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

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CARLISLE SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  166 surveys for this facility. Please select a date to view the survey results.

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CARLISLE SKILLED NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Revisit Survey completed on March 27, 2024, it was determined that Carlisle Skilled Nursing and Rehabilitation Center did not correct the deficiencies cited during the survey of January 18, 2024, under the requirements of the 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 document review and staff interview, it was determined that the facility failed to ensure a required minimum of one nurse aide per 12 residents on both day and evening shift and a minimum of one nurse aide per 20 residents during the night shift for five of seven days reviewed (March 19, 21, 22, 24, and 25, 2024).

Findings Include:

Review of the facility resident census and submitted staffing documentation revealed that the facility failed to meet the required Nurse Aide to resident ratios, as determined by the minimum hours required per resident census, and/or the minimum Full Time Equivalent (FTE - number of staff required to meet the required hours) for the following days and shifts:

March 19, 2024, during the evening shift the required Nurse Aide Ratio was 11.42, the facility provided 10.53.

March 21, 2024, during the day shift the required Nurse Aide Ratio was 11.33, the facility provided 10.33.

March 21, 2024, during the night shift the required Nurse Aide Ratio was 6.80, the facility provided 6.73.

March 22, 2024, during the evening shift the required Nurse Aide Ratio was 11.50, the facility provided 10.80.

March 24, 2024, during the day shift the required Nurse Aide Ratio was 11.50, the facility provided 11.00.

March 24, 2024, during the night shift the required Nurse Aide Ratio was 6.95, the facility provided 5.87.

March 25, 2024, during the day shift the required Nurse Aide Ratio was 11.50, the facility provided 10.00.

On March 27, 2024, at 10:58 AM, Employee 1 (Scheduling and Payroll Manager) confirmed that the facility did not meet the ratios, due in part to call offs.

On March 27, 2024, at 3:17 PM, the Nursing Home Administrator stated the facility is continuing to work on their staffing.


 Plan of Correction - To be completed: 04/30/2024

1. No residents or staff were harmed by deficient practice.

2. Daily staffing and census calls are held to ensure sufficicent staff to provide care and meet minimum nurse aide staffing ratio of one nurse aide per 12 residents on dayshift, one nurse aide per 12 residents on evening shift and one nurse aide per 20 residnet on overnight shift.

3. To ensure deficient practice does not re-occur, the NHA/designee educated the DON, RN Supervisors, Unit Managers, and Scheduler on PA State Regulation 5510. A weekly meeting with recruiter, Administrator, Scheduler and HR support is in place to develop strategies for increased applicant flow.

A daily meeting with Admin, DON, Scheduler to determine staffing needs for the upcoming days. Communication to Agency Service Manager to address their staff that called off or upcoming needs.

A daily meeting with Admin, DON and Admissions to determine ability to accept admissons based on staffing is in place.

Scheduler provided RN Supervisor a list of employees to contact when call offs occur and their phone numbers. Scheduler and RN Supervisors educated on the importance to work to cover call offs.

4.DON/designee will complete random audits of five shifts per week for four weeks to ensure compliance. Results of audits will be reported to QA Committee for review and recommendations.
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 document review and staff interview, it was determined that the facility failed to ensure a required minimum of one Licensed Practical Nurse (LPN) per 25 residents on the day shift for one of seven days reviewed (March 19, 2024) and one LPN per 40 residents on night shift for one of seven days reviewed (March 21, 2024).

Findings include:

Review of the facility resident census and submitted staffing documentation revealed that the facility failed to meet the required LPN to resident ratios, as determined by the minimum hours required per resident census, and/or the minimum Full Time Equivalent (FTE - number of staff required to meet the required hours) for the following days and shifts:

March 19, 2024, during the day shift the required LPN ratio was 5.48, the facility provided 4.94.

March 21, 2024, during the night shift the required LPN ratio was 3.40, the facility provided 2.88.

On March 27, 2024, at 10:58 AM, Employee 1 (Scheduling and Payroll Manager) confirmed that the facility did not meet the ratios, due in part to call offs.

On March 27, 2024, at 3:17 PM, the Nursing Home Administrator stated the facility is continuing to work on their staffing.


 Plan of Correction - To be completed: 04/30/2024

1. Nursing ratios were adjusted to ensure LPN 1:25 ratio on days and 1:30 evening shifts and 1:40 on night shifts.

2. LPN's will be scheduled 1:25 ratio on days, 1:30 on evenings and 1:40 on night shift.

3. Education will be provided to Scheduler, DON, Unit Mangers and RN Supervisors by the NHA/DON to ensure the required LPN ratio is met each shift. Education will include the importance to aggressivly work to have someone from prior shift stay if a no call/no show or call off, to ensure compliance with meeting the shift ratio. In addition the Scheduler will be educated by NHA/DON in using the DOH ratio/PPD matrix to double check the schedule prior to posting, to ensure compliance. Scheduler has an employee list of name and phone numbers to call and urgently recruit them to come in to cover a call off to ensure PPD compliance. DON and RN Managers rotate an on call schedule to be available to come in to cover open slot to ensure PPD compliance.

4.DON/designee will complete an audit of
(5) schedules per week for 4 weeks to ensure compliance. Results of audits will be reported to the QA Committee for review and recommendations.
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 review of nursing schedules, review of staffing information furnished by the facility, and staff interviews, it was determined that the facility failed to ensure the total number of nursing care hours provided in each 24 hour period be a required minimum of 2.87 hours of direct care for each resident for three of seven days reviewed (March 21, 24, and 25, 2024).

Findings include:

Review of nursing staff information provided by the facility dated March 19, 2024, to March 25, 2024, revealed that the facility provided less than the required 2.87 hours of direct nursing care on the following days:

On March 21, 2024, the facility provided 2.79 hours of direct care for each resident.

On March 24, 2024, the facility provided 2.78 hours of direct care for each resident.

On March 25, 2024, the facility provided 2.75 hours of direct care for each resident.

On March 27, 2024, at 10:58 AM, Employee 1 (Scheduling and Payroll Manager) confirmed that the facility did not meet the PPD, due in part to call offs.

On March 27, 2024, at 3:17 PM, the Nursing Home Administrator stated the facility is continuing to work on their staffing.


 Plan of Correction - To be completed: 04/30/2024

1.No Residents have harmed by deficient practice.

2. Nursing PPD will be scheduled at 2.87
or higher.

3. Education will be provided to Scheduler, DON, Unit Mangers and RN Supervisors by the NHA/DON to ensure a 2.87 PPD is met daily based on census changes.Multiple times a day review of census being monitored to ensure compliance. Education will include the importance to aggressivly work to have someone from prior shift stay if a no call/no show or call off, to ensure PPD compliance with 2.87 hours of direct care in each 24 hour period. In addition the Scheduler will be educated by NHA/DON in using the DOH ratio/PPD matrix to double check the schedule prior to posting, to ensure compliance. Scheduler has an employee list of name and phone numbers to call and urgently recruit them to come in to cover a call off to ensure PPD compliance. DON and RN Managers rotate an on call schedule to be available to come in to cover open slot to ensure PPD compliance.

To generate additional Aides, center sent Aide to Aide class at HACC 3-7-24. The next student will begin Aide class on 4-9-24. This new process will assist to ensure ratio and PPD compliance.

4.DON/designee will complete an audit of
5 schedules per week for 4 weeks to ensure compliance. Results of audits will be reported to the QA Committee for review and recommendations.

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