Pennsylvania Department of Health
OAKWOOD HEIGHTS VILLAGE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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OAKWOOD HEIGHTS VILLAGE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Follow-up Survey completed on October 16, 2024, it was determined that Oakwood Heights Village failed to correct all the deficiencies cited during the revisit survey of August 21, 2024, and continued to be out of compliance with the following requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on review of facility nursing staffing documents and staff interview, it was determined that the facility failed to meet the Nurse Aide (NA) ratios of one NA per 10 residents on the day shift for two of 17 days (10/04/24 and 10/07/24); one NA per 11 residents on the evening shift for two of 17 days reviewed (10/04/24 and 10/06/24); and one NA per 15 residents on the overnight shift for five of 17 days reviewed (9/29/24, 9/30/24, 10/02/24, 10/03/24 and 10/05/24).

Findings include:

Review of facility nursing staffing documents for the time period from 9/22/24, through 10/08/24, revealed the following NA staffing shortages for the day shift where the NA ratios were not met:

10/04/24census of 85 residents8.16 NAs worked and 8.50 were required
10/07/24 census of 84 residents 7.85 NAs worked and 8.40 were required

Review of facility nursing staffing documents for the time period from 9/22/24, through 10/08/24, revealed the following NA staffing shortages for the evening shift where the NA ratios were not met:

10/04/24census of 85 residents7.58 NAs worked and 7.73 were required
10/06/24 census of 84 residents 7.17 NAs worked and 7.64 were required

Review of facility nursing staffing documents for the time period from 9/22/24, through 10/8/24, revealed the following NA staffing shortages for the overnight shift where the NA ratios were not met:

9/29/24census of 83 residents5.47 NAs worked and 5.53 were required
9/30/24census of 82 residents4.81 NAs worked and 5.47 were required
10/02/24census of 83 residents3.77 NAs worked and 5.53 were required
10/03/24census of 83 residents4.52 NAs worked and 5.53 were required
10/05/24census of 84 residents4.52 NAs worked and 5.60 were required

During a telephone interview on 10/16/24, at 1:42 p.m. the Scheduler confirmed that the facility did not meet the minimum NA ratios for the above days and shifts.

Plan of Correction - To be completed: 11/17/2024

The facility acknowledges that, as of 10/16/2024, we are unable to change the results of the staffing ratio of nurse aides of one NA per 10 residents on the day shift for two of 17 days (10/04/24 and 10/07/24); one NA per 11 residents on the evening shift for two of 17 days reviewed (10/04/24 and 10/06/24); and one NA per 15 residents on the overnight shift for five of 17 days reviewed (9/29/24, 9/30/24, 10/02/24, 10/03/24 and 10/05/24).
The upcoming schedules are created by the scheduler and reviewed with the Director of Nursing (DON) and Administrator for approval.
Instruction have been provided to the DON, Scheduler and Nursing Supervisors to insure that they know how staffing ratios are met in creating schedules and deal with call offs
Oakwood has advanced a recruitment and retention effort to entice additional employees to us and keep the ones that we hire. The facility has also acquired agency staff to augment our staff. Bonuses and incentives are offered to staff who pick up shifts and stay overtime.
The Administrator performs a spot audit of schedules versus actual hours of care to track adherence to regulations. This will be applied to at least three days a week to insure that staffing ratios are within prescribed parameters. The results of the audits will be provided to the QAPI Committee for the next three meetings

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(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 nursing staffing documents and staff interview, it was determined that the facility failed to provide a minimum of one Licensed Practical Nurse (LPN) per 40 residents during the overnight shift for one of 17 days reviewed (10/03/24).

Findings include:

Review of facility nursing staffing documents for the time period from 9/22/24, through 10/08/24, revealed the following LPN staffing shortage for the overnight shift where the LPN ratios were not met:

10/03/24 census of 83 residents 1.74 LPNs worked and 2.08 were required

During a telephone interview on 10/16/24, at 1:42 p.m. the Scheduler confirmed that the facility did not meet the minimum LPN ratios for the above day and shift.

Plan of Correction - To be completed: 11/17/2024

The facility acknowledges that, as of 10/16/24, we are unable to change the results of where the LPN ratios were not met, specifically: the facility failed to provide a minimum of one Licensed Practical Nurse (LPN) per 40 residents during the overnight shift for one of 17 days reviewed (10/03/24).

The upcoming schedules are created by the scheduler and reviewed with the Director of Nursing (DON) and Administrator for approval.
Instruction have been provided to the DON, Scheduler and Nursing Supervisors to insure that they know how staffing ratios are met in creating schedules and deal with call offs
Oakwood has advanced a recruitment and retention effort to entice additional employees to us and keep the ones that we hire. The facility has also acquired agency staff to augment our staff. Bonuses and incentives are offered to staff who pick up shifts and stay overtime.
The Administrator performs a spot audit of schedules versus actual hours of care to track adherence to regulations. This will be applied to at least three days a week to insure that staffing ratios are within prescribed parameters. The results of the audits will be provided to the QAPI Committee for the next three meetings.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, 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 3.2 hours of direct resident care for each resident.

Observations:

Based on review of facility nursing staffing documents and staff interview, it was determined that the facility failed to provide the minimum number of general nursing care hours of 3.2 hours of direct resident care hours per resident in a twenty-four-hour period for six of 17 days reviewed (9/29/24, 9/30/24, 10/03/24, 10/04/24 10/05/24 and 10/06/24).

Findings include:

Review of facility nursing staffing documents for the time period of 9/22/24, through 10/8/24, revealed that the hours of direct resident care was below 3.2 minimum per patient per day (PPD) on the following dates:

9/29/24 3.14 PPD
9/30/24 3.06 PPD
10/03/24 3.02 PPD
10/04/24 2.99 PPD
10/05/24 3.00 PPD
10/06/24 3.13 PPD

During a telephone interview on 10/16/24, at 1:42 p.m. the Scheduler confirmed that the facility did not meet the 3.2 minimum hours of direct resident care on above dates.

Plan of Correction - To be completed: 11/17/2024

The facility acknowledges that, as of 10/16/24, we are unable to change the results of the minimum number of general nursing care hours of 3.2 hours of direct resident care hours per resident in a twenty-four-hour period for six of 17 days reviewed (9/29/24, 9/30/24, 10/03/24, 10/04/24 10/05/24 and 10/06/24).
The upcoming schedules are created by the scheduler and reviewed with the Director of Nursing (DON) and Administrator for approval.
Instruction have been provided to the DON, Scheduler and Nursing Supervisors to insure that they know how staffing ratios are met in creating schedules and deal with call offs
Oakwood has advanced a recruitment and retention effort to entice additional employees to us and keep the ones that we hire. The facility has also acquired agency staff to augment our staff. Bonuses and incentives are offered to staff who pick up shifts and stay overtime.
The Administrator performs a spot audit of schedules versus actual hours of care to track adherence to regulations. This will be applied to at least three days a week to insure that staffing ratios are within prescribed parameters. The results of the audits will be provided to the QAPI Committee for the next three meetings.

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