Pennsylvania Department of Health
LECOM AT ASBURY RIDGE DBA SAINT MARY'S ASBURY RIDGE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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LECOM AT ASBURY RIDGE DBA SAINT MARY'S ASBURY RIDGE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Complaint Survey completed on January 9, 2026, it was determined that LECOM at Asbury Ridge, dba Saint Mary's Asbury Ridge was not in compliance with the following 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 review of facility nursing staffing documents and staff interview, it was determined that the facility failed to meet the one Nurse Aide (NA) per 10 residents for the day shift, one NA per 11 residents for evening shift, and one NA per 15 residents for the overnight shift, for one of 21 days reviewed (10/31/25).

Findings include:

Review of nursing staffing documents for the time periods of 10/27/25, through 11/2/25, 11/15/25, through 11/21/25, and 12/1/25, through 12/7/25, revealed the following NA staffing shortage for the day shift:

10/31/25, facility census of 74 residents, 6.22 NA scheduled and 7.40 were required.

Review of nursing staffing documents for the time periods of 10/27/25, through 11/2/25, 11/15/25, through 11/21/25, and 12/1/25, through 12/7/25, revealed the following NA staffing shortage for the evening shift:

10/31/25, facility census of 75 residents, 6.03 NA scheduled and 6.82 were required.

Review of nursing staffing documents for the time periods of 10/27/25, through 11/2/25, 11/15/25, through 11/21/25, and 12/1/25, through 12/7/25, revealed the following NA staffing shortage for the overnight shift:

10/31/25, facility census of 75 residents, 4.63 NA scheduled and 5.00 were required.

During an interview on 1/9/26, at 10:39 a.m. the Nursing Home Administrator confirmed that the facility failed to meet the minimum NA ratio requirements on the above shifts and date.

Plan of Correction - To be completed: 02/22/2026

Nursing Administration reviewed the date(10/31/2025) that the Nurse aid ratios were below the minimum requirements of 1:10 on first shift, 1:11 on second shift and 1:15 on third shift on 10/31/2025. No adverse effects were identified relating to the residents regarding the deficiency in nurse aid staffing ratios.
Nursing Administration, Scheduling and Human Resources will be meeting daily to review staffing, ratios, census and HPPD's -Hours per patient day to assure that the Nurse aid ratios are being met per regulation. The schedules will be double checked for accuracy, call offs will be reviewed, and Administration will also look at staffing on holidays.
Nursing Administration will be meeting and educating the Charge Nurses on all three shifts and on-call staff regarding Nurse aid staffing ratios and regulations.
Administration has contracted with agency for Nurse aids on all three shifts. Human Resources and Nursing Administration will continue to advertise, interview and hire Nurse aids on all three shifts.
Nursing Administration and scheduling will complete a weekly Quality Assurance monitor to ensure that the Nurse aid ratios are met per regulation. This Quality Assurance monitor will be completed weekly for two months, then monthly. If the Quality Assurance Monitor reflects 100% compliance for three consecutive months, then the monitor may be completed on a quarterly basis.

§ 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 review of facility nursing staffing documents and staff interview, it was determined that the facility failed to provide the minimum number of general nursing care hours of 3.20 hours of direct resident care hours per resident in a twenty-four hour period for one of 21 days reviewed (10/31/25).

Findings include:

Review of nursing staffing documents for the time periods of 10/27/25, through 11/2/25, 11/15/25, through 11/21/25, and 12/1/25, through 12/7/25, revealed that the hours of direct resident care was below 3.20 minimum per patient day (PPD) on the following date:

10/31/25 3.01 PPD

During an interview on 1/9/26, at 10:39 a.m. the Nursing Home Administrator confirmed that the facility failed to meet the minimum PPD requirements on the above date.

Plan of Correction - To be completed: 02/22/2026

Nursing Administration reviewed 10/31/2025 the date the facility failed to provide the minimum number of general nursing care hours of 3.2 hours of direct resident care hours per resident in a twenty-four-hour period. No adverse effects were identified relating to the residents regarding the deficiency in failure to meet the State regulation of a minimum HPPD - Hours per patient day of 3.2 hours of direct resident care hours in a twenty-four-hour period on 10/31/2025.
Nursing Administration, Scheduling and Human Resources will be meeting daily to review the current staffing, census and HPPD's- Hours per patient day to assure that the regulation of a minimum of 3.2 hours of direct resident care hours per resident in a twenty-four-hour period are met. The schedules will be double checked for accuracy, call offs will be reviewed, and Administration will also look at staffing on holidays.
Nursing Administration will be meeting and educating the charge nurses on all three shifts and on-call staff regarding regulatory ratios and HPPD's- Hours per patient day.
Administration has contracted with agency for staffing on all three shifts. Human Resources and Nursing Administration will continue to advertise, interview and hire staff for all three shifts.
Nursing Administration and Scheduling will complete a weekly Quality Assurance monitor to ensure that the state regulations of a minimum HPPD - Hours per patient day of 3.2 hours of direct resident care hours in a twenty-four-hour are met per regulation. This Quality Assurance monitor will be completed weekly for two months, then monthly. If the Quality Assurance monitor reflects 100% compliance for three consecutive months, then the monitor may be completed on a quarterly basis.

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