Pennsylvania Department of Health
MASONIC VILLAGE AT WARMINSTER
Patient Care Inspection Results

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MASONIC VILLAGE AT WARMINSTER
Inspection Results For:

There are  37 surveys for this facility. Please select a date to view the survey results.

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MASONIC VILLAGE AT WARMINSTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey completed September 7, 2023, it was determined that Masonic Village at Warminster was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


§ 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 nursing time schedules it was determined that the facility failed to meet the minimum nursing staff to resident ratios for 21 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from July 1 to 7, 2023, August 1 to 7, 2023, and August 31 to September 6, 2023, revealed the following:

The facility failed to meet the minimum Licensed Practical Nurse (LPN) to resident ratio of one LPN for 25 residents on day (7:00 a.m. to 3:00 p.m.) shift on 11 days (July 1, July 2, July 4, July 4, August 5, August 6, August 31, September 1, September 2, and September 3, 2023).

The facility failed to meet the minimum LPN to resident ratio of one LPN for 30 residents on evening (3:00 p.m. to 11:00 p.m.) shift on all days reviewed.

The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on night (11:00 p.m. to 7:00 a.m.) shift on all days reviewed.


 Plan of Correction - To be completed: 11/17/2023

Will actively hire one additional LPN for evening shift and one additional LPN for night shift to meet current nursing staff to resident ratios. Director of Nursing/designee will ensure compliance for dayshift nursing staff to resident ratio by ensuring vacations/call-outs are covered with our own staff or agency staff if needed. Staffing ratios will be audited/monitored by DON/designee with results reported during quarterly QAPI meetings until staff ratio compliance is met 100% of the time for 6 consecutive months.

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