Pennsylvania Department of Health
GARDENS AT STROUD, THE
Patient Care Inspection Results

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GARDENS AT STROUD, THE
Inspection Results For:

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GARDENS AT STROUD, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a revisit survey completed on December 28, 2023, it was determined that the Gardens at Stroud corrected the federal deficiencies cited during the survey of October 11, 2023, under the requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care but continued to be out of compliance with the following requirements of 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 a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 12 shifts out of 42 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse aide staff of 1:12 on the day, evening shifts and 1:20 on the night shift based on the facility's census.

November 28, 2023 - 6 nurse aides on the evening shift, versus the required 7 for a census of 78.
November 29, 2023 - 6 nurse aides on the evening shift, versus the required 7 for a census of 78.
November 30, 2023 - 6 nurse aides on the evening shift, versus the required 7 for a census of 77.
December 1, 2023 - 6 nurse aides on the evening shift, versus the required 7 for a census of 78.
December 2, 2023 - 6 nurse aides on the evening shift, verses the required 7 for a census of 78.
December 2, 2023 - 3 nurse aides on the night shift, versus the required 4 for a census of 79.
December 3, 2023 - 4 nurse aides on the evening shift, versus the required 7 for a census of 78.
December 4, 2023 - 5 nurse aides on the evening shift, versus the required 7 for a census of 78.
December 23, 2023 - 6 nurse aides on the evening shift, versus the required 7 for a census of 80.
December 24, 2023 - 5 nurse aides on the day shift, versus the required 7 for a census of 80.
December 24, 2023 - 4 nurse aides on the evening shift, versus the required 7 for a census of 79.
December 25, 2023 - 6 nurse aides on the evening shift, versus the required 7 for a census of 79.


An interview with the Nursing Home Administrator on December 28, 2023, at approximately 2:15 PM, confirmed the facility had not met the required nurse aide to resident ratios the shifts on the above dates.



 Plan of Correction - To be completed: 02/20/2024

The facility cannot retroactively correct the deficiency.

The Nursing Staffing Coordinator will be re-educated regarding the ratios for nurse aides. The facility will focus on retention of existing nurse aides and recruitment of new nurse aides through efforts of the facility Recruitment & Retention Committee.

Calculation of the daily nurse aide ratios will be completed and reviewed for accuracy by the scheduler/designee.

Daily ratios will be audited weekly x4 then monthly x2. The audits will be taken to QAPI for further action planning as needed.


§ 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 a review of nurse staffing and resident census and staff interview, it was determined that the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Findings include:

A review of the facility's weekly staffing levels revealed that on the following dates the facility failed to provide minimum nurse staffing of 2.87 hours of general nursing care to each resident:

December 2, 2023 - 2.60 direct care nursing hours per resident
December 3, 2023 - 2.86 direct care nursing hours per resident
December 22, 2023 - 2.72 direct care nursing hours per resident
December 23, 2023 - 2.65 direct care nursing hours per resident
December 24, 2023 - 2.72 direct care nursing hours per resident
December 25, 2023 - 2.62 direct care nursing hours per resident
December 26, 2023 - 2.86 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 Nursing Home Administrator on December 28, 2023, at approximately 2:15 PM confirmed the facility failed to consistently provide minimum general nursing care hours to each resident daily.



 Plan of Correction - To be completed: 02/20/2024

The facility cannot retroactively correct the deficiency.

The Nursing Staffing Coordinator will be re-educated regarding the new staffing hours of 2.87. The facility will focus on retention of existing staff and recruitment of new staff through the facility Recruitment & Retention Committee.

Calculations of the daily staffing hours will be completed and reviewed for accuracy by the Nursing Staffing Coordinator /designee.

Daily hours will be audited weekly x4 then monthly x2. The audits will be taken to QAPI for further action planning as needed.


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