Pennsylvania Department of Health
GARDENS AT TUNKHANNOCK, THE
Patient Care Inspection Results

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GARDENS AT TUNKHANNOCK, THE
Inspection Results For:

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GARDENS AT TUNKHANNOCK, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a revisit and abbreviated complaint survey completed on March 14, 2024, it was determined that The Gardens at Tunkhannock corrected the federal deficiencies cited during the survey of January 22, 2024, under the requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care but continued to 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)(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 resident census, it was determined that the facility failed to provide a minimum of one nurse aide per 12 residents during the day and evening shifts, and one nurse aide per 20 residents during the night shift on 6 of 7 days reviewed. (3/07/24-3/12/24)

Findings include:

Review of facility census data indicated that on 3/07/24, the facility census was 82, which required 6.83 nurse aides during the evening shift.

Review of the nursing time schedules revealed only 6.55 nurse aides provided care on the evening shift on 3/07/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/07/24, the facility census was 82, which required 4.1 nurse aides during the night shift.

Review of the nursing time schedules revealed only 4.03 nurse aides provided care on the night shift on 3/07/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/08/24, the facility census was 82, which required 6.83 nurse aides during the day shift.

Review of the nursing time schedules revealed 6.05 nurse aides provided care on the day shift on 3/08/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/08/24, the facility census was 83, which required 6.92 nurse aides during the evening shift.

Review of the nursing time schedules revealed only 6.06 nurse aides provided care on the evening shift on 3/08/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/08/24, the facility census was 83, which required 4.15 nurse aides during the night shift.

Review of the nursing time schedules revealed only 4.13 nurse aides provided care on the night shift on 3/08/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/09/24, the facility census was 82, which required 6.83 nurse aides during the day shift.

Review of the nursing time schedules revealed 5.66 nurse aides provided care on the day shift on 3/09/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/09/24, the facility census was 82, which required 6.83 nurse aides during the evening shift.

Review of the nursing time schedules revealed only 5.18 nurse aides provided care on the evening shift on 3/09/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/09/24, the facility census was 82, which required 4.1 nurse aides during the night shift.

Review of the nursing time schedules revealed only 3.73 nurse aides provided care on the night shift on 3/09/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/10/24, the facility census was 82, which required 6.83 nurse aides during the day shift.

Review of the nursing time schedules revealed 6.11 nurse aides provided care on the day shift on 3/10/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/10/24, the facility census was 81, which required 6.75 nurse aides during the evening shift.

Review of the nursing time schedules revealed only 6.22 nurse aides provided care on the evening shift on 3/10/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/11/24, the facility census was 81, which required 6.75 nurse aides during the day shift.

Review of the nursing time schedules revealed only 5.88 nurse aides provided care on the day shift on 3/11/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/12/24, the facility census was 81, which required 6.75 nurse aides during the day shift.

Review of the nursing time schedules revealed only 6.5 nurse aides provided care on the evening shift on 3/12/24. No additional excess higher-level staff were available to compensate this deficiency.

The facility had not met the required nurse aide to resident ratios on the above shifts.



 Plan of Correction - To be completed: 04/19/2024

Facility cannot retroactively correct past CNA to resident ratios.
2. Facility is focusing on retention of existing nursing assistants and recruitment of new nursing assistants, through efforts of the Human Resources Manager and Nursing Administration. A third-party recruitment agency has been contracted to assist with candidates.

3. The scheduler has been re-educated regarding the CNA ratio regulatory requirements. Calculation of the daily CNA ratios will be completed and reviewed for accuracy by the scheduler/designee.

4. Daily ratios will be audited weekly X 4 weeks then monthly X 2 months. Audits will be reviewed at QAPI for compliance.

5. 4/19/2024
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 nurse staffing schedules and the resident census it was determined that the facility failed to provide one licensed practical nurse per 25 residents on the day shift, one LPN per 30 residents on the evening shift, and one LPN per 40 residents on the night shift on 7 of the 7 days reviewed. (3/07/24-3/12/24)

Findings include:

Review of facility census data indicated that on 3/07/24, the facility census was 82, which required 3.5 LPNs during the day shift.

Review of the nursing time schedules revealed 3.2 LPNs provided care on the day shift on 3/07/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/08/24, the facility census was 83, which required 2.95 LPNs during the evening shift.

Review of the nursing time schedules revealed 2.56 LPN provided care on the evening shift on 3/08/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/09/24, the facility census was 82, which required 2.92 LPNs during the evening shift.

Review of the nursing time schedules revealed 2.13 LPNs provided care on the evening shift on 3/09/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/09/24, the facility census was 82, which required 2.19 LPNs during the night shift.

Review of the nursing time schedules revealed 1.13 LPNs provided care on the night shift on 3/09/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/10/24, the facility census was 82, which required 3.5 LPNs during the day shift.

Review of the nursing time schedules revealed 3.23 LPNs provided care on the day shift on 3/10/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/10/24, the facility census was 81, which required 2.88 LPNs during the evening shift.

Review of the nursing time schedules revealed 2.67 LPNs provided care on the day shift on 3/10/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/10/24, the facility census was 81, which required 2.16 LPNs during the night shift.

Review of the nursing time schedules revealed 1.11 LPNs provided care on the night shift on 3/10/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/11/24, the facility census was 81, which required 2.88 LPNs during the evening shift.

Review of the nursing time schedules revealed 2.44 LPNs provided care on the day shift on 3/11/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/11/24, the facility census was 81, which required 2.16 LPNs during the night shift.

Review of the nursing time schedules revealed 1.12 LPNs provided care on the night shift on 3/11/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/12/24, the facility census was 81, which required 2.88 LPNs during the evening shift.

Review of the nursing time schedules revealed 2.12 LPNs provided care on the day shift on 3/12/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/12/24, the facility census was 81, which required 2.16 LPNs during the night shift.

Review of the nursing time schedules revealed 1.07 LPNs provided care on the night shift on 3/12/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/13/24, the facility census was 82, which required 2.92 LPNs during the evening shift.

Review of the nursing time schedules revealed 2.75 LPNs provided care on the day shift on 3/13/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/13/24, the facility census was 82, which required 2.19 LPNs during the night shift.

Review of the nursing time schedules revealed 1.09 LPNs provided care on the night shift on 3/13/24. No additional excess higher-level staff were available to compensate this deficiency.


The facility had not met the required LPN to resident ratios on the above shifts.



 Plan of Correction - To be completed: 04/19/2024

Facility cannot retroactively correct past LPN to resident ratios.
2. Facility is focusing on retention of existing LPNs and recruitment of new LPNs through efforts of the Human Resources Manager and Nursing Administration. A third party recruitment agency has been contracted to assist with candidates.

3. The scheduler has been re-educated regarding the LPN ratio regulatory requirements. Calculation of the daily LPN ratios will be completed and reviewed for accuracy by the scheduler/designee.

4. Daily ratios will be audited weekly X 4 weeks then monthly X 2 months. Audits will be reviewed at QAPI for compliance.

5. 4/19/2024
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 a review of nurse staffing schedules and resident census it was determined that the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse staffing of 2.87 hours of general nursing care to each resident:

March 7, 2024 - 2.74 nursing hours per resident per 24 hours.

March 8, 2024 - 2.48 nursing hours per resident per 24 hours.

March 9, 2024 - 2.30 nursing hours per resident per 24 hours

March 10, 2024 - 2.45 nursing hours per resident per 24 hours

March 11, 2024 - 2.47 nursing hours per resident per 24 hours

March 12, 2024 - 2.68 nursing hours per resident per 24 hours

March 13, 2024 - 2.61 nursing hours per resident per 24 hours

On the above noted dates, the facility failed to provide the minimum of 2.87 hours of direct nursing care daily for each resident.



 Plan of Correction - To be completed: 04/19/2024

Facility cannot retroactively correct past nursing hours.
2. Facility is focusing on retaining current nursing staff and recruitment using in-house recruitment resources and a third-party recruitment firm dedicated to only nursing applicants to correct nursing hours.

3. Facility is implementing staff incentives for current and new staff as well as reinforcing the facility call off policy to deter unnecessary call offs. NHA or designee will educate staff on incentives and call off policy.

4. NHA/designee will audit nursing hours weekly for three weeks then monthly X 3 months. Audits will be reviewed by QA monthly X 3 months to ensure compliance with POC.

5. 4/19/2024

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