Pennsylvania Department of Health
SCHUYLKILL CENTER
Patient Care Inspection Results

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SCHUYLKILL CENTER
Inspection Results For:

There are  107 surveys for this facility. Please select a date to view the survey results.

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SCHUYLKILL CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated survey in response to two complaints completed on September 22, 2024, at Schuylkill Center, it was determined that there were no federal deficiencies identified under the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care; however, the facility was not in compliance with the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(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 a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for 17 of 17 days reviewed.

Findings include:

Review of nursing schedules from September 5, 2024, through September 21, 2024, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for 10 residents on day (7:00 a.m. to 3:00 p.m.) shift on September 5, 7, 9, 13, 18, 19, 20, and 21, 2024.

The facility failed to meet the minimum NA to resident ratio of one NA for 11 residents on evening (3:00 p.m. to 11:00 p.m.) shift on September 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21, 2024.

The facility failed to meet the minimum NA to resident ratio of one NA for 15 residents on night (11:00 p.m. to 7:00 a.m.) shift on September 5, 8, 12, 14, 15, 16, 17, 18, 19, 20, and 21, 2024.


 Plan of Correction - To be completed: 12/04/2024

1. C.N.A. ratios for the dates noted in the survey cannot be corrected as this is a past event.
2. Calculation of shift C.N.A. ratios will be completed and reviewed daily for accuracy by the scheduler.
3. The facility has developed internal incentives to retain and attract new staff. The facility has attended job fairs and nursing schools to recruit direct care staff, in addition to other ongoing recruiting initiatives. We are using recruitment lists to call area CNAs to consider joining our facility. Facility has introduced an employee referral program to recruit staff also. Agency staff are being utilized 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 C.N.A. ratios as needed.
4. C.N.A. ratios 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 will be reported to QAPI committee.
5. Date of correction is December 4, 2024.

§ 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 nine of 17 days reviewed.

Findings include:

Review of nursing schedules for 17 days from September 5, 2024, through September 21, 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 September 7, 8, 14, 15, and 21, 2024.

The facility failed to meet the minimum LPN to resident ratio of one LPN for 30 residents on evening (3:00 p.m. to 11:00 p.m.) shift on September 14, 2024.

The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on night (11:00 p.m. to 7:00 a.m.) shift on September 8, 12, 13, 14, 16, and 17, 2024.


 Plan of Correction - To be completed: 12/04/2024

1. LPN ratios for the dates noted in the survey cannot be corrected as this is a past event.
2. Calculation of shift LPN ratios will be completed and reviewed daily for accuracy by the scheduler.
3. The facility has developed internal incentives to retain and attract new staff. Facility has attended LPN schools to recruit new staff, and introduced employee referral program, as well as calling area LPNs to consider joining facility staff. Agency staff are being utilized 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 LPN ratios as needed.
4. LPN ratios 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 will be reported to QAPI committee.
5. Date of correction is December 4, 2024.

§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(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 a review of nursing time schedules, it was determined that the facility failed to provide a minimum of 3.2 hours of direct care for each resident for 17 of 17 days reviewed.

Findings include:

Review of nursing schedules for 17 days from September 5, 2024, through September 21, 2024, revealed the following total nursing care hours below minimum requirements:

September 5, 2024: 2.91 care hours per resident.
September 6, 2024: 3.00 care hours per resident.
September 7, 2024: 2.92 care hours per resident.
September 8, 2024: 2.58 care hours per resident.
September 9, 2024: 2.92 care hours per resident.
September 10, 2024: 3.04 care hours per resident.
September 11, 2024: 3.10 care hours per resident.
September 12, 2024: 2.83 care hours per resident.
September 13, 2024: 2.82 care hours per resident.
September 14, 2024: 2.61 care hours per resident.
September 15, 2024: 2.40 care hours per resident.
September 16, 2024: 2.53 care hours per resident.
September 17, 2024: 2.79 care hours per resident.
September 18, 2024: 2.52 care hours per resident.
September 19, 2024: 2.45 care hours per resident.
September 20, 2024: 2.48 care hours per resident.
September 21, 2024: 2.16 care hours per resident.


 Plan of Correction - To be completed: 12/04/2024

1. Nursing hours noted in the survey cannot be corrected as this is a past event.
2. Calculation of daily PPD will be completed and reviewed daily for accuracy by the scheduler.
3. The facility has developed internal incentives to retain and attract new staff. A nurse aide training program continues in order to develop new nursing assistants. Agency contracts are in place in an effort to reach daily PPD requirements. The scheduler will look ahead for a minimum of 1 week to determine projected PPD to allow more time to achieve PPD hours requirements.
4. PPD hours 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 will be reviewed at QAPI meeting.
5. Date of compliance is 12/04/2024.


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