Pennsylvania Department of Health
LOCK HAVEN REHABILITATION AND SENIOR LIVING
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

LOCK HAVEN REHABILITATION AND SENIOR LIVING
Inspection Results For:

There are 83 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.


LOCK HAVEN REHABILITATION AND SENIOR LIVING - 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 June 10, 2024, it was determined that Lock Haven Rehabilitation and Senior Living 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 as they relate to the Health portion of the survey process.

Plan of Correction:

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

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(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based on observation and resident and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and orderly environment on two of four nursing units (Unit 3 and 4; Residents 3, 5, 6, and 7).

Findings include:

Observation of the facility on June 10, 2024, revealed concerns upon entry to Unit 4 at 3:42 PM. There was a faint underlying smell of urine with the urine smell becoming more notable/strong when nearing Resident 6's room and continued to Resident 5 and 7's room. Upon entering Resident 5 and 7's room a strong smell of urine was noted. When Resident 7 self-propelled into the room while speaking with Resident 5, the urine smell intensified. Undetermined spots and stains were noted in front of Resident 5's bed and to the right of Resident 7's recliner.

Interview with Resident 5 and her roommate Resident 7 on June 10, 2024, at 3:43 PM acknowledged their floor had unknown spots and stains that were "sticky." Resident 5 revealed their floors "aren't mopped/cleaned very often."

Interview with Resident 3 and her roommate Resident 4 on June 10, 2024, at 4:18 PM revealed concerns with cleanliness and odors in the facility. Resident 3 indicated that her floor had not been cleaned in a week and was "filthy" until she "threw a fit today" and staff "finally cleaned it." Resident 3 revealed that she has a disease that causes her to have difficulty controlling her muscles therefore she spills food and/or drinks when she eats, which fall on the floor. Staff don't pick it/wipe it up timely. Concurrent observation of Resident 3 and 4's room revealed a few small stains on the floor around Resident 3's wheelchair.

The surveyor reviewed the above information during an interview with the Nursing Home Administrator on June 10, 2024, at 5:30 PM.

483.10(i)(1)-(7) Safe/clean/comfortable/homelike Environment
Previously cited 11/3/23

28 Pa. Code 201.18(b)(3) Management

28 Pa. Code 207.2(a) Administrator's responsibility

Plan of Correction - To be completed: 07/05/2024

The corrections set forth in this document do not constitute admission or agreement by the provider of the true facts alleged, or the conclusions set forth, in the statement of deficiencies. The plan of correction is prepared solely because it is required by provisions of Federal and State law.

The rooms of residents 3, 4, 5, 6 and 7 were deep cleaned.

All residents have the potential to be affected.

Cleaning checklists and staff reminder sheets will be reviewed and revised as necessary.

The list of rooms that may require more frequent cleaning than once daily has been reviewed and updated.

All housekeeping staff will be reeducated regarding the proper procedures for daily cleaning and deep cleaning of resident's rooms.

The Administrator or designee will randomly check for cleanliness 10 resident rooms and one shower/tub room per week for 4 weeks then monthly for 3 months. Results of the audits will be shared with the facility Quality Assurance Committee for review and additional follow up, if necessary.

§ 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.

Plan of Correction - To be completed: 07/05/2024

The Administrator, nursing leadership and nursing scheduler meet daily to review future schedules, troubleshoot areas of concern and discuss possible solutions for any days/shifts that do not meet the required staffing ratios.

Schedule adjustments will be made as needed via schedule changes, utilizing temporary agency staff, offering bonuses, and utilizing administrative nursing staff.

Facility Administration will meet weekly via phone with the Regional Administrator to review recent hires, terminations and employee recruitment efforts and plan future recruitment and retention events.

The Director of Nursing or designee will reeducate the Nursing Scheduler and Nursing Supervisors regarding the need to maintain staffing ratios each shift.

The Administrator or designee will audit the daily staffing schedule to ensure there are adequate staffing ratios weekly x 4, then monthly x 3 months. Results of the audits will be submitted to the Quality Assurance Committee.

§ 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.

Observations:

Based on a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide per 12 residents during the day on one of 21 day shifts reviewed; a minimum of one nurse aide per 12 residents on three of 21 evening shifts reviewed; and failed to ensure a minimum of one nurse aide per 20 residents on two of 21 overnight shifts reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed the following nurse aides (NA) scheduled for the resident census:

Day shift:

May 19, 2024, 10.7 NAs for a census of 134, requires 11.17 NAs.

Evening shift:
.
May 21, 2024, 10.9 NAs for a census of 131, requires 10.92 NAs.

June 6, 2024, 10.5 NAs for a census of 128, requires 10.67 NAs.
June 7, 2024, 10.3 NAs for a census of 129, requires 10.75 NAs.

Overnight shift:

May 19, 2024, 6.3 NAs for a census of 134, requires 6.7 NAs.

June 7, 2024, 5.2 NAs for a census of 129, requires 6.45 NAs.

This surveyor reviewed this information during an interview with the Nursing Home Administrator on June 10, 2024, at 3:25 PM.

Plan of Correction - To be completed: 07/05/2024

The Administrator, nursing leadership and nursing scheduler meet daily to review future schedules, troubleshoot areas of concern and discuss possible solutions for any days/shifts that do not meet the required staffing ratios.

Schedule adjustments will be made as needed via schedule changes, utilizing temporary agency staff, offering bonuses, and utilizing administrative nursing staff.

Facility Administration will meet weekly via phone with the Regional Administrator to review recent hires, terminations and employee recruitment efforts and plan future recruitment and retention events.

The Director of Nursing or designee will reeducate the Nursing Scheduler and Nursing Supervisors regarding the need to maintain staffing ratios each shift.

The Administrator or designee will audit the staffing schedule daily to ensure there are adequate staffing ratios weekly x 4, then monthly x 3 months. Results of the audits will be submitted to the Quality Assurance Committee.

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