Pennsylvania Department of Health
QUALITY LIFE SERVICES - GROVE CITY
Patient Care Inspection Results

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QUALITY LIFE SERVICES - GROVE CITY
Inspection Results For:

There are  116 surveys for this facility. Please select a date to view the survey results.

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QUALITY LIFE SERVICES - GROVE CITY - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Complaint Survey completed on April 3, 2024, at Quality Life Services-Grove City it was determined that there were no federal deficiencies identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities as it relates to the Health portion of the survey process; however, the facility was not in compliance with 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 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 day shift, one NA per 12 residents on evening shift, and one NA per 20 residents on the overnight shift, for four of 21 days reviewed for staffing ratio (2/14/24, 2/28/24, 3/12/24, and 3/13/24).

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 day shift nurse staffing documentation revealed:

2/28/24, facility census of 97 residents, 7.50 NAs worked and 8.08 were required.
3/12/24, facility census of 95 residents, 7.81 NAs worked and 7.92 were required.

Review of 21 days of evening shift nurse staffing documentation revealed:

3/13/24, facility census of 96 residents, 7.88 NAs worked and 8.00 were required.

Review of 21 days of overnight shift nurse staffing documentation revealed:

2/14/24, facility census of 89 residents, 3.81 NAs worked 4.45 were required.

During an interview on 4/2/24, at approximately 3:00 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: 05/06/2024

1. Labor Manager will be educated by NHA or designee on ratio requirements
2. Staffing meetings will continue daily with NHA, DON, and Labor manager to ensure ratio's are being met for future days.

3. Nursing supervisor will be educated by NHA or designee that call offs resulting in ratio non-compliance need to be reported to NHA or DON for coverage efforts and possible mandation if coverage cannot be found. Recruitment efforts continue with central recruiting department.

4. CNA Ratios will be audited daily x2 weeks and weekly x6 weeks to ensure compliance by NHA or designee.

5. Results of audits will be reported in the monthly QAPI meeting for tracking and trending purposes.
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 the day shift, for one of 21 days reviewed for staffing ratio(2/25/24).

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 day shift nurse staffing documentation revealed:

2/25/24, facility census of 95 residents, 2.97 LPNs worked and 3.80 were required.

During an interview on 4/2/24, at approximately 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to meet the minimum LPN ratio requirements on the above shift and date.



 Plan of Correction - To be completed: 05/06/2024


1. Labor Manager will be educated by NHA or designee on ratio requirements
2. Staffing meetings will continue daily with NHA, DON, and Labor manager to ensure ratio's are being met for future days.

3. Nursing supervisor will be educated by NHA or designee that call offs resulting in ratio non-compliance need to be reported to NHA or DON for coverage efforts and possible mandation if coverage cannot be found. Recruitment efforts continue with central recruiting department.

4. LPN Ratios will be audited daily x2 weeks and weekly x6 weeks to ensure compliance by NHA or designee.

5. Results of audits will be reported in the monthly QAPI meeting for tracking and trending purposes.


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