Pennsylvania Department of Health
OAKWOOD HEIGHTS VILLAGE
Patient Care Inspection Results

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OAKWOOD HEIGHTS VILLAGE
Inspection Results For:

There are  63 surveys for this facility. Please select a date to view the survey results.

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

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey completed on March 29, 2024, it was determined that Oakwood Heights Village 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 observations, clinical record review, and staff interviews, it was determined that the facility failed provide an environment that enhances resident's quality of life for one of 22 residents reviewed (Resident R37).

Findings include:

Review of Resident R37's clinical record revealed an original admission date of 2/23/18, with diagnoses that included dementia, Type 2 Diabetes (condition of improper insulin levels that affects how the body uses blood sugar), heart failure, post traumatic seizures, bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and traumatic brain injury.

A departmental progress note dated 11/03/23, indicated that Resident R37 enjoys watching TV and spending time in the common areas on his/her neighborhood.

Observation on 3/26/24, at 2:15 p.m. Resident R37 was sitting alone in his/her room yelling out for help.

During an interview at the time of the observation, Resident R37 confirmed he/she wanted someone to visit with him/her and expressed interest in going out to the lounge to visit with other residents.

During an interview on 3/26/24, at 2:22 p.m. Nurse Aide (NA) Employee E2 confirmed that he/she would love to bring Resident R37 out to visit in the lounge, but that he/she often yells out and "sets off the other residents in the lounge."

Observation on 3/27/24, between 8:45 a.m. and 2:30 p.m. revealed Resident R37 was sitting in a wheelchair in front of the TV in his/her room without personal interactions.

Observations on 3/28/24, at 8:58 and 9:51 a.m. revealed Resident R37 was sitting in a wheelchair in front of the TV in his/her room without personal interactions; at 11:00 a.m. Resident R37 was in the beauty shop; at 11:35 a.m. Resident R37 was sitting near the nurse's station on the unit; at 12:30 p.m. was eating lunch in the lounge; from 1:30 p.m. to 2:42 p.m. Resident R37 was sitting in his/her wheelchair in his/her room sleeping with his/her head tipped forward, and the door was closed.

Observation on 3/29/24, at 8:55 a.m. revealed Resident R37 was sitting in his/her room with the door ajar and eating breakfast alone.

During an interview on 3/29/24, at 9:58 a.m. the Director of Nursing and Director of Activities confirmed that Resident R37 should not be left in his/her room for extended periods of time alone but brought out to common areas to interact with other residents and staff.

28 Pa. Code 201.29 (a) Resident Rights

28 Pa. Code 211.12 (d)(1)(3)(5) Nursing Services



 Plan of Correction - To be completed: 04/24/2024

1. This resident was invited to partake in typical functions of the community. The Interdisciplinary Team developed a plan of approaches and interventions pertaining to this individual.
2. The activity department reviewed all other residents of the facility with the potential to be in a similar situation and identified a small number of residents that attend minimal to no activities and are fully dependent on staff for engagement in leisure activities of their choosing.
3. The activity department is reviewing participation levels for all residents on an ongoing basis and has classified them into three categories based on their preferences to participate in group or self-directed activities. Those identified as attending minimal or no group activities are being care planned to have additional 1:1 activities or other leisure activities of their choosing. This is being reported out at the monthly QAPI meetings.
4. All staff will receive training pertaining to the requirements of 483.10(b)(1) and 483.10(b)(2).
5. Audits will be completed by the Director of Nursing (DON) or designee weekly x 4 then monthly x3 of those residents identified by the activity department (current and new residents) to ensure that no residents are in a condition free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility.
Results of the audits will be reported out at the monthly QAPI meetings.


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:


Based on review of facility policy, clinical and facility records, and resident and staff interviews, it was determined that the facility failed to ensure essential resident safety measures were followed to prevent a fall for two of 18 residents reviewed (Residents R26, R37).

Findings include:

Review of facility policy "Wheelchair, Geriatric Chair, Broda Chair, Misc. Resident Transport Chair Safety," dated 7/24/23, indicated "Foot rests must be used when staff are assisting residents who are transported by wheelchair and, Broda chair or any chair with attachable footrests to prevent accident/injury unless resident is able to self propel."

Review of Resident R26's clinical record revealed an admission date of 10/04/23, with diagnoses that included calculus of ureter (a formation kidney stones in a tube that urine passes from kidneys to bladder), neutropenia (a type of white blood cell and is at a low level in the blood), cystitis (infection of bladder), and muscle weakness.

Review of the Minimum Data Set (MDS-a federally mandated standardized assessment process conducted to plan resident care) assessment dated 1/10/24, revealed a BIMS (Brief Interview for Mental Status-a tool used to assess cognitive function) with score of 12/15, that indicated moderate cognitive impairment.

Review of an initial facility incident report dated 2/21/24, revealed a staff description and statement that Registered Nurse Supervisor watched CNA (Certified Nursing Assistant) push resident down the hallway in wheelchair with no legrests on chair. Nurse saw resident's feet drop down and start to go under chair - nurse yelled "Stop pushing resident, he/she's going to fall out his/her chair." At this time, resident was already being thrown from wheelchair and landed on the floor - face and forehead hit the floor.

The nursing progress notes dated 2/21/24, at 19:50 p.m. revealed Resident R26 was being pushed down the hallway in his/her wheelchair. Resident R26's legs dropped down. Nurse yelled to stop pushing resident that he/she was going to fall out of his/her wheelchair. Resident was thrown from his/her wheelchair and landed face down on the floor.

An interview with Resident R26 on 3/26/24, at 10:15 a.m. revealed that he/she was being pushed by a staff member in his/her wheelchair without the leg rests down the hallway on 2/21/24. He/she indicated that he/she always wants the leg rests on the wheelchair, because it makes him/her feel safer. Resident R26 further indicated that his/her legs got stuck under the wheelchair, and he/she was thrown to the floor. He/she indicated the fall could of been prevented if staff placed the wheelchair leg rests on prior to pushing him/her.

During an interview on 3/28/24, at 1:50 p.m. the Director of Nursing (DON) confirmed the wheelchair leg rests are always to be on a resident's wheelchair during transport. The DON confirmed that during Resident R26's transport on 2/21/24, the wheelchair leg rests were not in place which allowed the resident's legs to get lodged under the wheelchair resulting in him/her being thrown to the floor. The DON confirmed that Resident R26 should have had leg rests on his/her wheelchair to prevent injury when being pushed by staff.

Review of Resident R37's clinical record revealed an original admission date of 2/23/18, with diagnoses including dementia, Type 2 Diabetes (condition of improper insulin levels that affects how the body uses blood sugar), heart failure, post traumatic seizures, bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and traumatic brain injury.

Review of a physician's order dated 1/09/24, revealed that Resident R37 was to be transferred with the assistance of two staff while utilizing a wheeled walker.

A facility investigation dated 1/17/24, indicated that Resident R37 was being transferred to a chair with the assistance of one staff member, and during the transfer his/her knees "gave out" and he/she fell to his/her knees.

During an interview on 3/28/24, at 2:12 p.m. the DON confirmed Resident R37 should have had the assistance of two staff members and utilize a wheeled walker to transfer and that on 1/17/24, staff failed to transfer Resident R37 in a safe manner.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1) Management

28 Pa. Code 211.12 (d)(1)(5) Nursing services



 Plan of Correction - To be completed: 04/24/2024

Plan for situation A - pushing Resident R26 without leg rests:
1. As a result of the fall, Resident R26 was assessed by the nurse on duty and was sent to the ER for further evaluation. Evaluation from the hospital proved negative for fracture or other injury. The caregiver was provided immediate education pertaining to the proper techniques to be applied when transporting a resident via wheelchair. This individual also received appropriate corrective action.
2. All wheelchairs were audited to ensure that they possessed the appropriate leg rests, and that there was a transport bag installed on each chair in the event that they were needed. All employees will receive training pertaining to the proper techniques to be applied when transporting a resident via wheelchair. Managers were instructed to educate staff the moment that they observe a resident being transported in a wheelchair without the proper techniques being used.
3. Audits will be completed by the Director of Nursing (DON) or designee of staff members who are witnessed transporting a resident via wheelchair that leg rests are properly installed on the wheelchairs and that a storage bag is present. If the performance is not as trained, then immediate education will be provided by the Director of Nursing (DON) or designee. These audits will be completed weekly x 4 then monthly x3 and reported out at the monthly QAPI meeting.

Plan for situation B - transfer of Resident R37 without use of wheeled walker and assist of 2 staff members:

1) As a result of the fall when Resident R37 was lowered to the floor, Resident R37 was assisted into the chair and assessed for injuries by the nurse on duty. The caregiver was provided immediate education pertaining to the proper policies and procedures for transfer assists, and the facility's process used in identifying transfer status.
2) Transfer status of all residents will be marked outside the resident room doors on the nameplate using the facility's standard process. This indicator will be placed on wheelchairs and walkers as well. This will be audited weekly times 4 and then monthly and reported out at the monthly QAPI meeting. All employees will receive training pertaining to the policies and procedures for proper resident transfers.
3) Audits will be completed by the Director of Nursing (DON) or designee of staff members who are witnessed transferring residents. If the performance is not as trained, then immediate education will be provided by the Director of Nursing (DON) or designee. These audits will be completed weekly x 4 and then monthly x 3 and reported out at the monthly QAPI meeting.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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.
483.25(e) Incontinence.
483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:


Based on review of facility policy and clinical records, observations and staff interview, it was determined that the facility failed to provide appropriate care regarding a urinary catheter (a tube placed and held in the bladder to drain urine) for one of 18 residents reviewed (Resident R62).

Findings include:

Review of facility policy entitled "Emptying a Urinary Drainage Bag" (a bag that holds urine that comes from a tube placed and held in the bladder to drain urine), dated 7/24/23, indicated to "keep the drainage bag and tubing off the floor at all times..."

Review of Resident R62's clinical record revealed an admission date of 12/17/23, with diagnoses that included urinary tract infection (an infection in any part of the urinary system), hypertension (high blood pressure), and hyperlipidemia (high cholesterol).

Review of Resident R62's Quarterly Minimum Data Set (MDS-a mandated assessment of a residents abilities and care needs) assessment, dated 2/1/24, revealed that Resident R62 had an indwelling urinary catheter.

Observation on 3/27/24, at 8:50 a.m. revealed Resident R62's urinary drainage bag lying flat on the floor with no covering in place and the drainage spout (the part of the urinary bag that opens to empty urine from the bag) facing down and touching the floor.

Observation on 3/27/24, at 9:55 a.m. revealed Resident R62's urinary drainage bag remained lying flat on the floor with no covering in place and the drainage spout facing down and touching the floor.

During an interview on 3/27/24, at 9:55 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that the urinary drainage bag should not be on the floor. He/she also confirmed that there should be a privacy cover on the urinary drainage bag.

28 Pa. Code 211.12(d)(1)(5) Nursing services





 Plan of Correction - To be completed: 04/24/2024

1. Initial response was that the foley catheter bag for Resident R62 was changed, and that a dignity covering was placed on the bag. The bag was then hung on the side of the bed with no tubing touching the floor.
2. All residents within the community that use a catheter were checked and determined to have the correct bag and covering, and that the bags were hung so as to not touch the floor. Nurses and CNAs will be educated on dignity with a catheter and preventing UTI's.
3. Audits will be completed by the Director of Nursing (DON) or designee weekly x 4 then monthly x3 of all residents with a catheter to ensure that each resident's bag has a privacy cover and that tubing is not touching the floor. Results of the audits will be reported out at the monthly QAPI meetings.



211.5(f)(i)-(xi) LICENSURE Medical records.:State only Deficiency.
(f) In addition to the items required under 42 CFR 483.70(i)(5) (relating to administration), a resident ' s medical record shall include at a minimum:
(i) Physicians' orders.
(ii) Observation and progress notes.
(iii) Nurses' notes.
(iv) Medical and nursing history and physical examination reports.
(v) Admission data.
(vi) Hospital diagnoses authentication.
(vii) Report from attending physician or transfer form.
(vii) Diagnostic and therapeutic orders.
(viii) Reports of treatments.
(ix) Clinical findings.
(x) Medication records.
(xi) Discharge summary, including final diagnosis and prognosis or cause of death.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to include the recapitulation of stay (summary of residents stay and course of treatment in the facility) for one of three closed records reviewed (Resident CR91).

Findings include:

Review of Resident CR91's clinical record revealed an admission date of 12/20/23, with diagnoses that included pulmonary hypertension (a type of high blood pressure that affects the lungs), and heart failure (a condition that occurs when the heart can not pump enough blood for the body's needs).

Review of the clinical record revealed the Resident CR91 discharged to the hospital on 2/19/24, with no anticipated return to the facility.

Review of Resident CR91's clinical record lacked evidence of a recapitulation of Resident CR91's stay.

During an interview on 3/28/24, at 2:09 p.m. with the Director of Nursing (DON) he/she confirmed that Resident CR91's closed record lacked a recapitulation of his/her stay. The DON also confirmed that a recapitulation of Resident CR91's stay should have been completed.




 Plan of Correction - To be completed: 04/24/2024

1. The record for Resident CR91 has been closed appropriately.
2. All medical records of recent residents that were discharged were reviewed to ensure the recapitulation of stay was completed.
3. The Medical Records coordinator is going to be responsible to ensure that the recapitulation of stay is opened and completed timely. This will be monitored by the Administrator to ensure compliance.
4. The Medical Records coordinator and the Interdisciplinary Team will be educated on the change in process and the requirements.
3. Medical Records will keep a log of the completion of Recapitulation of Stay and will report success rates to the next three QAPI meetings.
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 nursing time schedules and staff interview, it was determined that the facility failed to provide a minimum of one nurse aide (NA) per 20 residents during the overnight shift for one of 21 days reviewed (3/28/24).

Findings include:

Review of the facility census data revealed that on 3/28/24, the facility census was 91 which required a minimum of 4.55 NAs during the overnight shift. Review of the nursing time schedules revealed that only 4.14 NAs worked on 3/28/24, during the overnight shift therefore not meeting the NA ratio for that date.

During an interview on 3/29/24, at 11:15 a.m. the Nursing Home Administrator confirmed that the facility did not meet the NA ratios for the above identified date and shift.










 Plan of Correction - To be completed: 04/24/2024

1. The facility must maintain the minimum of one nurse aide per 12 residents during the day, one nurse aide per 12 residents during the evening and one nurse aide per 20 residents overnight.

2. To ensure that this regulatory requirement is met the following action plan will be implemented:
Education will be provided to the scheduler and the Director of Nursing to ensure that they understand the regulatory staffing requirements for nurse aides.
The nurse aide schedule will be reviewed by the scheduler and Director of Nursing or designee to ensure that nurse aide ratios are met prior to posting of the schedule.
In the event of call-offs by staff, all other staff/agency will be contacted to cover any open shifts to ensure ratios are met. The Director of Nursing or designee and or the Scheduler are responsible for handling call offs on the off shifts and weekends.
The Administrator and Director of Nursing will monitor staff ratios in relation to current census and place a hold on new admissions if staffing ratios would not be met.
The Administrator, Director of Nursing, scheduler and human resource director will continue to report staffing vacancies on the weekly staffing call with the firm that manages recruitment and retention and discuss strategies to increase recruitment of nursing personnel.

3. An audit will be developed and completed by the Director of Nursing or Designee daily for 4 weeks, then 3 times a week for 3 weeks, then 2 times a week for 2 weeks then weekly ongoing, to ensure that nurse aide ratios are met for the day, evening and overnight shifts. The audit will be monitored by the Administrator or Designee.
Results of the audit will be presented at the next three QAPI meetings and recommendations will be implemented.

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 nursing time schedules and staff interview, it was determined that the facility to provide a minimum of one Licensed Practical Nurse (LPN) per 25 residents during the day shift for one of 21 days reviewed (3/24/24), one LPN per 30 residents during the evening shift for two of 21 days reviewed (3/25/24 and 3/26/24) and one LPN per 40 residents during the overnight shift for two of 21 day reviewed (3/25/24 and 3/28/24).

Findings include:

Review of the facility census date revealed that on 3/24/24, the facility census was 91 which required a minimum of 3.64 LPNs during the day shift. Review of the nursing time schedules revealed that only 3.25 LPNs worked the day shift on 3/24/24,, therefore not meeting the LPN ratio for that date.

Review of the facility census data revealed that on 3/25/24 and 3/26/24, the facility census was 92 which required a minimum of 3.07 LPNs during the evening shift. Review of the nursing time schedules revealed that only 2.91 LPNs worked the evening shift on 3/25/24 and only 2.98 LPNs worked the evening shift on 3/26/24, therefore not meeting the LPN ratio for those dates.

Review of the facility census data revealed that on 3/25/24, the facility census was 92 which required a minimum of 2.30 LPNs during the overnight shift. Review of the nursing time schedules revealed that only 2.07 LPNs worked the overnight shift on 3/25/24, therefore not meeting the LPN ratio for those dates.

Review of the facility census data revealed that on 3/28/24, the facility census was 91 which required a minimum of 2.28 LPNs during the overnight shift. Review of the nursing time schedules revealed that only 2.22 LPNs worked the overnight shift on 3/28/24, therefore not meeting the LPN ratio for those dates.

During an interview on 3/29/24, at 11:15 a.m. the Nursing Home Administrator confirmed that the facility did not meet the LPN ratios for the above identified dates and shift.





 Plan of Correction - To be completed: 04/24/2024

1. The facility must maintain the minimum of one Licensed Practical Nurse (LPN) per 25 residents on the day shift, and 1 LPN per 30 residents on the evening shift and one LPN for every 40 residents on the overnight shift.
2. To ensure that this regulatory requirement is met the following action plan will be implemented:
Education will be provided to the scheduler and the Director of Nursing to ensure that they understand the regulatory staffing requirements for Licensed Practical Nurses.
The LPN schedule will be reviewed by the scheduler and Director of Nursing or designee to ensure that LPN ratios are met prior to posting of the schedule.
In the event of call-offs by staff, all other staff/agency will be contacted to cover any open shifts to ensure ratios are met. The Director of Nursing or designee and or the Scheduler are responsible for handling call-offs on the off shifts and weekends.
The Administrator and Director of Nursing will monitor staff ratios in relation to current census and place a hold on new admissions if staffing ratios would not be met.
The Administrator, Director of Nursing, scheduler and human resource director will continue to report staffing vacancies on the weekly staffing call with the firm that manages recruitment and retention and discuss strategies to increase recruitment of nursing personnel.

3. An audit will be developed and completed by the Director of Nursing or Designee daily for 4 weeks, then 3 times a week for 3 weeks, then 2 times a week for 2 weeks then weekly ongoing, to ensure that LPN ratios are met for the day, evening and overnight shifts. The audit will be monitored by the Administrator or Designee.
Results of the audit will be presented at the next three QAPI meetings and recommendations will be implemented.

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 facility provided staffing documents and staff interview, it was determined that the facility failed to provide the minimum number of general nursing care hours of 2.87 hours of direct resident care hours per resident in a twenty-four hour period for one of 21 days reviewed (3/25/24).

Findings include:

During a review of nursing schedules for the time period of 3/22/24, through 3/29/24, it was revealed that the hours of direct resident care was below 2.87 minimum per patient per day (PPD) on the following date:

3/25/24 2.84

During an interview on 3/29/24, at 11:15 a.m. the Nursing Home Administrator confirmed the facility did not meet the 2.87 minimum hours of direct resident care on 3/25/24.





 Plan of Correction - To be completed: 04/24/2024

1. The facility must provide a total number of hours of general nursing care in each 24-hour period that totals a minimum of 2.87 hours of direct resident care for each resident.

2. To ensure that this regulatory requirement is met the following action plan will be implemented:
Education will be provided to the scheduler and the Director of Nursing to ensure that they understand the regulatory staffing requirements regarding the minimum hours of direct resident care required in a 24-hour period. The daily deployment sheets will be reviewed by the scheduler and Director of Nursing or designee to ensure that a minimum of 2.87 hours of direct resident care is provided for each resident. In the event of call-offs by staff, all other staff/agency will be contacted to cover any open shifts to ensure staffing requirements are met. The Director of Nursing or designee and or the Scheduler are responsible for handling call offs on the off shifts and weekends.
The Administrator and Director of Nursing will monitor nursing care hours in relation to current census and place a hold on new admissions if staffing requirements would not be met.
The Administrator, Director of Nursing, scheduler and human resource director will continue to report staffing vacancies on the weekly staffing call with the firm that manages recruitment and retention and discuss strategies to increase recruitment of nursing personnel.

3. An audit will be developed and completed by the Director of Nursing or Designee daily for 4 weeks, then 3 times a week for 3 weeks, then 2 times a week for 2 weeks then weekly ongoing, to ensure that the minimum staffing requirements are met. The audit will be monitored by the Administrator or Designee.

Results of the audit will be presented at the next three QAPI meetings and recommendations will be implemented.


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