Pennsylvania Department of Health
SINKING SPRING SKILLED NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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SINKING SPRING SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  132 surveys for this facility. Please select a date to view the survey results.

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SINKING SPRING SKILLED NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated survey in response to a complaint completed on June 6, 2024, it was determined that Sinking Spring Skilled Nursing and Rehabilitation Center 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:


483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:
Based on clinical record review and resident interview, it was determined that the facility failed to provide services to enhance each resident's quality of life by offering showers as scheduled to two of ten sampled residents. (Residents 1, 10)

Findings include:

Clinical record review revealed that Resident 1 had diagnoses that included hemiplegia and diabetes mellitus. The Minimum Data Set (MDS) assessment dated May 27, 2024, indicated that the resident was oriented and required staff assistance for bathing. The resident was to receive a shower twice per week. During an interview on June 6, 2024, at 11:45 a.m., the resident reported that he preferred to take a shower twice a week and was not offered the opportunity to do so. Resident 1 stated that he would not refuse the opportunity to shower. Review of documentation in the clinical record revealed that the resident was not offered a shower four of nine scheduled times in the past 30 days.

Clinical record review revealed that Resident 10 had diagnoses that included osteoporosis and depression. The MDS assessment dated April 18, 2024, indicated the resident was oriented and required staff assistance for bathing. During an interview on June 6, 2024, at 12:00 p.m., Resident 10 stated that she preferred to take a shower twice a week and was not offered the opportunity to do so. Resident 10 stated that she would not refuse the opportunity to shower. Review of documentation in the clinical record revealed that the resident was not offered a shower six of nine scheduled times in the past 30 days.

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






 Plan of Correction - To be completed: 07/10/2024

1.Residents 1 and 10 both received showers.
2.An audit will be conducted to ensure that all residents have the shower task entered into the system.
3.Education will be provided to all nursing staff on NSG 200 ADLs policy specifically regarding showers and bathing and licensed staff how to enter the shower task upon admission.
4.Audits will be conducted weekly x4 then monthly x2 to ensure all residents have the tasks entered correctly and receive their showers.

§ 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 nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for seven of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from May 16, 2024, through June 5, 2024, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for 12 residents on day (7:00 a.m. to 3:00 p.m.) shift on May 26, 2024.

The facility failed to meet the minimum NA to resident ratio of one NA for 12 residents on evening (3:00 p.m. to 11:00 p.m.) shift on May 18, 20, and 31, 2024, and June 1, 2, and 5, 2024.

The facility failed to meet the minimum NA to resident ratio of one NA for 20 residents on night (11:00 p.m. to 7:00 a.m.) shift on June 1, 2024.


 Plan of Correction - To be completed: 07/10/2024

1,2) Nurse aide staffing ratios will be reviewed for the last 7 days to evaluate if nurse aide ratios is met.
3) Nursing admin and scheduler will be re-educated on new July 1 nurse staffing and PPD requirements.
4) Weekly audit of nurse aid ratios will be conducted for 60 days by NHA/designee to assure nurse aid ratios is met. Tracking and trends to be submitted to QAPI committee.

§ 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 licensed practical nurse (LPN) to resident ratios for two of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from May 16, 2024, through June 5, 2024, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 25 residents on day (7:00 a.m. to 3:00 p.m.) shift on June 1 and 2, 2024.






 Plan of Correction - To be completed: 07/10/2024

1,2) LPN staffing ratios will be reviewed for the last 7 days to evaluate if LPN ratios is met.
3) Nursing admin and scheduler will be re-educated on new July 1 nurse staffing and PPD requirements.
4) Weekly audit of LPN ratios will be conducted for 60 days by NHA/designee to assure LPN ratios is met. Tracking and trends to be submitted to QAPI committee.

§ 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 nursing time schedules, it was determined that the facility failed to provide a minimum of 2.87 hours of direct care for each resident for six of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from May 16, 2024, through June 5, 2024, revealed the following total nursing care hours below minimum requirements:

May 18, 2024: 2.71 care hours per resident.
May 19, 2024: 2.64 care hours per resident.
May 26, 2024: 2.75 care hours per resident.
May 31, 2024: 2.85 care hours per resident.
June 1, 2024: 2.40 care hours per resident.
June 2, 2024: 2.59 care hours per resident.


 Plan of Correction - To be completed: 07/10/2024

1,2) HPPD and nurse aide staffing ratios will be reviewed for the last 7 days to evaluate if state minimum PPD and CNA/LPN ratios are met.
3) Nursing admin and scheduler will be re-educated on new July 1 LPN/CNA staffing ratio and PPD requirements.
4) Weekly audit of HPPD will be conducted for 60 days by NHA/designee to ensure minimal HPPD and LPN/CNA ratios are met. Results of the audits will be reviewed by the QAA committee.


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