Pennsylvania Department of Health
CRAWFORD CARE CENTER
Patient Care Inspection Results

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CRAWFORD CARE CENTER
Inspection Results For:

There are  73 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.
CRAWFORD CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Complaint Survey completed on April 12, 2024, it was determined that Crawford Care Center was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.60 REQUIREMENT Provided Diet Meets Needs of Each Resident:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
483.60 Food and nutrition services.
The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.
Observations:

Based on review of facility policy and planned written menus, observations, and resident and staff interviews, it was determined the facility failed to provide each resident with a nourishing, well-balanced diet that meets his/her daily nutritional needs for one of one meal observed (lunch meal 4/01/24) and three of three meals reviewed (lunch, dinner meal 4/01/24 and breakfast meal 4/02/24).

Findings include:

Review of a facility policy entitled, "Resident Food Preferences," dated 2/12/24, revealed "Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. The food services department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night."

Review of the facility menu for cycle week 3 for the lunch meal on 4/01/24, revealed Chicken Pot Pie w/Biscuit, Alternate- Hamburger on a Bun-Lettuce & Tomato-Ketchup-Pickle Spear, Tossed Salad w/Dressing, Broccoli Florets, Tater Tots-Ketchup Deluxe Fruit Salad.

Review of the facility menu for cycle week 3 for the dinner meal on 4/01/24, revealed Butter Crumb Tilapia Fillet, Alternate-Glazed Baked Pork Chop, Green Peas, Sliced Carrots, Baked Potato-Sour Cream-Margarine, Parsley Rice, Dinner Roll/Bread, Blondie.

Review of the facility menu for cycle week 3 for the breakfast meal on 4/02/24, revealed Scrambled Eggs w/Cheese, Biscuit-Margarine-Jelly.

Observations of the lunch meal service on 4/01/24, revealed noodles were provided instead of the chicken pot pie and biscuit. Also, no hamburger buns and tomato were available for the alternate.

Facility resident census was 93 on 4/01/24.

Observations of one of two unit pantries on 4/01/24 at 1:38 p.m. revealed only 13 sugar free cookies, no juice, and no other snacks available.

Observations of the kitchen on 4/01/24 at 2:00 p.m. revealed the only snacks available were one case of cream pies, a half case of graham crackers, half box of peanut butter crackers and 8 sugar free cookies, the only ice cream available was 18 individual cups of vanilla and 10 individual cups of chocolate, alternate menu for hamburgers revealed only seven hamburgers and zero hamburgers in the freezer, zero buns, the only milk was one gallon of 1%, three gallons of whole milk, 41 individual serve cartons of 1% milk, and 19 individual cartons of chocolate milk, the juice station revealed three juice concentration boxes hooked up to the juice station which two of the boxes were empty and one was observed with a small amount of juice. Further observations revealed 16 black tea bags, one and a half standard size boxes of green tea bags, zero fresh fruit, one small container of shredded lettuce in water, zero tomatoes, zero pickles, zero biscuits, and zero peas.

Residents' R1, R7, R8, R9 indicated during interviews on 4/01/24, that the facility food supply consistently runs out before the next delivery; they have been out of coffee for days, can have green tea, but not black tea due to nobody enjoys green tea and the stock of it stays the same and is then available. Residents further indicated recently there has been no creamer, fresh lettuce, hamburgers, buns for hamburgers (and other sandwiches), tomatoes, salad, fresh fruit, juice, milk - typically only 1%, and snacks are very limited. Resident R8 indicated, menus are not followed, and residents never know what they are going to get for a meal, until they open the cover when the meal arrives. Residents then request an alternate food and find out that it is not available as well. The residents further indicated that they were not notified of any menu changes on 4/01/24, and/or prior to 4/01/24.

During an interview on 4/01/24, at 3:18 p.m. the Dietary Manager confirmed that noodles and not chicken pot pie with biscuits were served for the lunch meal on 4/01/24, and the residents were not notified of the change on the menu. The Dietary Manager further confirmed the facility had no coffee for breakfast and he/she had to run out to a local store to retrieve some on 4/01/24, and there were no peas for dinner on 4/01/24 -serving green beans with no notification to residents, no biscuit for breakfast for 4/02/24 -serving English muffins with no notification to residents of the changes. He/she confirmed the facility only had seven hamburgers for the alternate menu for 4/01/24, and the facility had zero in the freezer, and the facility had no buns for the hamburgers or tomatoes. He/she further confirmed the only snack available to offer diabetic residents was sugar free cookies, due to the facility had no fresh fruit salad and the juice station containers were empty with all juice poured into containers for later use during dinner and breakfast the next day. No extra juice was observed to offer the residents except for the two later meals. The Dietary Manager confirmed that the food supply truck was not expected to make a delivery until after 12:00 p.m. on 4/02/24.

The facility failed to ensure that the dietary department was effectively managed to ensure the appropriate ordering and acquisition of food items was completed to fulfill the residents' nutritional needs for each meal and provide a variety of food at each scheduled meal.

28 Pa. Code 201.18 (b)(3) Management

28 Pa. Code 211.6 (a) Dietary services






 Plan of Correction - To be completed: 05/14/2024

1.The Dietary Supervisor ordered an adequate supply of food and snack items to meet the residents' dietary nutritional needs. The Dietary Department ordered extra juice (apple, orange, and cranberry), to keep in stock to prevent a shortage. The Dietary Department ordered an extra supply of coffee, tea, (black and green), and creamer to meet the requests of the residents. The Dietary Department have adjusted and increased their par-levels of fresh fruit, snack selections, bread products, (including hamburger buns), milk, (1%, 2%, Whole) and side condiments, (tomato, lettuce, pickles, etc.), for various food items offered to meet resident needs and choice.
2.The Dietary Manager will submit the food order to the District Manager prior to the order being placed for approval. The Dietary Manager and/or designee will notify residents of the any meal changes where menus are posted. The Dietary Manager will notify the facility Registered Dietician for approval prior to menu substitutions. The Dietary staff will be educated by the Dietary Supervisor on the addition of increased par-levels, the approval process of meal substitutions and notification to the Dietary Supervisor when items required are not available per the menu.
3.The Dietary Manager and/or designee will complete an audit daily for two (2) weeks to ensure food supplies are available in the kitchen to prepare resident meals and daily monitoring of snacks available at the request of the resident. The Dietary Manager and/or designee will conduct resident interviews to ensure meals are being followed and requested items are being received.
4.The Dietary Manager will submit all food supply and snack audits to the Quality Assessment Performance Improvement (QAPI) Committee for review and recommendation at the monthly meeting.

483.10(f)(1)-(3)(8) REQUIREMENT Self-Determination: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.
483.10(f) Self-determination.
The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.

483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.
Observations:

Based on observations, review of clinical records, and resident and staff interviews, it was determined that the facility failed to provide a bath/shower as resident preference for four of 26 residents reviewed (Residents R1, R4, R5, R6).

Findings include:

No policy was provided on baths/showers.

Resident's R1's clinical record revealed an admission date of 9/03/21, with diagnoses that included polyosteoarthritis (joint pain and stiffness), dysuria (discomfort, pain, or burning when urinating), hypothyroidism (a condition when the thyroid gland doesn't produce enough thyroid hormone), and presence of artificial eye.

During an interview with Resident R1 on 4/01/24, at 1:25 p.m. he/she indicated their bath/shower was scheduled for Wednesday and Saturday evenings, but he/she has not received the scheduled bath/shower in at least the past 10 days. Resident R1 verbalized, "I told several people that I would like my bath on the dayshift, due to more reliable staff work those hours. It all depends on who and how many are working if you get a bath or not." Resident was observed with greasy hair.

Review of Resident R1's bath/shower documentation for 3/01/24 through 4/03/24 revealed he/she was scheduled for a bath/shower on Wednesday/Saturday 3-11 p.m., however, no bath/shower was provided on 3/06/24, 3/20/24, and 3/30/24.

Resident's R4's clinical record revealed an admission date of 3/06/24, with diagnoses that included heart failure, high blood pressure, chronic pulmonary obstructive disease (a chronic disease of the respiratory system that affects breathing), and hypothyroidism.

Review of Resident R4's bath/shower documentation for 3/06/24 through 4/03/24 revealed he/she was scheduled for a bath/shower on Tuesday/Friday 3-11 p.m., however, no bath/shower was provided for the month of March 2024.

Resident's R5's clinical record revealed an admission date of 3/19/24, with diagnoses that included heart failure, cardiac pacemaker (a small device used to keep the heart from beating too fast and/or too slow), lumbago with sciatica (low back that shoots down legs), and anxiety.

Review of Resident R5's bath/shower documentation for 3/19/24 through 4/03/24 revealed he/she was scheduled for a bath/shower on Monday/Thursday 7-3 p.m., however, no bath/shower was provided on 3/21/24, 3/25/24, and 4/01/24.

Resident's R6's clinical record revealed an admission date of 3/03/24, with diagnoses that included cerebral infarction due to occlusion (stroke where blood circulation in the brain is disrupted), urinary tract infection, high blood pressure, and heart failure.

Review of Resident R6's bath/shower documentation for 3/03/24 through 4/03/24 revealed he/she was scheduled for a bath/shower on Monday/Thursday 3-11 p.m., however, no bath/shower was provided on 3/04/24, 3/07/24, 3/11/24, 3/14/24, 3/18/24, and 3/21/24.

During an interview on 4/03/24, at 3:55 p.m. the Nursing Home Administrator confirmed that the frequency of Baths/Showers are based on resident preference.

An interview with the Director of Nursing on 4/04/24, at 12:20 p.m. confirmed that baths/showers were not provided according to residents'' scheduled days and preference for the period of 3/01/24 through 4/03/24 for the above noted residents.

28 Pa. Code 211.10(d) Resident care policies

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



 Plan of Correction - To be completed: 05/14/2024

1.Identified residents, R-1, R-4, R-5 and R-6 were given their showers per their request. The resident shower schedules for all residents were reviewed and updated per the residents' preferences. The residents had the choice to decide the day and shift they preferred their shower and/or bath. The resident shower assignments and care plans were updated to reflect the residents' preferences per facility policy "Resident Self Determination and Participation".
2.All current residents had their assigned shower days and shifts audited to ensure the residents' preferences were updated on the list for each hall assignment. All new residents will be asked, with input from floor staff, at the time of admission on their bathing/shower preference. The nursing assistants and professional nursing staff will be educated by the Director of Nursing and/or Assistant Director of Nursing on how to properly document in the Point Of Care (POC) system when showers are completed and/or refused by the resident. The nursing assistants will also be educated when a resident refuses a shower, the nursing assistant will make three (3) attempts to persuade the resident to take a shower. After the third (3rd) attempt they will report the refusal to their wing nurse who will write a nursing note in the resident's medical record.
3.The Director of Nursing and/or the Assistant Director of Nursing will audit all assigned showers daily to ensure the residents received their showers and proper documentation is completed and present on the shower sheets and resident medical record. Resident interviews will be conducted by Social Services, Assistant Director of Nursing, Director of Nursing, Nursing Home Administrator and/or designee to ensure showers are received as scheduled.
4.The Director of Nursing and/or Assistant Director of Nursing will present all shower audits to the Quality Assessment and Improvement Committee (QAPI) for review and recommendation at the monthly meeting.

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 review of clinical records, and staff and resident interviews, it was determined that the facility failed to follow physician orders for three of six residents reviewed (Residents R1, R2, and R3).

Findings include:

Resident's R1's clinical record revealed an admission date of 9/03/21, with diagnoses that included polyosteoarthritis (joint pain and stiffness), dysuria (discomfort, pain, or burning when urinating), hypothyroidism (a condition when the thyroid gland doesn't produce enough thyroid hormone), and presence of artificial eye.

Review of Resident R1's "Medication Administration Record" (MAR) revealed a physician order with start date of 2/25/22, Levothyroxine Sodium 100 micrograms (mcg) give one tablet by mouth one time a day for hypothyroidism. Resident R1's MAR further revealed for the month of March 2024 that his/her Levothyroxine Sodium 100 mcg was not administered per physician order on 3/03/24, 3/04/24, 3/06/24, 3/09/24, 3/11/24, 3/12/24, and 3/13/24.

During an interview on 4/01/24, at 1:25 p.m. Resident R1 indicated he/she has not received his/her medication for hypothyroidism as the physician ordered.


Resident's R2's clinical record revealed an admission date of 3/13/24, with diagnoses that included urinary tract infection, muscle weakness, need for assistance with personal care, and unsteadiness on feet.

Review of Resident R2's MAR revealed a physician order with start date of 3/14/24, and end date of 3/18/24, Nubega Oral Tablet 300 milligrams (mg) (Darolutamide) give 2 tablets by mouth two times a day related to Urinary Tract Infection. Resident R2's MAR further revealed for the month of March 2024 that his/her Nubega 300 mg 2 tablets was not administered per physician order on 3/15/24, at 8:00 a.m. and 9:00 p.m., 3/17/24, at 8:00 a.m., and 3/18/24, at 8:00 a.m.

Resident R2's MAR further revealed a successive physician order with start date of 3/18/24, and end date of 4/03/24, Nubega Oral Tablet 300 mg (Darolutamide) give 2 tablets by mouth two times a day related to Urinary Tract Infection. Resident R2's MAR further revealed for the month of March 2024 that his/her Nubega 300 mg 2 tablets was not administered per physician order on 3/19/24, at 8:00 a.m and 3/30/24, at 8:00 a.m.


Resident's R3's clinical record revealed an admission date of 1/15/24, with diagnoses that included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (stroke with paralysis and weakness to left side of body), high blood pressure, gastro-esophageal reflux disease (a digestive disease in which the stomach acid or bile irritates the food pipe lining), and rheumatoid arthritis (a chronic inflammatory painful disorder affecting typically affecting small joints in the hands and feet).

Review of Resident R3's MAR revealed a physician order with start date of 3/03/24, Norco Oral Tablet 7.5-325 mg (Hydrocodone-Acetaminophen) give 1 tablet by mouth every 12 hours for Pain "Total dose = 7.5-487.5 mg" Not to exceed 3000 mg acetaminophen every 24 hours. Resident R3's MAR further revealed for the month of March 2024 that his/her Norco Oral Tablet 7.5-325 mg (Hydrocodone-Acetaminophen) was not administered per physician order on 3/04/24, at 6:00 a.m., 3/14/24, at 6:00 a.m. and 6:00 p.m., 3/15/24, at 6:00 a.m. and 6:00 p.m., 3/16/24, at 6:00 a.m. and 6:00 p.m., 3/17/24, at 6:00 a.m. and 6:00 p.m., 3/18/24, at 6:00 a.m. and 6:00 p.m., and 3/19/24, at 6:00 a.m. and 6:00 p.m.

During an interview on 4/04/24, at 12:20 p.m. the Director of Nursing confirmed the medications noted above were not administered per physician orders for Residents R1, R2, and R3 during the month of March 2024.

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




 Plan of Correction - To be completed: 05/14/2024

1.The attending physician was contacted and notified about Resident R-1, R-2, and R-3 had their physician orders re-confirmed for accuracy.
2.The Director of Nursing and/or Assistant Director of Nursing audited all resident Medicine Acceptance Records (MAR) to identify any current resident documented that did not receive their medication per physician order. The licensed professional staff will be educated on 5/1/2024 on the process of when a medication is not available, given, or refused.
3.The Director of Nursing and/or Assistant Director of Nursing will monitor Medication Administration Audit Report daily to ensure the professional licensed staff are providing residents their medication per physician order.
4.All Medication Administration Order Audits will be submitted to the Quality Assurance Performance Improvement (QAPI) Committee for review and recommendation at the monthly meeting.

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 facility staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide (NA) per 12 residents on the day and evening shifts, and one NA per 20 residents on the overnight shift, for 12 of 21 days reviewed for staffing ratio.

Findings include:

Review of facility census on the following shifts revealed that the facility failed to meet the minimum required NA ratio.


Review of 21 days of nursing staffing documentation for the day shift revealed:

3/9/24, facility census of 88 residents, 6.34 NA scheduled and 7.33 were required.

3/10/24, facility census of 88 residents, 5.22 NA scheduled and 7.33 were required.

3/11/24, facility census of 87 residents, 7.20 NA scheduled and 7.25 were required.

3/15/24, facility census of 91 residents, 7.08 NA scheduled and 7.58 were required.

3/17/24, facility census of 91 residents, 6.94 NA scheduled and 7.58 were required.

3/18/24, facility census of 91 residents, 6.12 NA scheduled and 7.58 were required.

3/21/24, facility census of 90 residents, 6.34 NA scheduled and 7.50 were required.

3/23/24, facility census of 90 residents, 6.26 NA scheduled and 7.50 were required.


Review of 21 days of nursing staffing documentation for the evening shift revealed:

3/9/24, facility census of 88 residents, 5.33 NA scheduled and 7.33 were required.

3/10/24, facility census of 88 residents, 5.60 NA scheduled and 7.33 were required.

3/11/24, facility census of 88 residents, 7.11 NA scheduled and 7.33 were required.

3/15/24, facility census of 91 residents, 6.98 NA scheduled and 7.58 were required.

3/16/24, facility census of 91 residents, 7.06 NA scheduled and 7.58 were required.

3/17/24, facility census of 91 residents, 6.12 NA scheduled and 7.58 were required.

3/18/24, facility census of 92 residents, 6.05 NA scheduled and 7.67 were required.

3/19/24, facility census of 92 residents, 5.63 NA scheduled and 7.67 were required.

3/20/24, facility census of 93 residents, 3.22 NA scheduled and 7.75 were required.

3/23/24, facility census of 89 residents, 7.40 NA scheduled and 7.42 were required.

3/29/24, facility census of 91 residents, 6.60 NA scheduled and 7.58 were required.


Review of 21 days of nursing staffing documentation for the overnight shift revealed:

3/10/24, facility census of 87 residents, 4.14 NA scheduled and 4.35 were required.

3/16/24, facility census of 91 residents, 4.13 NA scheduled and 4.55 were required.

3/18/24, facility census of 92 residents, 4.08 NA scheduled and 4.60 were required.

3/19/24, facility census of 92 residents, 4.11 NA scheduled and 4.60 were required.

During an interview on 4/11/24, at 12:34 p.m. the Nursing Home Administrator confirmed that the facility failed to meet the minimum NA ratio requirements on the above shifts and dates.



 Plan of Correction - To be completed: 05/14/2024

The facility must maintain the minimum of one (1) Nurse Aide per twelve (12) residents on the day and evening shift and one (1) Nurse Aide per twenty (20) residents on the night shift. To ensure that this regulatory requirement is met the following action plan will be implemented:
1.Additional Staffing Agencies have been added for the facility to provide additional nursing staff to meet the state minimum requirement of one (1) nursing assistant for every twelve (12) residents on the day and evening shift, and one (1) nursing assistant for every twenty (20) residents on the night shift. Education will be provided to the Director of Nursing, Asst. Director of Nursing and the Scheduler no later than 05/2/2024 to ensure that they understand the regulatory staffing requirements for nursing assistants.

2.The nursing assistant schedule will be reviewed by the Scheduler, Director of Nursing and/or Asst. Director of Nursing to ensure that nursing assistant ratios are met prior to posting of the schedule. In the event of call-offs by staff, all other staff/agency will be contacted to cover any open shifts to ensure ratios are met. The facility continues to utilize job boards and various recruiting venues to attract, interview, recruit, and hire new staff. The facility conducts Recruitment and Retention Committee meetings weekly and has adopted a monthly rewards and recognition programs to retain current staff. The facility will conduct Staffing Meetings and Quality Calls with upper management five (5) day per week to ensure compliance.

3.An audit will be conducted by the scheduler daily for two (2) weeks, three (3) times per week for three (3) weeks, two (2) times per week for two (2) weeks then weekly ongoing to ensure that nursing assistant ratios are met for the day, evening, and night shifts. The audit will be monitored by the Director of Nursing or Designee.

4.All recruiting and retention meeting minutes along with Staffing Audits will be submitted to the Quality Assessment and Performance Improvement (QAPI) Committee at the monthly meeting for review and recommendation.

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 review of facility staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one Licensed Practical Nurse (LPN) per 25 residents on day shift, one LPN per 30 residents on evening shifts and one LPN per 40 residents on the overnight shift, for seven of 21 days reviewed for staffing ratio.

Findings include:

Review of facility census on the following shifts revealed that the facility failed to meet the minimum required LPN ratio.


Review of 21 days of nursing staffing documentation for day shift revealed:

3/9/24, facility census of 88 residents, 3.16 LPN scheduled and 3.52 were required.

3/23/24, facility census of 90 residents, 3.20 LPN scheduled and 3.60 were required.


Review of 21 days of nursing staffing documentation for evening shift revealed:

3/10/24, facility census of 88 residents, 2.90 LPN scheduled and 2.93 were required.


Review of 21 days of nursing staffing documentation for overnight shift revealed:

3/13/24, facility census of 92 residents, 2.20 LPN scheduled and 2.30 were required.

3/17/24, facility census of 91 residents, 2.04 LPN scheduled and 2.28 were required.

3/18/24, facility census of 92 residents, 2.14 LPN scheduled and 2.30 were required.

3/22/24, facility census of 90 residents, 2.11 LPN scheduled and 2.25 were required.

During an interview on 4/11/24, at 12:34 p.m. the Nursing Home Administrator confirmed that the facility failed to meet the minimum LPN ratio requirements on the above shifts and dates.



 Plan of Correction - To be completed: 05/14/2024

The facility must maintain the minimum of one Licensed Practical Nurse (LPN) per twenty five (25) residents on the day shift, one (1) LPN for every thirty (30) residents on the evening shift and one (1) LPN for every forty (40) residents on the night shift. To ensure that this regulatory requirement is met the following action plan will be implemented:
1.Additional Staffing Agencies have been added for the facility to provide additional professional nursing staff to meet the state minimum requirement of one (1) Licensed Practical Nurse (LPN) per twenty five (25) residents on the day shift, one (1) LPN for every thirty (30) residents on the evening shift and one (1) LPN for every forty (40) residents on the night shift. Education will be provided to the Director of Nursing, Asst. Director of Nursing and the Scheduler no later than 05/2/2024 to ensure that they understand the regulatory staffing requirements for professional nursing staff.

2.The Licensed Practical Nurse (LPN) schedule will be reviewed by the Scheduler, Director of Nursing and/or Asst. Director of Nursing to ensure that LPN ratios are met prior to posting of the schedule. In the event of call-offs by the professional staff, all other facility staff and/or agency will be contacted to cover any open shifts to ensure ratios are met. The facility continues to utilize job boards and various recruiting venues and offer sign-on bonuses periodically to attract, interview, recruit, and hire new professional staff. The facility conducts Recruitment and Retention Committee meetings weekly and has adopted a monthly rewards and recognition programs to retain current staff. The facility will conduct Staffing Meetings and Quality Calls with upper management five (5) day per week to ensure compliance.

3.An audit will be conducted by the Scheduler daily for two (2) weeks, three (3) times per week for three (3) weeks, two (2) times per week for two (2) weeks then weekly ongoing to ensure that Licensed Practical Nursing ratios are met for the day, evening, and night shifts. The audit will be monitored by the Director of Nursing or Designee.

4.All recruiting and retention meeting minutes along with Staffing Audits will be submitted to the Quality Assessment and Performance Improvement (QAPI) Committee at the monthly meeting for review and recommendation.

211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, 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 2.87 hours of direct resident care for each resident.

Observations:

Based on review of facility staffing documents and staff interview, it was determined that the facility failed to provide the minimum number of general nursing care hours of 2.87 hours of direct resident care hours per resident in a twenty-four hour period for 12 of 21 days reviewed (3/9/24, 3/10/24, 3/11/24, 3/13/24, 3/15/24, 3/16/24, 3/17/24. 3/18/24, 3/19/24, 3/20/24, 3/23/24 and 3/29/24).

Findings include:

During a review of nursing schedules for the time period of 3/9/24, through 3/29/24, it was revealed that the hours of direct resident care was below 2.87 minimum per patient day (PPD) on the following dates:

3/9/242.46 PPD
3/10/242.43 PPD
3/11/242.86 PPD
3/13/242.84 PPD
3/15/242.85 PPD
3/16/242.72 PPD
3/17/242.53 PPD
3/18/242.36 PPD
3/19/242.65 PPD
3/20/242.65 PPD
3/23/242.63 PPD
3/29/242.71 PPD

During an interview on 4/11/24, at 12:34 p.m. the Nursing Home Administrator confirmed the accuracy of the above low PPD levels.




 Plan of Correction - To be completed: 05/14/2024

The facility is required to maintain a total number of general nursing care hours provided in each 24 hour period for the entire facility at a minimum of 2.87 hours of direct care for each resident. To ensure that this regulatory requirement is met the following action plan will be implemented:

1.Additional Staffing Agencies have been added for the facility to provide additional nursing staff to meet the state minimum requirement of 2.87 hours of direct resident care for each resident in a 24 hour period. Education will be provided to the Director of Nursing, Asst. Director of Nursing and the Scheduler no later than 05/2/2024 to ensure that they understand the regulatory staffing requirement.

2.The nursing schedule consisting of all three (3) disciplines (RN/LPN/CNA) will be reviewed by the Scheduler, Director of Nursing and/or Asst. Director of Nursing to ensure that the requirement of 2.87 direct nursing care hours are met prior to posting of the schedule. In the event of call-offs by staff, all facility nursing staff and/or agency staff will be contacted to cover any open shifts to ensure the 2.87 direct nursing care ratio is met. The facility continues to utilize job boards and various recruiting venues to attract, interview, recruit, and hire new staff. The facility conducts Recruitment and Retention Committee meetings weekly and has adopted a monthly rewards and recognition programs to retain current staff. The facility will conduct Staffing Meetings and Quality Calls with upper management five (5) day per week to ensure compliance.

3.An audit will be conducted by the Scheduler daily for two (2) weeks, three (3) times per week for three (3) weeks, two (2) times per week for two (2) weeks then weekly ongoing to ensure that 2.87 hours of direct nursing care ratio is met for the 24 hour period. The audit will be monitored by the Director of Nursing and/or Assistant Director of Nursing

4.All staffing audits will be submitted to the Quality Assessment and Performance Improvement (QAPI) Committee at the monthly meeting for review and recommendation


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