aides was met.

2.There was the potential for any resident to be affected.

3.The facility continues to recruit and hire Certified Nursing Assistants and utilizes staffing agencies to help fill open shifts. 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 daily to ensure the correct nurse aide ratio requirements have been met. Audits will occur 1x a week for 4 weeks 2x a month x 2 months then monthly x 3 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. Quality Monitoring schedule modified based on findings.

5.Date of completion will be 8/6/24.

§ 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 staffing hours and staff interview, it was determined that the facility failed to ensure the total of nursing care hours provided in each 24-hour period was a minimum of 3.2 hours per patient day (PPD), effective July 1, 2024, on 18 of 21days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed the following nursing care hours for each 24-hour period of concern:

July 4, 2024, PPD was 2.98.
July 5, 2024, PPD was 3.00.
July 6, 2024, PPD was 3.06.
July 7, 2024, PPD was 2.97.
July 8, 2024, PPD was 3.18.
July 9, 2024, PPD was 2.95.
July 11, 2024, PPD was 2.92.
July 12, 2024, PPD was 3.17.
July 13, 2024, PPD was 3.13.
July 15, 2024, PPD was 3.10.
July 16, 2024, PPD was 3.13.
July 17, 2024, PPD was 2.98.
July 19, 2024, PPD was 3.14.
July 20, 2024, PPD was 2.74.
July 21, 2024, PPD was 3.16.
July 22, 2024, PPD was 3.02.
July 23, 2024, PPD was 3.09.
July 24, 2024, PPD was 3.04.

Interview with the Director of Nursing on July 25, 2024, at 12:30 PM confirmed that the facility failed to meet the required nursing staffing PPD as listed above.

Plan of Correction - To be completed: 08/06/2024

1.The facility cannot retroactively correct the identified days the facility failed to ensure that a PPD of 3.2 was met.

2.There was the potential for any resident to be affected.

3.The facility continues to recruit and hire direct care staff and utilizes staffing agencies to help fill open shifts. 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, to include the daily PPD, with the scheduling department.

4.The Director of Nursing/Designee will monitor staffing daily to ensure the PPD requirements have been met. Audits will occur 1x a week for 4 weeks 2x a month x 2 months then monthly x 3 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. Quality Monitoring schedule modified based on findings.

5.Date of completion will be 8/6/24.

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