Pennsylvania Department of Health
SPRING HILL REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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SPRING HILL REHABILITATION AND NURSING CENTER
Inspection Results For:

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SPRING HILL REHABILITATION AND NURSING CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a revisit survey completed on March 19, 2024, it was determined that Spring Hill Rehabilitation and Nursing Center corrected the deficiency identified during the survey of January 30, 2024, as related to the requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(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 review of nursing time schedules and staff interview, it was determined that the facility administrative staff failed to provide a minimum of one nursing assistant per 12 residents during the day shift on three of seven days (3/14/24, 3/16/24 and 3/17/24) and one nursing assistant per 12 residents during the evening shift on six of seven days (3/11/24, 3/13/24 through 3/17/24).

Findings include:

Review of the facility census data and nursing time schedules revealed the following nursing assistant staffing shortages:

Day shift:
3/14/24census 6330.03 actual hours39.38 hours required.
3/16/24census 6436.95 actual hours40.00 hours required.
3/17/24census 6436.18 actual hours40.00 hours required.

Evening shift:
3/11/24census 5817.95 actual hours36.25 hours required.
3/13/24census 5932.00 actual hours36.88 hours required.
3/14/24census 6339.05 actual hours39.38 hours required.
3/15/24census 6424.05 actual hours40.00 hours required.
3/16/24census 6436.95 actual hours40.00 hours required.
3/17/24census 6436.18 actual hours40.00 hours required.

During an interview on 3/19/24, at 2:00 p.m. the Nursing Home Administrator confirmed the facility failed to provide a minimum of one nursing assistant per 12 residents during the day and evening shifts as required.


 Plan of Correction - To be completed: 05/20/2024

1. The residents had no negative outcome from not meeting a minimum of one nurse aide per twelve residents during the day and/or evening shift, and/or one nurse aide per twenty residents on night.

2. NHA/designee will provide the staffing coordinator/HR with re-education on the Pennsylvania staffing requirements.

3. The facility had increased wages, attend daily corporate labor calls, and instituted staffing meetings to track staffing.

4. The facility will use the ratio spreadsheet and NHA/Designee will educate scheduler and licensed nurses to alert NHA/DON to shortages/call offs.

5. Staffing coordinator/designee will audit the ratios weekly x4 weeks and monthly x3 months.

6. Results of audits will be submitted to QAPI committee for tracking and further recommendations

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