Pennsylvania Department of Health
GROVE AT NORTH HUNTINGDON, THE
Patient Care Inspection Results

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GROVE AT NORTH HUNTINGDON, THE
Inspection Results For:

There are  201 surveys for this facility. Please select a date to view the survey results.

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GROVE AT NORTH HUNTINGDON, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a complaint survey completed on March 5, 2024, it was determined that The Grove at North Huntingdon 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:


483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff: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.
483.35(a) Sufficient Staff.
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e).

483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (e) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
Observations:
Based on a review of facility policy, resident observations and interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 13 of 16 residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, and R13).

Findings include:

Review of the facility policy, "Nursing Department Staffing" dated 11/30/23, indicated "The facility will provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
-Licensed nurses
-Other nursing personnel

During an observation on 2/25/24, at 1:15 p.m., Resident R1 was noted to have long, greasy-appearing hair, that was not brushed.

During an observation on 2/25/24, at 1:16 p.m., Resident R2 was noted to be wheeling around the dining room, with bare feet.

During an observation on 2/25/24, at 1:22 p.m., Resident R3's room smelled of urine. Upon entering the room, the surveyor stepped in a yellow liquid on the floor. The sheet was noted to have a large, yellowed, circular area on the middle of it, dry to the touch.

During an interview on 2/25/24, at 1:25 p.m., when asked about facility staffing and care, Resident R4 stated, "I've had so many bad experiences with that." "They don't empty the urinal, say they have to get gloves, and they don't come back." "They don't help me wash up." When asked about call light response, Resident R4 stated, "Forever."

During an observation on 2/25/24, at 2:27 p.m., Resident R5 was noted to have a soiled shirt on, one sock on, one foot bare, long jagged fingernails, toenails that were jagged and appeared to have a red substance on them.

During an interview on 2/25/24, at 2:30 p.m., when asked about facility staffing and care, Resident R6 stated, "There are not enough people." When asked about call light response, Resident R6 stated, "Call lights are long sometimes."

During an interview on 2/25/24, at 2:32 p.m., when asked about facility staffing and care, Resident R7 stated, "No, they work too hard."

During an observation on 2/25/24, at 2:35 p.m., Resident R8 was noted to food spilled on his shirt and greasy appearing hair.

During an interview on 2/25/24, at 2:38 p.m., when asked about facility staffing and care, Resident R9 stated, "There's never enough." When asked about call light response, Resident R9 stated, "They are too busy."

During an observation on 2/25/24, at 2:45 p.m., Resident R10 was noted to have unbrushed, greasy appearing hair.

During an interview on 2/25/24, at 2:49 p.m., when asked about facility staffing and care, Resident R11 stated, "There's not enough aides on the weekend." When asked about call light response, Resident R11 stated, "Yesterday our button wasn't working. I was waiting from 9:20 until 10:30-11:00."

During an interview on 2/25/24, at 2:55 p.m., when asked if there was sufficient facility staffing and care, Resident R12 stated, "No!" When asked if staffing was worse on the weekends, Resident R12 stated, "Oh yeah."

During an interview on 2/26/24, at 11:00 a.m., when asked if there was sufficient facility staffing and care, Resident R13 stated, "Absolutely not. Some aides never answer the call light. I've waited for over an hour."

Confidential staff interviews conducted during the survey about sufficient facility staffing indicated the following:

Employee E1 stated "It's terrible."

Employee E2 stated, "Almost all the staff are agency, and they never show up."

Employee E3 stated, "I'm agency, so it's fine with me."

Employee E4 stated, "I have to do my job, and other peoples' jobs too because they don't have enough."

During an interview on 2/26/24, at approximately 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to have sufficient nursing staff to provide nursing and related services to 13 of 16 residents.


28 Pa. Code: 201.14(a) Responsibility of licensee.

28 Pa. Code: 201.18(e)(6) Management.

28 Pa. Code: 201.20(a) Staff development.

28 Pa. Code: 211.12(a) (c)(d)(1)(2)(3)(4)(5) Nursing services.


 Plan of Correction - To be completed: 04/02/2024

The facility will have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of its residents. Resident R1's hair was washed and brushed. Footwear was placed on resident R2's feet and careplan was updated to ensure appropriate footwear is on at all times. Resident R3's room floor was mopped and bed sheets changed. Resident R5 was washed and put in a new pair of clothes fingernails and toenails also appropriately trimmed. Resident R8 was washed and changed and hair was brushed. Resident R11's call-bell checked to ensure it is fully functioning.

The Nursing Home Administrator with re-educate the Director or Nursing and HR/Scheduler on federal tag F0725 and the requirement to employ sufficient staff to carry out nursing services to maintain the highest practical physical, mental, and psychosocial well-being of residents.

The administrator or designee will audit staffing levels to ensure sufficient nurse staffing is provided to carry out nursing services that maintain the highest practical physical, mental, and psychosocial well-being of residents. The Director of Nursing or designee will complete call-bell audits 5x/ week x4 weeks and then monthly x3 months to ensure appropriate call bell response. Director or Nursing or designee will also audit 5 shower/bed bath task records, resident fingernails, and clothing to ensure it is clean and appropriate weekly x4 weeks and then monthly 3 months to ensure appropriate hygienic care is being given as ordered.

The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.
483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:
Based on review of facility polices, documentation, review of Pennsylvania Department of Health (PADOH) guidelines for Group A Streptococcus (GAS, bacteria commonly found in the throat and on the skin that can cause a variety of infections) infections, Centers for Disease Control (CDC) recommendations, and staff interviews, it was that the facility failed to respond to GAS infections in the facility for twelve of 15 residents (Resident R6, R11, R13, R14, R15, R16, R17, R18, R19, R20, R21, and R22).

Review of the PADOH document "Overview for Long-Term Care Facilities: Invasive Group A Streptococcus" (invasive GAS is an infection of group A strep in an area of the body generally considered sterile, such as blood, bone, spinal fluid, and internal body sites) updated August 2022, indicated:
Group A Streptococcus (GAS) is a type of bacteria that can cause infection. It's also known as Streptococcus pyogenes.
These bacteria can infect people in different ways:
-Common and non-invasive: strep throat, body rash, sores
-Serious and invasive: pneumonia, bacteremia, toxic shock, necrotizing fasciitis ("flesh-eating infection"). Although rare, these types of infection may result in death.

Review of CDC document "Investigate All Outbreaks of Group A Streptococcus Infections in Long-Term Care Facilities" most recently reviewed 3/9/23, indicated "Given the potential to prevent additional cases and subsequent outbreaks in this population at high risk of severe outcomes, an investigation is warranted for even a single case of invasive GAS (invasive GAS infection in a resident of a LTCF (long-term care facility). The purpose of the investigation is to:
1. Identify any additional symptomatic cases among residents and staff.
2. Identify and treat asymptomatic carriers.
3. Assess and improve current infection control practices in the facility.
4. Identify potential transmission routes (when two or more cases are identified in a 3-4-month period).

Review of the clinical record indicated Resident R14 was admitted to the facility on 9/18/22.

Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 1/9/24, included diagnoses of lumbar disc degeneration (wear and tear of discs in the back that may lead bulging, compression, and pain) and chronic pain.

Review of a progress note dated 8/14/23, at 6:50 p.m. indicated the provider was notified of a deterioration of Resident R14's condition.

Review of a progress note dated 8/14/23, at 8:08 p.m. indicated Resident R14 had a temperature of 101.4 (Fahrenheit), heart rate 114 (normal between 60-100 beats per minute), left lower extremity was swollen and hot to the touch.

Review of a progress note dated 8/15/23, at 12:15 a.m. indicated that Resident R14 was sent to the hospital, at the resident's insistence.

Review of a progress note dated 8/16/23, at 3:31 a.m. indicated that Resident R14 was admitted to the hospital for sepsis/cellulitis (life-threatening complication of an infection/bacterial skin infection).

Review of a progress note dated 8/23/23, at 10:03 p.m. indicated Resident R14 had returned to the facility and was "In isolation for rare strep throat."

Review of a nurse practitioner re-admission note dated 8/24/23, at 11:33 a.m. indicated "Pt (patient) had been sent to [the hospital] in the early morning hours of 8/15 after having an acute change in MS (mental status). Staff had notified [provider] and obtained orders for STAT CXR (urgent chest x-ray) and labs, however pt continued to decline prompting further evaluation. In the ER she was noted with mild hypoxia (low levels of oxygen in the body tissues) and lethargy (drowsiness and an unusual lack of energy and mental alertness." "Blood cultures did return positive for Group A streptococcus (Streptococcus pyogenes)."

Review of facility census information revealed that Resident R14 had a roommate, Resident R18, while she was symptomatic. Further chart review failed to indicate any screening completed on Resident R18.

Review of a letter sent to the former Nursing Home Administrator dated 8/23/23, from the Pennsylvania Department of Health, Bureau of Epidemiology, indicated "The Pennsylvania Department of Health recently became aware of one case of invasive group A Streptococcus (GAS) in a resident at your facility. Although most GAS infections cause mild illness, the bacteria do have the potential to cause severe, life-threatening diseases. It is important to understand that a single case of invasive GAS requires public health action. The purpose of this letter is to provide you with some recommendations and emphasize the importance of infection control practices to reduce the potential for additional cases of GAS and other transmissible infections."
The recommendations included:
Identification of additional cases:
-Conduct a retrospective chart review of facility residents over the previous month (to look for
previously unidentified culture-confirmed infections). Review wound, throat, ostomy site,
device-insertion site, and blood cultures.
-Monitor residents daily for symptoms of invasive (i.e., blood or other sterile sites) and noninvasive (i.e., wound or throat) infections for 4 months following the last case identified.
-Maintain transmission-based precautions according to the enclosed guidance entitled "Transmission-based Precautions for Residents in Long-term Care Facilities with Group A Streptococcal Infection or Colonization."
-Monitor staff involved in direct patient care for symptoms of GAS, and culture anyone with symptoms.
-Ensure that any positive GAS cultures collected from residents at the hospital or other external
providers are reported to you or other facility staff responsible for infection control.

Identification and decolonization of potential carriers:
-Collect samples from those who have come in close contact with the index case resident to test for GAS.
-Any resident found to be colonized with GAS during screening should be prescribed an
appropriate antibiotic regimen as recommended by the CDC.
-For any resident found to be colonized, swabs from all sites (including those that were initially
negative if more than one specimen was taken) should be collected again 7-10 days after antibiotic completion.
Infection Control:
-Review and audit hand hygiene practices, wound care aseptic technique, and cleaning and
disinfection procedures with staff.
-Educate staff on the importance of not working while ill.
Additionally, links CDC and PADOH reference materials were provided to the facility.

Review of facility-provided infection control documentation on 2/26/24, failed to include a retrospective chart review, evidence of daily monitoring of residents, evidence of staff monitoring, the collection of samples of close contacts, evidence of repeat swabs from colonized or infected residents, or staff education.

Review of a letter sent to the Nursing Home Administrator dated 9/8/23, from the PADOH, Bureau of Epidemiology, indicated "In August 2023, a single case of invasive Group A streptococcal (GAS) infection was identified in [the facility]. Since then, 3 additional cases of GAS have been identified. Because of the severity of GAS infections, and the high likelihood of person-to-person transmission, cases of invasive GAS in a nursing care setting require immediate and comprehensive action.

Review of the 9/8/23, letter from the PADOH, Bureau of Epidemiology included the reiteration of the original recommendations, and the additional recommendations of:
-Collect samples from all residents to test for the presence of GAS.
-Collect samples from wound care staff including agency wound care staff.
-Ensure the facility-specific hand hygiene policy emphasizes preferred use of alcohol based
hand rub (ABHR) over hand washing according to CDC guidelines.

Review of facility-provided infection control documentation on 2/26/24, failed to include evidence of the collection of samples from residents, the collection of samples from wound care staff, and education of the staff on the preferred use of ABHR over hand washing.

On 3/4/24, the facility was requested to provide the names of the three additional cases of GAS identified by the Bureau of Epidemiology, noted in the 9/8/23 letter.

On 3/5/24, the facility provided the cases: Resident R6, Resident R17, and Nurse Practitioner Employee E1.

Review of progress notes for Resident R6 indicated a strep swab ordered on 9/4/23. Additional facility documentation indicated that due to a clerical error, the strep swab was not completed.

Review of progress notes for Resident R17 failed to include documentation of a concern for GAS until 12/4/23.

Review of facility progress notes revealed a nurse practitioner note written by NP Employee E1, dated 8/7/23, at 10:33 a.m. for Resident R19 indicated a worsened left heel wound was cultured and the presence of GAS was found, with additional bacteria. Resident R19 was not documented on the facility provided line-list.

Review of facility progress notes revealed a nurse practitioner note written by NP Employee E1 dated 8/26/23, at 12:43 p.m. indicated Resident R21 had ongoing issues with her wound, "cultures on 8/15 returning positive for multiple species including streptococcus A." Resident R21 was not documented on the facility provided line-list.

Review of a letter sent to the Nursing Home Administrator dated 1/25/24, from the PADOH, Bureau of Epidemiology, indicated In August 2023, two residents and two staff of The Grove at North Huntingdon were reported to have group A streptococcal (GAS) infections. Investigators from The Pennsylvania Department of Health (Department), Bureau of Epidemiology performed a site visit at [the facility] on September 6, 2023, as part of our GAS outbreak response. We reviewed infection control practices and made recommendations including screening of residents for GAS colonization in a letter dated September 8, 2023. It was reported to us that no screening was completed. Another invasive GAS infection was identified in a resident in October 2023, and a call was held on October 24, 2023, between the Department and [facility] leadership to discuss the rationale for GAS colonization screening. Again, it was reported to us that no screening was completed. In January 2024, a sixth GAS infection, the third invasive infection, was identified in a resident who was in the facility during their potential exposure period. The purpose of this letter is to reiterate the Department's recommendations, based on CDC guidance, to screen all residents and staff who have direct contact with residents for GAS colonization. Because of the severity of GAS infections, especially in those persons over 65 years, and the high likelihood of person-to-person transmission, cases of invasive GAS in a nursing care setting require immediate and comprehensive action."

Review of the clinical record indicated Resident R15 was admitted to the facility on 5/13/20.

Review of the MDS dated 2/5/24, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness).

Review of a progress note dated 10/5/23, at 1:02 p.m. indicated Resident R15 was cool and clammy, blood pressure 84/32 (under 90/60 mm Hg, in considered abnormally low), temperature 100.7Resident R15 was sent to the emergency room.

Review of a progress note dated 10/9/23, at 5:51 p.m. indicated Resident R15 was admitted to the hospital with respiratory distress and urosepsis.

Review of a progress note dated 10/17/23, at 8:00 p.m. indicated Resident R15 returned to the facility.

Review of a nurse practitioner follow-up note on 10/18/23, indicated Resident R15 was seen for readmission to the facility, after having been admitted to the hospital intensive care unit. Resident R15 treated for septic shock secondary to streptococcal bacteremia (presence of streptococcal bacteria in the blood) and right lower extremity cellulitis.

Review of the clinical record indicated Resident R20 was admitted to the facility on 1/3/24.

Review of the MDS dated 2/18/24, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles) and a seizure disorder.

Review of a nurse practitioner progress note dated 2/1/24, at 2:35 p.m. indicated Resident R20's assessment revealed "there is an odor to wounds today and there is bright green drainage noted."

Review of a progress note dated 2/3/24, at 10:24 a.m. indicated Resident R20 had "diffuse red area to LLE (left lower extremity) from knee to groin. warm and painful with itch."

Review of a progress note dated 2/3/24, at 3:53 p.m. indicated Resident R20 was sent to the hospital at family request.

Review of facility census information indicated Resident R20 returned to the facility on 2/12/24.

Review of a nurse practitioner progress note dated 2/15/24, at 4:29 p.m. indicated "Patient was out to hospital last week for sepsis from BLE (bilateral lower extremity) wounds. Found to have strep A in wounds."

Review of facility census information revealed that Resident R20 had a roommate, Resident R22, while he was symptomatic. Chart review failed to reveal testing of Resident R22 for GAS.

Review of the clinical record indicated Resident R11 was admitted to the facility on 5/2/23.

Review of the MDS dated 2/1/24, included diagnoses of multiple sclerosis (a disease that affects central nervous system) and lymphedema (the build-up of fluid in soft body tissues).

Review of a progress note dated 2/7/24, at 6:38 a.m. indicated Resident R11 complained of a sore throat, "area is red with white patches."

Review of a progress note dated 2/8/24, at 3:04 a.m. indicated Resident R11 had a temperature of 105.4F.

Review of a progress note dated 2/9/24, at 6:38 a.m. indicated Resident R11 complained of "severe pain in her throat related to strep."

Review of facility census information revealed that Resident R11 had a roommate, Resident R13, while she was symptomatic. Chart review revealed Resident R13 complained of a sore throat on 2/7/24. Further chart review failed to reveal testing of Resident R13 for GAS.

During an interview on 2/26/24, at approximately 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to respond to GAS infections in the facility for twelve of 15 residents.

28. Pa Code: 201.14(a) Responsibility of licensee.

28 Pa. Code: 211.12(c)(d)(5) Nursing services.




 Plan of Correction - To be completed: 04/02/2024

The facility will respond to Group A Streptococcus (GAS) infections as appropriate according to state and federal guidelines as well as facility policy and procedure. The facility cannot retroactively correct the concerns identified for residents R6, R11, and residents R13-R22.

The Infection Preventionist or designee will complete a 30 day look back audit to validate GAS infections were responded to appropriately for residents.

The Director of Nursing or designee will educate nursing staff, including agency and new hires, on the facility's Infection Control policies and procedures and state/federal guidelines for responding to GAS infections.

The Director or Nursing or designee will enhance the clinical start up process to review progress notes to identify residents with symptoms of possible GAS infections to ensure the facility responded appropriately. The Infection Preventionist or Designee will complete an audit of three times a week for four weeks then monthly for three months to validate that any resident with signs or symptoms of GAS infections are treated appropriately.

The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.
51.3 (e) LICENSURE NOTIFICATION:State only Deficiency.
51.3 Notification

(e) If a health care facility is
aware of information which shows that
the facility is not in compliance with
any of the Department's regulations
which are applicable to that health
care facility, and that the
noncompliance seriously compromises
quality assurance or patient safety,
it shall immediately notify the
Department in writing of its
noncompliance.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for the failure to comply and the
steps which the health care facility
shall take to bring it into compliance
with the regulation.
Observations:
Based on a review of facility provided documents, facility policy, and staff interview, it was determined that the agency failed to notify the Department of Health (DOH) of reportable incidents.

Findings include:

Review of "28 Pa. Code Specific identified reportable diseases, infections, and conditions", indicated the diseases, infections and conditions that are reportable to the Department or the appropriate local health authority. Review of this list revealed that Streptococcal invasive disease (group A) was included in the list of reportable diseases, and must be reported by healthcare practitioners and healthcare facilities within five work days after being identified by symptoms, appearance or diagnosis.

Review of the facility policy "IC Plan, Program, and Committee" dated 11/30/23, previously reviewed 11/1/22, indicated the facility will report according to specific Department of Health, state, and local regulations.

Review of facility provided documents from 8/1/23, through 2/25/24, failed to reveal any notification to the DOH for residents positive for Group A Streptococcus.

Review of clinical records on 3/5/25, revealed that the facility had five positive residents between 8/1/23, and 2/25/24.

During a follow-up communication on 3/6/23, at , at 2:13 p.m. the Nursing Home Administrator awas made aware that the facility failed to notify the DOH of reportable incidents.


 Plan of Correction - To be completed: 04/02/2024

The facility will notify the Department of Health (DOH) of reportable diseases and infections. Facility reported the five Streptococcal invasive diseases (group A) identified during survey which were not reported.

The facility will complete a 30-day lookback of healthcare acquired infections to ensure any and all reportable diseases were reported as appropriate to the Department of Health.

The facility's Regional Clinical Consultant will re-educate the Nursing Home Administrator on state tag P0007 and the requirement for the facility to report the Department of Health of all reportable diseases and infections.

The Director of Nursing or designee will audit monthly to ensure that any newly acquired healthcare infection that qualifies as a reportable disease will be reported to the Department of Health as appropriate.

The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
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 policy, nursing time schedules and staff interviews, it was determined that the facility administrative staff failed to provide a minimum of one nurse aide per 12 residents during the day and/or evening shifts, and one nurse aide per 20 residents during the night shift on five of 21 days (2/11/24, 2/17/24, 2/18/24, 2/21/24, and 2/24/24).

Findings include:

Review of the facility policy, "Nursing Department Staffing" dated 11/30/23, indicated "The facility will provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
-Licensed nurses
-Other nursing personnel

Review of the nursing schedules and census information for 2/4/24, through 2/24/24, revealed that the facility failed to meet the following:

02/11/24: Night shift required 38.25 hours of nurse aide care, facility provided 30.00.
02/17/24: Night shift required 37.88 hours of nurse aide care, facility provided 37.50.
02/18/24: Evening shift required 62.50 hours of nurse aide care, facility provided 61.50.
02/21/24: Day shift required 63.75 hours of nurse aide care, facility provided 63.50.
02/24/24: Night shift required 38.25 hours of nurse aide care, facility provided 30.00.

During an interview on 2/26/24, at approximately 3:00 p.m., the Nursing Home Administrator confirmed that the facility administrative staff failed to provide a minimum of one nurse aide per 12 residents during the day and/or evening shifts, and one nurse aide per 20 residents during the night shift on five of 21 days.


 Plan of Correction - To be completed: 04/02/2024

The facility cannot correct that nurse aide staffing ratios were not met on the following dates: 2/11/24, 2/17/24, 2/18/24, 2/21/24, and 2/24/24.

The facility will ensure that nurse aide staffing ratios are met every shift.

The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5510 and ensuring nurse aide staffing ratios are met each shift. Daily shift staffing ratios will be reviewed at daily staffing meeting. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist.

The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure nurse aide staffing ratios are being met.

The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.
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 policy, nursing time schedules and staff interviews, it was determined that the facility administrative staff failed to provide a minimum of licensed practical nurse (LPN) per 25 residents during the day shift and one LPN per 30 residents during the evening shift, on three of 21 days (2/11/24, 2/16/24, and 2/17/24).

Findings include:

Review of the facility policy, "Nursing Department Staffing" dated 11/30/23, indicated "The facility will provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
-Licensed nurses
-Other nursing personnel

Review of the nursing schedules and census information for 2/4/24, through 2/24/24, revealed that the facility failed to meet the following:

02/11/24: Day shift required 36.24 hours of LPN care, facility provided 24.00. Evening shift required 27.20 hours of LPN care, facility provided 24.00.
02/16/24: Evening shift required 26.93 hours of LPN care, facility provided 20.00.
02/17/24: Day shift required 32.32 hours of LPN care, facility provided 32.00.

During an interview on 2/26/24, at approximately 3:00 p.m., the Nursing Home Administrator confirmed that the facility administrative staff failed to provide a minimum of licensed practical nurse (LPN) per 25 residents during the day shift and one LPN per 30 residents during the evening shift, on three of 21 days.


 Plan of Correction - To be completed: 04/02/2024

The facility cannot correct that LPN staffing ratios were not met on the following dates: 2/11/24, 2/16/24, and 2/17/24.

The facility will ensure that LPN staffing ratios are met every shift.

The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5530 and ensuring LPN staffing ratios are met each shift. Daily shift staffing ratios will be reviewed at daily staffing meeting. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist.

The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure LPN staffing ratios are being met.

The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.

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