Pennsylvania Department of Health
LUTHER WOODS NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
LUTHER WOODS NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  106 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
LUTHER WOODS NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey and State Licensure Survey, completed on March 22, 2024, it was determined that Luther Woods Nursing and Rehabilitation Center, was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.





 Plan of Correction:


483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:

Based on facility policy review, clinical record review, and staff interviews, it was determined the facility failed to develop and implement a comprehensive person-centered care plan to attain or maintain the highest practicable level in reference to communication for one of 26 residents reviewed (Resident 75).

Findings include:

Review of facility policy, titled "Resident Assessment & Care Planning", effective date November 1, 2019 read, "A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health -related care and services to attain or maintain the highest practical physical, mental and psychosocial well-being of the patient".

Review of Resident 75's clinical record revealed admission date of November 2, 2023 with the diagnoses of Corticobasal degeneration (CBD) (a rare neurodegenerative disorder characterized by a progressive loss of nerve cells (neurons) in certain areas of the brain), paralysis of the vocal cords and larynx, bilaterally, alexander disease (a rare and progressive neurological disorder that primarily affects the central nervous system, particularly the brain)

Review of Resident 75's care plan revealed a focus on "increase communication between resident/family/caregivers about care and living." Review of the Resident R75's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated February 11, 2024, indicated that the resident's BIMS (Brief Interview of Mental Status) is cognition intact.

On March 20, 2024, at 9:34 a.m. an interview with the unit manager, Employee E3 reported that Resident R75 does communicate via paper and writing, but Resident R75 is nonverbal.

On March 21, 2024, at 10:44 a.m. an interview with Resident R75 revealed that the resident prefered the use of paper and pen to communicate. On Resident's R75 tray a communication list was available and when surveyor tried to use it to communicate with Resident R75 became frustrated and started screaming noise. Nursing aide, Employee E8 came in and had to calm Resident R75 down by repeating that Resident R75 needs to write what she desires and not get frustrated. Employee E8 reported that Resident R75 only prefered to use paper and pen to write her needs and wants. Resident R75 did not like to use the communication board nor the ipad that a spouse obtained for her.

On March 21, 2024 at 11:15 a.m. an interview was held with speech therapist, Employee E13 who concurred that Resident R75 exhibited a preference for communicating using traditional paper and pen rather than utilizing modern communication aids such as a communication board or an iPad. Despite efforts to provide alternative means of communication for quicker expression of needs, the resident remains resistant to these methods and continues to favor the use of paper and pen.

On March 21, 2024, at 12:34 a.m. an interview with the unit manager, Employee E3 confirmed that Resident R75 has a strong preference to use paper and pen to communicate her needs and the comprehensive care plan did not provide any preference nor interventions to support the Resident R75 in the communication efforts.

28 Pa. Code 211.12(d)(1)(2)(5) Nursing services



 Plan of Correction - To be completed: 04/10/2024

Develop/Implement Comprehensive Care Plan
Immediately, the care plan for resident R75 was updated by employee E3.

Facility wide education was provided to nursing staff regarding care plan policy.

Care plans will be audited quarterly by a licensed nurse to ensure accuracy using the newly implemented audit tool. Admission batch orders/admission tool updated to reflect need for care plan with specific communication needs. MDS coordinator and Clinical Managers will be responsible for care plan development. Random audit of 5 charts per month times 3 months to be completed by Clinical Managers to ensure accuracy. Residents with any communication needs to be discussed during QAPI x 3 months.
483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:

Based on review of facility policy, review of clinical records, and interviews with residents and staff, it was determined that the facility failed to identify, implement, monitor, and modify interventions consistent with the resident's assessed needs to maintain acceptable parameters of nutritional status for two of two residents reviewed for weight loss (Resident R65 and R30).

Findings include:

Review of the facility policy titled "Weight Monitoring and Tracking" dated November 1, 2019, revealed the procedure for weight loss is as follows: the director of nursing is responsible for ensuring patients are weighed in a timely manner using proper techniques, an electronic system will be utilized for recording tracking and reporting weights and weight variances, weight will be verified within five days of a weight variance of five pounds since last weight or when a significant weight loss is identified , the significant weight loss will be identified and discussed by a interdisciplinary team, and the committee will investigate the possible causes of weight change, discuss interventions and document a progress note in the residents medical record.

Review of Resident R65's clinical record revealed that Resident R65 was admitted to the facility on October 2022 with the diagnosis of schizoaffective disorder bipolar type (a mental health disorder that is marked by a combination of schizophrenia mood disorder of bipolar disorder), chronic respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide in the body), COPD (Chronic obstructive pulmonary disease is a chronic disease that causes obstructed airflow from the lungs), type 2 diabetes (long term medical condition in which the body does not use insulin properly, resulting in unusual blood sugars), chronic kidney disease(also known as chronic kidney failure, a gradual loss of kidney function), chronic diastolic (congestive ) heart failure (a clinical syndrome of heart failure with a preserved left ventricular ejection fraction) peripheral vascular disease(a circulation disorder caused by narrowing, blockage or spasms in blood vessels), Major depressive disorder (a mood disorder that causes a persistent feeling of sadness) and as of February 6, 2024 an above the knee amputation of her right leg.

Continued review of Resident R65's clincial record revealed a critical weight loss presented in the resident's documented history of vitals. Resident R65 had a documented weight loss begining on November 10, 2023, the resident's weight was documented as 190.2 pounds. The next weight documented for Resident R65 was December 6, 2023, which the significant loss was evident, the resident weight 164.4 pounds (a weight loss of 25.8 pounds in one month). The resident was re-weighed five days later and on December 11, 2023, and still exhibited weight loss at a weight documented of 163.8pounds. Resident R65 was not re-weighted until January 6, 2024 at that time, revealed a continued trend of weight loss, the resident weighed 155 pounds (a loss of 35.2 pounds). Resident R65 continued to show gradual weight loss as of March 4, 2024. Resident R65's documented weight was 141.0 pounds.

Further review of Resident R65's dietary note dated December 20, 2023, two weeks after documented weight loss of twenty-five pounds, revealed that resident R65 was triggered for significant weight loss. The notation declared that Resident R65 weight loss was unplanned and unfavorable. It has been evident that Resident R65 has had decrease of intakes at meals. Likely contributing to the weight loss. The professional recommendation of this weight loss was to recommend adding magic cup 4oz three times a day (290kcal, 9g each) at meals to meet kcal needs. The goals of this dietary intervention were that the resident will maintain current weight without any significant changes and the Resident R65 will consume >75% of each meal without refusals.

Interview with Register Dietician, Employee E6 and Regional Registered Dietician, Employee E5 on March 21, 2024 at 2:05 p.m., revealed that they were both aware of Resident R65 weight loss , it was believed to be contributed by the resident's leg amputation. Residents leg amputation was two months after the initial weight loss. Employee E6 was unable to comment to why this weight loss was not assessed and lack of any intervention in a timely manner.

Review of Resident R30's quarterly Minimum Data Set (MDS - federally mandated resident assessment) dated February 4, 2024, revealed the resident had diagnoses of dementia (loss of cognitive functioning that interferes with daily life and activities) and dysphagia (swallowing difficulties).

Review of Resident R30's comprehensive care plan revised March 19, 2024, revealed the resident was at risk for malnutrition (condition that develops when the body is deprived of vitamins, minerals and other nutrients it needs to maintain healthy tissues and organ function) related to dementia, dysphagia, and low BMI (body mass index - a measure of body fat based on height and weight).

Review of Resident R30's weight history revealed a documented weight of 170.4 pounds on September 6, 2024.

Review of Resident R30's clinical record revealed the resident was readmitted to the facility, from the hospital, on September 25, 2024.

Review of Resident R30's nutrition assessment dated September 27, 2024, completed by Employee E6, Registered Dietitian, revealed the readmission weight was pending and would further assess when available. Further review of the assessment revealed the resident was at risk for malnutrition and interventions included to monitor weekly weights as ordered.

Review of Resident R30's physician order summary revealed weekly weights were ordered September 25, 2024.

Review of Resident R30's clinical record revealed no documented evidence weekly weights were completed as ordered.

Review of Resident R30's clinical record revealed the facility did not obtain a re-admission weight for the resident until October 2, 2024, seven days after readmission. Readmission weight obtained on October 2, 2024, revealed the resident weighed 160.4 pounds, reflecting a significant weight loss of 10 pounds and 5.8% in one month.

Continued review of Resident R30's clinical record revealed the Registered Dietitian did not reassess the resident and modify interventions consistent with the residents needs until October 18, 2024, sixteen days after the identified weight loss.

Further review of Resident R30's clinical record revealed the resident had a documented weight of 143 pounds on January 8, 2024, reflecting a 10 pound and 6.5% significant weight loss in one month (in comparison to a documented weight of 153 pounds on December 5, 2023).

Review of Resident R30's clinical record revealed nutrition note dated January 15, 2024, by Registered Dietitian, Employee E6. Review of the nutrition note revealed it did not address Resident R30's significant weight loss on January 8, 2024. Resident R30's nutritional status was not accurately assessed to identify and modify interventions consistent with the resident's needs to maintain acceptable parameters of nutritional status.

Continued review of Resident R30's clinical record revealed the Registered Dietitian did not reassess the resident and modify interventions consistent with the residents needs until January 24, 2024, 16 days after the identified weight loss.

Interview was conducted with the Registered Dietitian, Employee E6, on March 13, 2024, at 2:13 p.m. Registered Dietitian, Employee E6, was unable to explain why the weights and nutritional status were not being monitored or addressed in a timely manner.

28 Pa. Code 201.18 (b) Management

28 Pa. Code 211.10 (c) Care policies

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






 Plan of Correction - To be completed: 04/11/2024

Corrective Actions for Residents Identified:
● Residents #65 and #30 were affected by this deficient practice. The residents were re-assessed to ensure adequate nutritional interventions were in place to deter/prevent further weight loss.
● The Registered Dietitian was re-educated on the weight assessment and intervention policy, appropriate interventions, and follow-up to prevent further weight loss.

Residents at Risk:

● All patients have the potential to be affected by this deficient practice.
● The monthly weight change report was reviewed immediately and Residents with significant weight changes were audited to ensure interventions and follow-up were in place.

Systematic Changes:

● The facility policy titled, "Weight Monitoring and Tracking" was reviewed. No revisions were needed.
● All significant weight changes will be assessed monthly at a minimum and appropriate interventions will be documented.
● An audit tool was created to monitor compliance.

Monitoring of Corrective Actions:

● All monthly significant weight changes will be audited for appropriate interventions weekly x 4 weeks, then monthly for 3 months. The expectation on weekly audits is that weight trends are reviewed with the IDT and documented in order of clinical acuity so that all changes are addressed by the end of the month. Results will be presented during the monthly QAPI meeting.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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.
483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:

Based on review of facility policy, review of clinical records, and interview with staff, it was determined the facility failed to provide pharmaceutical services to meet resident's needs including acquiring, receiving, and administering medications for one of 26 residents reviewed (Resident R45).

Findings Include:

Review of facility policy "Medication Management/Medication Unavailability" dated 04/21/2022 revealed the pharmacy provides and maintains written contractual services and procedures that ensure safe and effective drug therapy, distribution, control and use within the facility. If medications are determined to be unavailable for administration, the licensed nurse will notify the provider of the unavailability and request an alternate treatment if possible. The licensed nurse will document notification to the provider of the unavailability in the medical record. If alternate treatment is not available, then licensed nurse will activate backup pharmacy process and procedures.

Review of Resident R45's physician order summary revealed an order dated February 10, 2024, to administer Pregabalin 50 milligrams (mg) two times a day, in the morning and at night (medication used to treat pain caused by nerve damage).

Review of Resident R45's medication administration record revealed the resident did not receive the medication on 2/29/2024 morning dose, 03/01/2024 morning and night dose, 03/03/2024 night dose, and 03/04/2024 morning dose.

Review of Resident R45's clinical record revealed nursing notes on the above dates that the medication was not administered because it was unavailable and awaiting delivery from the pharmacy.

Continued review of Resident R45's clinical record revealed no documented evidence that the physician was made aware of the missed doses or that an alternate treatment was requested. Further review of the clinical record revealed no documented evidence the licensed nurse activated backup pharmacy process and procedures to obtain and administer the medication.

Interview with the Director of Nursing, Employee E2, on March 21, 2024, at 2:24 p.m. confirmed Resident R45 missed doses of his medication and confirmed nursing staff did not follow policy and procedure to acquire and administer medication.


28 Pa. Code 211.9 (a)(1) Pharmacy Services.

28 Pa. Code 211.9 (d) Pharmacy Services.

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






 Plan of Correction - To be completed: 04/10/2024

Pharmacy Services

Education provided to nursing staff regarding pharmacy policy and facility protocol for unavailable medications. Education included; med dispense availability, proper documentation, physician notification and requesting possible alternative when a medication is not available from back up supply. Clinical Mangers to monitor 24-hour PCC report routinely and follow up on any medications documented as unavailable.
Pharmacy review will be monitored weekly x 2 months then bi-monthly times 2 months.
483.70(n)(2)(i)(ii)(3)-(5) REQUIREMENT Entering into Binding Arbitration Agreements: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.
483.70(n) Binding Arbitration Agreements
If a facility chooses to ask a resident or his or her representative to enter into an agreement for binding arbitration, the facility must comply with all of the requirements in this section.

483.70(n)(1) The facility must not require any resident or his or her representative to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility and must explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at, the facility.

483.70(n)(2) The facility must ensure that:
(i) The agreement is explained to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands;
(ii) The resident or his or her representative acknowledges that he or she understands the agreement;

483.70(n)(3) The agreement must explicitly grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it.

483.70(n) (4) The agreement must explicitly state that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility.

483.70(n) (5) The agreement may not contain any language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care Ombudsman, in accordance with 483.10(k).
Observations:

Based on review of facility documents and resident clinical record reviews and staff and resident interviews, it was determined that the facility failed to ensure a resident and resident's representative had the capacity to understand the terms of a binding arbitration agreement for four of 4 residents reviewed (Resident R35, R48, R93, R113,).

Findings include:

A review of the facility policy Binding Arbitration part 17. Revealed "The resident and the facility agree that, unless prohibited by applicable federal or Pennsylvania law and except solely for any claims by the Facility regarding the Resident's failure to timely pay all amounts owed to the Facility under this Agreement, for which claim the Facility shall have the right specified in Section 21 and 22 , above any dispute whatsoever between or among the Resident the Responsible Party or any other of the Resident's representatives, guardians, heirs, executors and/or administrations and the Facility and/or its agents shall be resolved by binding arbitration. In the event of a dispute, the Resident and the Facility shall each select an attorney, both of which attorneys shall mutually agree upon an arbitrator who must be an attorney with an office in ... Pennsylvania. The arbitrator shall investigate the facts and may, in his/her discretion, hold hearings at which the Resident and/or the Responsible Party may present evidence and arguments, be represented by counsel and conduct cross examination . The arbitrator shall render a written decision on the dispute as soon as practicable after her/his appointment. The arbitrator's decision, which may include equitable relief, shall be final and binding on the parties and judgment upon the decision may be entered in any court of competent jurisdiction".

Review of admission record indicated Resident R35 was admitted to the facility on December 6, 2019. Review of the quarterly Minimum Data Set (MDS- a periodic assessment of resident care needs ) dated February 15, 2024, indicated that a Brief Interview for Mental Status (BIMS) score of 15 - cognition intact.

Review of Resident R35's Binding Arbitration Agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) indicated she signed the document on admission on September 17, 2019.

Review of admission record indicated Resident R48 was admitted to the facility on June 5, 2022. Review of the quarterly Minimum Data Set (MDS- a periodic assessment of resident care needs ) dated January 30, 2024, indicated that a Brief Interview for Mental Status (BIMS) score of 15 - cognition intact.

Review of Resident R48's Binding Arbitration Agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) indicated she signed the document on admission on June 14, 2022

Review of admission record indicated Resident R93 was admitted to the facility on April 3, 2023. Review of the quarterly Minimum Data Set (MDS- a periodic assessment of resident care needs ) effective January 30, 2024, indicated that a Brief Interview for Mental Status (BIMS) score of 15 - cognition intact.

Review of Resident R93's Binding Arbitration Agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) indicated she signed the document on admission on April 3, 2023.

Review of admission record indicated Resident R113 was admitted to the facility on May 1, 2023. Review of the Minimum Data Set (MDS- a periodic assessment of resident care needs ) effective February 21, 2024, indicated that a Brief Interview for Mental Status (BIMS) score indicated 15 - cognition intact.

Review of Resident R35's Binding Arbitration Agreement a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) indicated she signed the document on admission on February 9, 2023.

On March 19, 2024, at 10:08 a.m. during entrance meeting Administrator, Employee E1 who reported that Admission Director, Employee E9 is the Lead on the Arbitration process.

On March 20, 2024, at 10:30 a.m. a Resident Council meeting was held with 13 alert and oriented Residents (R31, R4, R48, R93, R21, R27, R55, R113, R35, R78, R36, R72). Four residents (R35, R48, R93, R113,) reported facility did not explain in the language that they would understand; therefore, they would like to revoke their signature from the arbitration agreement.

On March 21, 2024, at 9:59 a.m. an interview was held with Admission Director, Employee E4, who confirmed that the arbitration agreement was missing the key elements of the arbitration "it's not a condition of admission', the right to rescind the agreement within 30 calendar days of signing, and agreement may not contain any language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials, including but not limited to federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care ombudsman.

Employee E4 also reported that she/he was not aware of the time frame to rescind the arbitration and Employee E4 would read the arbitration agreement to the Residents or Resident Representatives instead of to explain in the language that would they understand.

28 Pa. Code: 201.14(a)(c)(d)(e) Responsibility of licensee

28 Pa. Code: 201.18(e)(1) Management












 Plan of Correction - To be completed: 04/11/2024

Effective today, 4/11/2024, the Binding Arbitration agreement has been removed from our Admission Packet paperwork and will no longer be a part of it.
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 staff schedules, punch reports and interviews with staff, it was determined that the facility failed to maintain required staffing ratios, including one nurse aide per 12 residents during the day and evening shifts and one nurse aide per 20 residents during the overnight shift, on ten of twenty-one days reviewed (November 19, 22, 23, 24 and 25, 2023; January 7, 9, 10 and 13, 2024; and March 17, 2024).

Findings include:

Review of facility census data revealed that on November 19, 2023, the facility census was 135, which required 84.38 hours of nurse aides during the day shift. Review of the nursing time schedules and punch reports revealed 77.50 hours of nurse aide care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on November 22, 2023, the facility census was 134, which required 83.75 hours of nurse aides during the evening shift. Review of the nursing time schedules and punch reports revealed 69.50 hours of nurse aide care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on November 23, 2023, the facility census was 136, which required 85.00 hours of nurse aides during the day shift. Review of the nursing time schedules and punch reports revealed 83.75 hours of nurse aide care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on November 23, 2023, the facility census was 136, which required 85.00 hours of nurse aides during the evening shift. Review of the nursing time schedules and punch reports revealed 75.50 hours of nurse aide care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on November 24, 2023, the facility census was 136, which required 85.00 hours of nurse aides during the evening shift. Review of the nursing time schedules and punch reports revealed 81.00 hours of nurse aide care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on November 25, 2023, the facility census was 137, which required 85.63 hours of nurse aides during the evening shift. Review of the nursing time schedules and punch reports revealed 73.50 hours of nurse aide care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on January 7, 2024, the facility census was 134, which required 83.75 hours of nurse aides during the day shift. Review of the nursing time schedules and punch reports revealed 59.00 hours of nurse aide care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on January 7, 2024, the facility census was 134, which required 83.75 hours of nurse aides during the evening shift. Review of the nursing time schedules and punch reports revealed 66.50 hours of nurse aide care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on January 7, 2024, the facility census was 134, which required 50.25 hours of nurse aides during the overnight shift. Review of the nursing time schedules and punch reports revealed 30.25 hours of nurse aide care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on January 9, 2024, the facility census was 133, which required 83.13 hours of nurse aides during the evening shift. Review of the nursing time schedules and punch reports revealed 81.50 hours of nurse aide care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on January 9, 2024, the facility census was 133, which required 49.88 hours of nurse aides during the overnight shift. Review of the nursing time schedules and punch reports revealed 37.75 hours of nurse aide care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on January 10, 2024, the facility census was 134, which required 83.75 hours of nurse aides during the evening shift. Review of the nursing time schedules and punch reports revealed 83.00 hours of nurse aide care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on January 13, 2024, the facility census was 131, which required 49.13 hours of nurse aides during the overnight shift. Review of the nursing time schedules and punch reports revealed 45.00 hours of nurse aide care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on March 17, 2024, the facility census was 129, which required 48.38 hours of nurse aides during the overnight shift. Review of the nursing time schedules and punch reports revealed 45.50 hours of nurse aide care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Staffing calculations, nursing staff schedules and staff punch reports were reviewed with Employee E12, Payroll Coordinator, on March 22, 2024, at 12:10 p.m. Employee E12, Payroll Coordinator, confirmed that the required staffing ratios for nurse aides were not met on the above dates.




 Plan of Correction - To be completed: 04/10/2024

Nursing Services

Nursing facility will provide a PPD of 2.87 or greater of direct resident care in a 24-hour period. Audit tool was implemented for the payroll department to perform daily checks to ensure that CNA hours were met. Random audit of twenty days throughout the quarter to be performed and findings to be reported at QAPI.
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 staff schedules, punch reports and interviews with staff, it was determined that the facility failed to maintain required staffing ratios, including one LPN (Licensed Practical Nurse) per 25 residents during the day shift, one LPN per 30 residents during the evening shift, and one LPN per 40 residents during the overnight shift, on seventeen of twenty-one days reviewed (November 19, 20, 22, 23, 24 and 25, 2023; January 7, 8, 9, 10, 11 and 12, 2024; and March 16, 17, 18, 20 and 21, 2024).

Findings include:

Review of facility census data revealed that on November 19, 2023, the facility census was 135, which required 43.20 hours of LPNs during the day shift. Review of the nursing time schedules and punch reports revealed 40.75 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on November 19, 2023, the facility census was 135, which required 27.00 hours of LPNs during the overnight shift. Review of the nursing time schedules and punch reports revealed 23.00 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on November 20, 2023, the facility census was 137, which required 27.40 hours of LPNs during the overnight shift. Review of the nursing time schedules and punch reports revealed 17.25 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on November 22, 2023, the facility census was 134, which required 35.73 hours of LPNs during the evening shift. Review of the nursing time schedules and punch reports revealed 35.00 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on November 22, 2023, the facility census was 134, which required 26.80 hours of LPNs during the overnight shift. Review of the nursing time schedules and punch reports revealed 15.50 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on November 23, 2023, the facility census was 136, which required 43.52 hours of LPNs during the day shift. Review of the nursing time schedules and punch reports revealed 40.50 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on November 23, 2023, the facility census was 136, which required 36.27 hours of LPNs during the evening shift. Review of the nursing time schedules and punch reports revealed 34.25 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on November 23, 2023, the facility census was 136, which required 27.20 hours of LPNs during the overnight shift. Review of the nursing time schedules and punch reports revealed 17.75 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on November 24, 2023, the facility census was 136, which required 27.20 hours of LPNs during the overnight shift. Review of the nursing time schedules and punch reports revealed 17.25 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on November 25, 2023, the facility census was 137, which required 43.84 hours of LPNs during the day shift. Review of the nursing time schedules and punch reports revealed 36.25 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on November 25, 2023, the facility census was 137, which required 36.53 hours of LPNs during the evening shift. Review of the nursing time schedules and punch reports revealed 31.00 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on November 25, 2023, the facility census was 137, which required 27.40 hours of LPNs during the overnight shift. Review of the nursing time schedules and punch reports revealed 17.50 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on January 7, 2024, the facility census was 134, which required 42.88 hours of LPNs during the day shift. Review of the nursing time schedules and punch reports revealed 39.25 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on January 7, 2024, the facility census was 134, which required 26.80 hours of LPNs during the overnight shift. Review of the nursing time schedules and punch reports revealed 24.75 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on January 8, 2024, the facility census was 133, which required 26.60 hours of LPNs during the overnight shift. Review of the nursing time schedules and punch reports revealed 17.00 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on January 9, 2024, the facility census was 133, which required 35.47 hours of LPNs during the evening shift. Review of the nursing time schedules and punch reports revealed 29.75 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on January 9, 2024, the facility census was 133, which required 26.60 hours of LPNs during the overnight shift. Review of the nursing time schedules and punch reports revealed 19.00 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on January 10, 2024, the facility census was 134, which required 35.73 hours of LPNs during the evening shift. Review of the nursing time schedules and punch reports revealed 29.80 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on January 10, 2024, the facility census was 134, which required 26.80 hours of LPNs during the overnight shift. Review of the nursing time schedules and punch reports revealed 18.00 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on January 11, 2024, the facility census was 132, which required 35.20 hours of LPNs during the evening shift. Review of the nursing time schedules and punch reports revealed 33.75 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on January 11, 2024, the facility census was 132, which required 26.40 hours of LPNs during the overnight shift. Review of the nursing time schedules and punch reports revealed 15.50 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on January 12, 2024, the facility census was 133, which required 35.47 hours of LPNs during the evening shift. Review of the nursing time schedules and punch reports revealed 29.00 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on January 12, 2024, the facility census was 133, which required 26.60 hours of LPNs during the overnight shift. Review of the nursing time schedules and punch reports revealed 25.00 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on March 16, 2024, the facility census was 132, which required 42.24 hours of LPNs during the day shift. Review of the nursing time schedules and punch reports revealed 37.25 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on March 17, 2024, the facility census was 129, which required 25.80 hours of LPNs during the overnight shift. Review of the nursing time schedules and punch reports revealed 25.00 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on March 18, 2024, the facility census was 130, which required 26.00 hours of LPNs during the overnight shift. Review of the nursing time schedules and punch reports revealed 16.75 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on March 20, 2024, the facility census was 129, which required 25.80 hours of LPNs during the overnight shift. Review of the nursing time schedules and punch reports revealed 22.75 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data revealed that on March 21, 2024, the facility census was 131, which required 26.20 hours of LPNs during the overnight shift. Review of the nursing time schedules and punch reports revealed 24.25 hours of LPN care was provided during the shift. No additional excess higher-level staff were available to compensate this deficiency.

Staffing calculations, nursing staff schedules and staff punch reports were reviewed with Employee E12, Payroll Coordinator, on March 22, 2024, at 12:10 p.m. Employee E12, Payroll Coordinator, confirmed that the required staffing ratios for LPNs were not met on the above dates.



 Plan of Correction - To be completed: 04/10/2024

Nursing Services

Nursing facility will provide a PPD of 2.87 or greater of direct resident care in a 24-hour period. Audit tool was implemented for the payroll department to perform daily checks to ensure that LPN hours were met. Random audit of twenty days throughout the quarter to be performed and findings to be reported at QAPI.
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 nursing time schedules, punch reports and staff interviews, it was determined that the facility administrative staff failed to provide a minimum of 2.87 hours of direct nursing care per resident on ten of twenty-one days reviewed (November 19, 22, 23, 24 and 25, 2023; and January 7, 8, 9, 10 and 12, 2024).


Findings include:

Review of facility census data, punch reports and nursing time schedules revealed that on November 19, 2023, the facility census was 135, and a total of 364.25 direct nursing staff hours were provided, which equaled 2.698 hours of direct nursing care per resident.

Review of facility census data, punch reports and nursing time schedules revealed that on November 22, 2023, the facility census was 134, and a total of 371.25 direct nursing staff hours were provided, which equaled 2.770 hours of direct nursing care per resident.

Review of facility census data, punch reports and nursing time schedules revealed that on November 23, 2023, the facility census was 136, and a total of 335.00 direct nursing staff hours were provided, which equaled 2.463 hours of direct nursing care per resident.

Review of facility census data, punch reports and nursing time schedules revealed that on November 24, 2023, the facility census was 136, and a total of 360.50 direct nursing staff hours were provided, which equaled 2.650 hours of direct nursing care per resident.

Review of facility census data, punch reports and nursing time schedules revealed that on November 25, 2023, the facility census was 137, and a total of 343.25 direct nursing staff hours were provided, which equaled 2.505 hours of direct nursing care per resident.

Review of facility census data, punch reports and nursing time schedules revealed that on January 7, 2024, the facility census was 134, and a total of 285.75 direct nursing staff hours were provided, which equaled 2.132 hours of direct nursing care per resident.

Review of facility census data, punch reports and nursing time schedules revealed that on January 8, 2024, the facility census was 133, and a total of 369.25 direct nursing staff hours were provided, which equaled 2.776 hours of direct nursing care per resident.

Review of facility census data, punch reports and nursing time schedules revealed that on January 9, 2024, the facility census was 133, and a total of 366.5 direct nursing staff hours were provided, which equaled 2.755 hours of direct nursing care per resident.

Review of facility census data, punch reports and nursing time schedules revealed that on January 10, 2024, the facility census was 134, and a total of 364.05 direct nursing staff hours were provided, which equaled 2.716 hours of direct nursing care per resident.

Review of facility census data, punch reports and nursing time schedules revealed that on January 12, 2024, the facility census was 133, and a total of 380.75 direct nursing staff hours were provided, which equaled 2.862 hours of direct nursing care per resident.

Staffing calculations, nursing staff schedules and staff punch reports were reviewed with Employee E12, Payroll Coordinator, on March 22, 2024, at 12:10 p.m. Employee E12, Payroll Coordinator, confirmed that the required staffing minimum of 2.87 hours of direct nursing care per resident was not met on the above dates.



 Plan of Correction - To be completed: 04/10/2024

Nursing Services
Nursing facility will provide a PPD of 2.87 or greater of direct resident care in a 24-hour
period. Audit tool was implemented for the payroll department to perform daily checks to ensure that PPD was met. Random audit of twenty days throughout the quarter to be performed and findings to be reported at QAPI

Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port