Pennsylvania Department of Health
NORTHERN DAUPHIN NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

NORTHERN DAUPHIN NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 203 surveys for this facility. Please select a date to view the survey results.

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NORTHERN DAUPHIN 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 June 13, 2024, it was determined that Northern Dauphin Nursing and Rehabilitation Center did not correct the deficiencies cited during the survey of May 2, 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. :

(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 staffing documents and staff interview, it was determined that the facility failed to ensure a required minimum of one nurse aide (NA) per 12 residents on day shift for one of seven days reviewed (June 8, 2024); one NA per 12 residents on evening shift for one of seven days reviewed (June 7, 2024); and one NA per 20 residents on the overnight shift for one of seven days reviewed (June 7, 2024).

Findings Include:

Review of facility-provided staffing ratio information for June 7, 2024, on evening shift, revealed a census of 145 residents. Further review revealed a NA ratio of 6.00 of a required 12.08; therefore, the facility did not meet the required minimum NA ratio for the facility census on that shift.

Review of facility-provided staffing ratio information for June 7, 2024, on night shift, revealed a census of 145 residents. Further review revealed a NA ratio of 6.17 of a required 7.25; therefore, the facility did not meet the required minimum NA ratio for the facility census on that shift.

Review of facility-provided staffing ratio information for June 8, 2024, on day shift, revealed a census of 147 residents. Further review revealed a NA ratio of 10.07 of a required 12.25; therefore, the facility did not meet the required minimum NA ratio for the facility census on that shift.

On June 12, 2024, at 8:18 AM, the Nursing Home Administrator confirmed that the facility did not meet the minimum NA ratio for the aforementioned dates and shifts.

Plan of Correction - To be completed: 07/29/2024

1. CNA ratios on 1st shift 06/08/2024; 2nd shift 06/07/2024; and 3rd shift 06/07/2024 cannot be corrected as this is a past event.
2. Calculation of shift CNA ratios will completed and reviewed daily for accuracy by the scheduler and DON/designee. Re-education to scheduler and on call administration nursing staff regarding the required ratios.
3. The facility has developed internal incentive to retain and attract new staff. Agency contracts are in place in an effort to reach daily shift ratios. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate CNA ratios as needed.
1. HR continues to be set-up and available at the Gratz auction weekly; this facility has submitted an application to become part of Northern Dauphin Chamber of Commerce as a means to market/attract candidates. HR will also be attending job fairs as available. The facility utilizes sign -on bonuses in efforts to retain and attract new staff. Agency contracts are in place in an effort to reach daily shift ratios. NHA and HR working with ancillary staff members to attend NA training course and also promoting classes with in-house staff. The scheduler will look ahead a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate CNA ratios as needed. The facility will monitor census each shift and make all attempts to adjust CNA staffing to ensure ratio requirements are met. Ratio will be audited by scheduler and DON daily for 4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results to QAPI.
4. Date of Correction – 07/29/2024

§ 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.

Plan of Correction - To be completed: 07/29/2024

1. LPN ratios for 06/09/2024 1st shift; 06/07 & 06/09/2024 2nd shift; and 3rd shift 06/04, 05, 07, 08, and 06/09/2024 cannot be corrected as this is a past event.
2. Calculation of shift LPN ratios will completed and reviewed daily for accuracy by the scheduler. Re-education to scheduler and on call administration nursing staff regarding the required ratios.
3. HR continues to be set-up and available at the Gratz auction weekly; this facility has submitted an application to become part of Northern Dauphin Chamber of Commerce as a means to market/attract candidates. HR will also be attending job fairs as available. The facility utilizes sign -on bonuses in efforts to retain and attract new staff. Agency contracts are in place in an effort to reach daily shift ratios. The scheduler will look ahead a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate LPN ratios as needed. The facility will monitor census each shift and make all attempts to adjust LPN staffing to ensure ratio requirements are met. Ratio will be audited by scheduler and DON daily for 4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. LPN ratio will be audited by scheduler and DON daily for 4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results to QAPI.
4. Date of Correction 07/29/2024

§ 211.12(i)(1) LICENSURE Nursing services.:

(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 staffing documents and staff interview, 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 two of seven days reviewed (June 7 and 8, 2024).

Findings Include:

Review of facility provided staffing information dated June 4, through 10, 2024, revealed that the facility provided only 2.42 hours of direct care for each resident on June 7, 2024; and 2.68 hours of direct care for each resident on June 8, 2024.

On June 12, 2024, at 8:18 AM, the Nursing Home Administrator confirmed that the facility did not meet the minimum of 2.87 hours of direct care for each resident for the aforementioned dates.

Plan of Correction - To be completed: 07/29/2024

1. Nursing hours for 06/07 & 06/08/2024 cannot be corrected as this is a past event.
2. Calculation of daily PPD will completed and reviewed daily for accuracy by the scheduler. Re-education to scheduler and on call administration nursing staff regarding the required ratios.
3. The facility has developed internal incentive to retain and attract new staff. In addition to previous corrective actions. HR is marketing/recruiting at the Gratz auction weekly and has completed an application for Northern Dauphin Chamber of Commerce as a means to market/attract candidates. HR will also be attending job fairs as available. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate PPD as needed. PPD will be audited by scheduler and DON daily for 4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results to QAPI.
4. Date of Correction 07/29/2024

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