Pennsylvania Department of Health
 RIVERSTREET MANOR
Patient Care Inspection Results

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RIVERSTREET MANOR
Inspection Results For:

There are  127 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
RIVERSTREET MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Complaint Survey completed on February 20, 2025, at Riverstreet Manor, it was determined there were no federal deficiencies, related to the Health portion of the survey process, 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. :State only Deficiency.
(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 nurse staffing and staff interview, it was determined the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 26 shifts out of 63 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following date the facility failed to provide minimum nurse aide staff of 1:10 on the day shift, based on the facility's census:

February 8, 2025- 8.6 NAs on the day shift, versus the required 10.5 for a census of 105.
February 9, 2025- 8.17 NAs on the day shift, versus the required 10.5 for a census of 105.
February 11, 2025- 8.47 NAs on the day shift, versus the required 10.4 for a census of 104.
February 12, 2025- 9.03 NAs on the day shift, versus the required 10.4 for a census of 104.
February 14, 2025- 9.13 NAs on the day shift, versus the required 10.2 for a census of 102.
February 15, 2025- 8.87 NAs on the day shift, versus the required 10.3 for a census of 103.
February 16, 2025- 9.6 NAs on the day shift, versus the required 10.3 for a census of 103.
February 17, 2025- 10.07 NAs on the day shift, versus the required 10.2 for a census of 102.

A review of the facility's weekly staffing records revealed that on the following date the facility failed to provide minimum nurse aide staff of 1:11 on the evening shift, based on the facility's census:

January 31, 2025- 7.76 NAs on the evening shift, versus the required 9.73 for a census of 107.
February 3, 2025- 7.77 NAs on the evening shift, versus the required 9.82 for a census of 108.
February 9, 2025- 9.50 NAs on the evening shift, versus the required 9.55 for a census of 105.
February 10, 2025- 7.90 NAs on the evening shift, versus the required 9.55 for a census of 105.
February 13, 2025- 8.6 NAs on the evening shift, versus the required 9.36 for a census of 103.
February 14, 2025- 7.4 NAs on the evening shift, versus the required 9.27 for a census of 102.
February 15, 2025- 7.03 NAs on the evening shift, versus the required 9.36 for a census of 103.
February 17, 2025- 7.97 NAs on the evening shift, versus the required 9.18 for a census of 101.

A review of the facility's weekly staffing records revealed that on the following date the facility failed to provide minimum nurse aide staff of 1:15 on the night shift, based on the facility's census:

January 29, 2025- 6.22 NAs on the night shift, versus the required 7.2 for a census of 108.
February 1, 2025- 6.07 NAs on the night shift, versus the required 7.2 for a census of 108.
February 2, 2025- 6.25 NAs on the night shift, versus the required 7.2 for a census of 108.
February 8, 2025- 6.43 NAs on the night shift, versus the required 7.0 for a census of 105.
February 10, 2025- 6.53 NAs on the night shift, versus the required 7.0 for a census of 105.
February 12, 2025- 6.47 NAs on the night shift, versus the required 6.93 for a census of 104.
February 14, 2025- 6.13 NAs on the night shift, versus the required 6.8 for a census of 102.
February 15, 2025- 6.53 NAs on the night shift, versus the required 6.87 for a census of 103.
February 16, 2025- 5.40 NAs on the night shift, versus the required 6.8 for a census of 102.
February 17, 2025- 6.30 NAs on the night shift, versus the required 6.73 for a census of 101.

On the above dates mentioned no additional excess higher-level staff were available to compensate this deficiency.

An interview with the Director of Nursing, on February 20, 2025, at approximately 12:30 PM, confirmed the facility had not met the required nurse aide to resident ratios on the above dates.




 Plan of Correction - To be completed: 04/22/2025

-The facility will provide nurse aide ratios at a minimum of 1:10 on the day shift, 1:11 on the evening shift, and 1:15 on the night shift based on facility's census to meet the needs of the residents. The nursing schedule and ratios will be reviewed daily Monday through Friday to include projected weekend ratios by the Administrator, Director of Nursing, and Center Scheduling Manager to validate nurse aide staff ratios are being met and adjustments will be made as necessary. An outside agency is available and will assist with staffing needs if the need arises to ensure adequate staff are available.

-Facility residents have the potential to be affected by this practice.

-The Administrator, Nursing Team Management, and Center Scheduling Manager will be re-educated concerning minimum nurse aide ratios and the appropriate response to unplanned variation in ratios.

-NHA/Designee will complete random audits to ensure ratios are being met weekly for 4 weeks.

-Results of the audits will be presented at the monthly QAPI Meeting monthly for further review and recommendations.

§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(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 nurse staffing and staff interview, it was determined the facility failed to ensure the minimum licensed practical nurse staff to resident ratio was provided on each shift for 2 shifts out of 63 shifts reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:25 on the day shift based on the facility's census.

February 9, 2025 - 4.00 LPNs on the day shift, versus the required 4.2 for a census of 105.

A review of the facility's weekly staffing records revealed that on the following date the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:40 on the night shift based on the facility's census.

February 12, 2025 - 2.16 LPNs on the night shift, versus the required 2.6 for a census of 104.

On the above dates mentioned no additional excess higher-level staff were available to compensate this deficiency.

An interview with the Director of Nursing on February 20, 2025, approximately 12:30 PM, confirmed the facility had not met the required LPN to resident ratio on the above dates.




 Plan of Correction - To be completed: 04/22/2025

 -The facility will provide LPN ratios at a minimum of 1:25 on the day shift and 1:40 on the night shift based on facility's census to meet the needs of the residents. The nursing schedule and ratios will be reviewed daily Monday through Friday to include projected weekend ratios by the Administrator, Director of Nursing, and Center Scheduling Manager to validate LPN staff ratios are being met and adjustments will be made as necessary. An outside agency is available and will assist with staffing needs if the need arises to ensure adequate staff are available which will assist with LPN needs.

-Facility residents have the potential to be affected by this practice.

-The Administrator, Nursing Team Management, and Center Scheduling Manager will be re-educated concerning minimum LPN ratios and the appropriate response to unplanned variation in ratios.

-NHA/Designee will complete random audits to ensure ratios are being met weekly for 4 weeks.

-Results of the audits will be presented at the monthly QAPI Meeting monthly for further review and recommendations.

§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(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 nurse staffing and resident census and staff interview, it was determined the facility failed to consistently provide minimum general nursing care hours to each resident daily on 17 out of the 21 days reviewed.

Findings include:

A review of the facility's staffing levels revealed that on the following dates the facility failed to provide minimum nurse staffing of 3.2 hours of general nursing care to each resident:

January 29, 2025- 3.17 direct care nursing hours per resident.
January 30, 2025- 3.13 direct care nursing hours per resident.
January 31, 2025- 2.92 direct care nursing hours per resident.
February 1, 2025- 2.97 direct care nursing hours per resident.
February 2, 2025- 2.99 direct care nursing hours per resident.
February 3, 2025- 2.84 direct care nursing hours per resident.
February 6, 2025- 3.17 direct care nursing hours per resident.
February 7, 2025- 3.13 direct care nursing hours per resident.
February 8, 2025- 2.85 direct care nursing hours per resident.
February 9, 2025- 2.85 direct care nursing hours per resident.
February 10, 2025- 2.88 direct care nursing hours per resident.
February 11, 2025- 3.07 direct care nursing hours per resident.
February 12, 2025- 3.06 direct care nursing hours per resident.
February 14, 2025- 3.06 direct care nursing hours per resident.
February 15, 2025- 2.91 direct care nursing hours per resident.
February 16, 2025- 2.96 direct care nursing hours per resident.
February 17, 2025- 3.09 direct care nursing hours per resident.

The facility's general nursing hours were below minimum required levels on the dates noted above.

An interview with the Director of Nursing on February 20, 2025, at approximately 12:30 PM confirmed that the facility failed to consistently provide minimum general nursing care hours to each resident daily.




 Plan of Correction - To be completed: 04/22/2025

The facility will provide a minimum of 3.2 hours of direct resident care for each resident. The nursing schedule and HPPD will be reviewed daily Monday through Friday to include projected weekend HPPD by the Administrator, Director of Nursing, and Center Scheduling Manager to validate the hours of direct care for each resident being met and adjustments will be made as necessary. An outside agency is available and will assist with staffing needs if the need arises to ensure adequate staff are available to meet the nursing care hours need for patient care.

Facility residents have the potential to be affected by this practice.
The Administrator, Nursing Team Management, and Center Scheduling Manager will be re-educated concerning the minimum 3.2 hours of direct resident care for each resident and the appropriate response to unplanned variation below that number.

NHA/Designee will complete random audits to ensure 3.2 hours or greater are being met weekly for 4 weeks.

Results of the audits will be presented at the monthly QAPI Meeting monthly for further review and recommendations.


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