Pennsylvania Department of Health
EMBASSY OF SAXONBURG
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

EMBASSY OF SAXONBURG
Inspection Results For:

There are 123 surveys for this facility. Please select a date to view the survey results.

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EMBASSY OF SAXONBURG - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Survey in response to four complaints, and an incident completed on February 19, 2026, it was determined that Embassy of Saxonburg was not in compliance with the following 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.

Plan of Correction:

483.75(a)(1)-(4)(b)(1)-(4)(f)(1)-(6)(h)(i) REQUIREMENT QAPI Prgm/Plan, Disclosure/Good Faith Attmpt:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.

§483.75(a) Quality assurance and performance improvement (QAPI) program.
Each LTC facility, including a facility that is part of a multiunit chain, must develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility must:

§483.75(a)(1) Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements of this section. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities;

§483.75(a)(2) Present its QAPI plan to the State Survey Agency no later than 1 year after the promulgation of this regulation;

§483.75(a)(3) Present its QAPI plan to a State Survey Agency or Federal surveyor at each annual recertification survey and upon request during any other survey and to CMS upon request; and

§483.75(a)(4) Present documentation and evidence of its ongoing QAPI program's implementation and the facility's compliance with requirements to a State Survey Agency, Federal surveyor or CMS upon request.

§483.75(b) Program design and scope.
A facility must design its QAPI program to be ongoing, comprehensive, and to address the full range of care and services provided by the facility. It must:

§483.75(b)(1) Address all systems of care and management practices;

§483.75(b)(2) Include clinical care, quality of life, and resident choice;

§483.75(b)(3) Utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents of a SNF or NF.

§483.75(b) (4) Reflect the complexities, unique care, and services that the facility provides.

§483.75(f) Governance and leadership.
The governing body and/or executive leadership (or organized group or individual who assumes full legal authority and responsibility for operation of the facility) is responsible and accountable for ensuring that:

§483.75(f)(1) An ongoing QAPI program is defined, implemented, and maintained and addresses identified priorities.

§483.75(f)(2) The QAPI program is sustained during transitions in leadership and staffing;
§483.75(f)(3) The QAPI program is adequately resourced, including ensuring staff time, equipment, and technical training as needed;

§483.75(f)(4) The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information.

§483.75(f)(5) Corrective actions address gaps in systems, and are evaluated for effectiveness; and

§483.75(f)(6) Clear expectations are set around safety, quality, rights, choice, and respect.

§483.75(h) Disclosure of information.
A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section.

§483.75(i) Sanctions.
Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

Observations:

Based on a review of the facility's plan of correction, documents and staff interviews it was determined that the facility failed to make a good faith effort to correct and sustain improvement for one of two citations issued for failure to provide the required number of Nurse Aides (NA) per resident per shift as required (Citation P5520).

Findings include:

A review of the facility's plan of correction revealed the following:

Administrator and Director of Nursing (DON) educated by Regional Director of Clinical Operations on 1.19.26 on required state Certified Nursing Assistant ratios.

In an attempt to achieve appropriate staffing ratios the facility has implemented a daily assignment grid that designates the required Certified Nursing Assistant ratios to meet state requirements. Assignment grids will be reviewed during labor meetings no less than 3x a week for 3 weeks.

When a call off is received the supervisor will make every effort to fully replace hours. In the event it cannot be covered, the Director of Nursing will be notified so Administrative staff can reach out to employees for coverage.

The facility will continue with recruitment and retention efforts to include enforcing the attendance policy.

The facility will monitor staffing ratios utilizing the DOH staffing calculator tool 3x a week for 3 weeks. The results will be reviewed in future QAPI meetings to determine further need of audits.
A review of facility-provided documents revealed the Nursing Home Administrator (NHA) and Director of Nursing (DON) received in-service education on 1/20/26, regarding the required state Certified Nurse Aide ratios. The provided documentation failed to include the assignment grids that were to be reviewed during labor meetings three times a week for three weeks.

A review of the facility's staffing worksheet completed for 1/29/26, through 2/3/26, revealed that the facility was using an outdated staffing hours calculator that does not reflect current NA ratio regulations.

During an interview on 2/19/26, at 10:57 a.m. the NHA confirmed that the facility was mistakenly using a staffing data calculator intended for outdated staffing regulations.

A review of the facility's staffing worksheet, completed using the current staffing hours calculator, revealed that the facility failed to improve and sustain improvement regarding staffing ratios for NAs. It was determined that for the time period of 1/25/26, through 2/13/26, the facility failed to provide staffing to provide care to residents for 40 of 63 shifts for the NA position.

During an interview on 2/19/26, at 4:06 p.m. information was disseminated to the NHA and DON that the facility failed to make a good faith effort to correct and sustain improvement for one of two citations issued for failure to provide the required number of Nurse Aides (NA) per resident per shift as required (Citation P5520).

28 Pa. Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1) Management.
28 Pa. Code: 211.12(d)(1)(2)(3)(4)(f.1)(i)(2) Nursing services.

Plan of Correction - To be completed: 03/14/2026

No adverse effects were noted as a result of this citation. The facility will make a good faith effort to sustain improvements for any plans of corrections.

Administrator/Director of Nursing will be educated by the Regional Director of Clinical Operations by 3.4.26 on QAPI purpose, expectations, and regulations. The correct DOH staffing tool has been provided to the facility.
No less than twice a week,

Administrator/DON will review current QAPI standards as they relate to staffing trends and the staffing plan of correction, with the Regional Director of Clinical Operations and the Regional Director of Operations, beginning 3.4.26
Ad Hoc QAPI will be held on 3.04.26 with

Administrator, Director of Nursing, available Interdisciplinary Team members, and the Regional Director of Clinical Operations will be present to audit the process.

Monthly QAPI will be held by 3.18.26 and the Regional Director of Clinical Operations will be present to audit the process.

Staffing has been added to the QAPI agenda and will be reviewed monthly for the next 3 months, including tracking and trending.

The facility will continue with recruitment and retention efforts to include the enforcement of the attendance policy.

QAPI committee will continue to review to determine further need.

§483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff:

This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.

§483.35 Nursing Services.

The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71.

§483.35(a) Sufficient Staff.

§483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:

(i) Except when waived under paragraph (e) of this section, licensed nurses; and

(ii) Other nursing personnel, including but not limited to nurse aides.

§483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.

Observations:

Based on review of facility policy, resident observations, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of five of six residents (Residents R2, R3, R4, R5, and R6).

Findings include:

Review of facility policy "Activities of Daily Living (ADLs)" dated 1/15/26, indicated care and services will be provided for the following activities of daily living: bathing, dressing, grooming, and oral care; transfer and ambulation; toileting; eating to include meals and snacks, and using speech, language or other functional communication systems. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Review of facility policy "Activities" dated 1/15/26, indicated it is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. All staff will assist residents to and from activities when necessary. The facility will consider accommodations in schedules, supplies and timing in order to optimize a resident's ability to participate in an activity of choice.

During an interview on 2/19/26, at 11:09 a.m. Resident R2 stated, "Things are not good at all. There is no staff, mostly the aides. We go to Bingo every Monday, Wednesday, and Saturday and we haven't been there for a week because there's no staff on the 2 p.m. to 10 p.m. shift to get us back into bed. We don't get up out of bed at all sometimes because there is not enough staff to get us back to bed. If there aren't enough staff on the day shift, I don't get my shower. I'll put my call light on and sometimes it can take up to an hour for someone to answer it. It has been really bad lately. The Activities Director has come in and said we aren't having Bingo today because we don't have enough staff on 2 p.m. to 10 p.m. shift to put residents back to bed."

During an interview on 2/19/26, at 11:29 a.m. Resident R3 stated, "I think if you ask any resident here, they'll all tell you the same thing. We don't get out of bed now, maybe that will change if we get more staff. They have cancelled activities because there aren't enough staff. I've missed some of my showers, they tell me they can't do it on my shower days because there aren't enough staff."

During an interview on 2/19/26, at 1:28 p.m. Resident R4 stated, "They are running a little short-handed. Sometimes it takes up to 30 minutes to answer my call bell. I think they did once cancel an activity due to not having enough staff."

During an interview on 2/19/26, at 1:34 p.m. Resident R5 stated, "Activities are being cancelled due to not having enough staff. We haven't had Bingo since last week. We haven't been able to go down to the dining room to eat on-and-off because there aren't enough staff to supervise and help the people who need it. Staff have told me we can't go to the dining room because there aren't enough staff for the shift. It has been happening since the end of January; people are not coming out to work. I like to play cards with Resident R2, but if there aren't enough staff to get Resident R2 out of bed, we can't play cards."

During an interview on 2/19/26, at 1:50 p.m. Resident R6 stated, "Things are terrible. There are not enough staff, especially the aides. Staff say they can't give showers because we don't have enough help. It makes me so frustrated."

During an interview on 2/19/26 at 4:06 p.m. the Nursing Home Administrator confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of five of six residents (Residents R2, R3, R4, R5, and R6).

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(6) Management.
28 Pa. Code: 211.12(d)(1)(2)(3)(4)(f.1)(i)(2) Nursing services.

Plan of Correction - To be completed: 03/14/2026

R2, R3, R4, R5, and R6 showed adverse outcomes as a result of this occurrence.

Administrator/designee to meet with these residents to ensure they have no outstanding needs that can be addressed by 3.4.26.

Director of Nursing /Administrator educated as to the staffing guidelines and importance of providing care to meet the needs of the residents by the Regional Director of Clinical Operations by 3.4.26.

Director of Nursing/Administrator will educate all Interdisciplinary Team and direct care staff on staffing guidelines and the importance of providing care to meet the needs of the residents; to include, but not limited to showers, call light response time, getting out of bed, Activities of Daily Living (ADLs) assistance and providing activities as scheduled by 3.4.26. Audits will be completed 3 x a week x 3 weeks to ensure all provisions of care/showers/getting out of bed are completed.

Director of Nursing/Administrator will interview 3-5 residents 3x a week x 3 weeks to ensure all needs are met and care provided.

Results will be reviewed by QAPI to determine further need for audits.

483.25 REQUIREMENT Quality of Care:

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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that a resident received neurological assessments after an incident involving a fall for one of five residents (Resident R1).

Findings include:

Review of facility policy "Fall Prevention and Management" dated 1/15/26, indicated in the event of a fall, the resident will be assessed by a Licensed Nurse, the Physician/Nurse Practitioner and Responsible Party will be notified and an intervention(s) aimed to prevent further falls will be implemented. Details of the fall will be gathered and documentation completed as indicated.

Review of the clinical record revealed Resident R1 was admitted to the facility on 1/18/19.

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/20/26, indicated diagnoses of high blood pressure, seizure disorder, and hyponatremia (low levels of sodium in the blood).

Review of a nursing progress note dated 1/18/26, stated, "At 1615 (4:15 p.m.) LPN (Licensed Practical Nurse) floor nurse notified writer that resident was on the floor in his room in front of his bed sitting on his buttocks. Resident was laughing at the situation. Walker was on the floor on it's side. Wheelchair was bedside resident. Resident denies pain or discomfort. ROM (range of motion) was completed and wnl (within normal limits). No apparent injuries. VSS (vital signs stable). VS: 97.9 (temperature) - 113/74 (blood pressure) - 89 (heart rate) - 18 (respirations) - 98% on RA (oxygen saturation on room air). Resident was redirected to ring his call bell and not attempt to stand up and self-transfer himself. Resident was transferred per orders back into his wheelchair. Sister was notified. Director of Nursing and physician were notified. Neuro checks (neurological assessment) initiated per facility protocol. All appropriate paperwork was completed. Resident is in his wheelchair eating his supper in his room. Call bell within reach and safety measures in place."

Review of a "72-Hour Neurological Assessment Sheet" indicated this assessment should be completed at the following intervals for follow up for all falls. A fall that is unwitnessed, or in which the head is struck, requires neurological checks. Any chang in resident condition requires a phone call to the primary care physician. Initial assessment, followed by every 15 minutes x 4, every 30 minutes x 4, every hour x 2, once per shift for 72 hours.

Review of Resident R1's "72-Hour Neurological Assessment Sheet" dated 1/18/26, indicated only eight neurological checks were completed out of 18 opportunities.

During an interview on 2/19/26, at 4:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to ensure that a resident received neurological assessments after an incident involving a fall for one of five residents (Resident R1)

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 03/14/2026

R1 had no adverse outcome as a result of this occurrence.
Regional Director of Clinical Operations educated Director of Nursing on 3.4.26 on the fall policy to include obtaining neurological assessments.

Director of Nursing/Designee will educate all nursing staff by 3.4.26 on the fall policy to include obtaining neurological assessments.

Falls will be reviewed by Director of Nursing/designee 3x a week x3 weeks to ensure neurological assessments are obtained.

Results will be reviewed by QAPI to determine further need for audits.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(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 review of nursing time schedules and staff interviews, it was determined that the facility administrative staff failed to provide a minimum of one nurse aide (NA) per 10 residents during the day shift for 12 of 21 days (1/25/26, 1/26/26, 1/27/26, 1/28/26, 1/30/26, 2/2/26, 2/8/26, 2/9/26, 2/10/26, 2/12/26, 2/13/26, and 2/14/26), one nurse aide per 11 residents on evening shift for 16 of 21 days (1/26/26, 1/28/26, 1/29/26, 1/30/26, 2/2/26, 2/3/26, 2/4/26, 2/6/26, 2/7/26, 2/8/26, 2/9/26, 2/10/26, 2/11/26, 2/12/26, 2/13/26, and 2/14/26), and one nurse aide per 15 residents on night shift, on 17 of 21 days (1/25/26, 1/26/26, 1/27/26, 1/28/26, 1/29/26, 1/30/26, 1/31/26, 2/2/26, 2/3/26, 2/4/26, 2/6/26, 2/8/26, 2/9/26, 2/10/26, 2/11/26, 2/12/26, and 2/13/26).

Findings include:

Review of facility census data and nursing time schedules from 1/25/26 through 2/14/26, revealed the following NA staffing shortages:

Day Shift:

1/25/26, Census 52, 4.13 Full-Time Equivalents (FTEs) present, 5.20 FTEs required.
1/26/26, Census 52, 4.97 FTEs present, 5.20 FTEs required.
1/27/26, Census 52, 4.32 FTEs present, 5.20 FTEs required.
1/28/26, Census 57, 5.06 FTEs present, 5.70 FTEs required.
1/30/26, Census 51, 4.74 FTEs present, 5.10 FTEs required.
2/2/26, Census 50, 4.94 FTEs present, 5.00 FTEs required.
2/8/26, Census 55, 5.26 FTEs present, 5.50 FTEs required.
2/9/26, Census 56, 4.58 FTEs present, 5.60 FTEs required.
2/10/26, Census 57, 5.06 FTEs present, 5.70 FTEs required.
2/12/26, Census 57, 4.65 FTEs present, 5.70 FTEs required.
2/13/26, Census 57, 4.84 FTEs present, 5.70 FTEs required.
2/14/26, Census 57, 4.90 FTEs present, 5.70 FTEs required.

Evening Shift:

1/26/26, Census 52, 4.39 FTEs present, 4.73 FTEs required.
1/28/26, Census 56, 4.26 FTEs present, 5.09 FTEs required.
1/29/26, Census 52, 4.32 FTEs present, 4.73 FTEs required.
1/30/26, Census 51, 4.26 FTEs present, 4.64 FTEs required.
2/2/26, Census 51, 4.42 FTEs present, 4.64 FTEs required.
2/3/26, Census 50, 4.35 FTEs present, 4.55 FTEs required.
2/4/26, Census 49, 4.03 FTEs present, 4.45 FTEs required.
2/6/26, Census 51, 4.23 FTEs present, 4.64 FTEs required.
2/7/26, Census 55, 4.84 FTEs present, 5.00 FTEs required.
2/8/26, Census 56, 4.61 FTEs present, 5.09 FTEs required.
2/9/26, Census 57, 4.61 FTEs present, 5.18 FTEs required.
2/10/26, Census 58, 4.68 FTEs present, 5.27 FTEs required.
2/11/26, Census 57, 4.77 FTEs present, 5.18 FTEs required.
2/12/26, Census 57, 4.77 FTEs present, 5.18 FTEs required.
2/13/26, Census 57, 4.87 FTEs present, 5.18 FTEs required.
2/14/26, Census 58, 4.84 FTEs present, 5.27 FTEs required.

Night Shift:

1/25/26, Census 52, 2.06 FTEs present, 3.47 FTEs required.
1/26/26, Census 52, 2.55 FTEs present, 3.47 FTEs required.
1/27/26, Census 52, 2.45 FTEs present, 3.47 FTEs required.
1/28/26, Census 56, 3.00 FTEs present, 3.73 FTEs required.
1/29/26, Census 51, 2.97 FTEs present, 3.40 FTEs required.
1/30/26, Census 51, 3.13 FTEs present, 3.40 FTEs required
1/31/26, Census 50, 2.94 FTEs present, 3.33 FTEs required.
2/2/26, Census 51, 3.00 FTEs present, 3.40 FTEs required.
2/3/26, Census 50, 3.03 FTEs present, 3.33 FTEs required.
2/4/26, Census 49, 2.81 FTEs present, 3.27 FTEs required.
2/6/26, Census 51, 2.94 FTEs preset, 3.40 FTEs required.
2/8/26, Census 56, 3.03 FTEs present, 3.73 FTEs required.
2/9/26, Census 57, 2.90 FTEs present, 3.80 FTEs required.
2/10/26, Census 58, 2.87 FTEs present, 3.87 FTEs required.
2/11/26, Census 57, 2.99 FTEs present, 3.80 FTEs required.
2/12/26, Census 57, 2.97 FTEs present, 3.80 FTEs required.
2/13/26, Census 57, 2.97 FTEs present, 3.80 FTEs required.

During an interview on 2/19/26, at 10:57 a.m. the Nursing Home Administrator (NHA) confirmed that the facility was mistakenly using a staffing data calculator intended for outdated staffing regulations. Due to using the outdated staffing data calculator, the facility was unaware that they were not in compliance with current regulations regarding staffing ratios.

During an interview on 2/19/26, at 4:06 p.m. the NHA confirmed that the facility failed to provide a minimum of one nurse aide per 10 residents during the day shift, one nurse aide per 11 residents on evening shift, and one nurse aide per 15 residents on night shift as required with no additional excess higher-level staff to compensate this deficiency.

Plan of Correction - To be completed: 03/14/2026

Administrator and Director of Nursing, educated by Regional Director of Clinical Operations by 3.4.26 on required state Certified Nursing Assistant ratios.

In an attempt to achieve appropriate staffing ratios, the facility has implemented a daily assignment grid that designates the required Certified Nursing assistant ratios needed to meet state requirements. Assignment grids will be reviewed during labor meetings no less than 3x per week for 3 weeks.
When a call off is received, the nursing supervisor will make every effort to fully replace staff hours. In the event it cannot be covered, the Director of Nursing will be notified so that administrative staff can reach out to employees for coverage. Administrative coverage will be obtained should we not find staff coverage.

The facility will continue with recruitment and retention efforts to include enforcing the attendance policy.
The facility will monitor staffing ratios utilizing the DOH Staffing Calculator tool 3x per week for 3 weeks. The results will be reviewed in future QAPI meetings to determine further need for audits.

§ 211.12(i)(2) LICENSURE Nursing services.:

(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 review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24 hour period on ten of 21 days (1/25/26, 1/26/26, 1/28/26, 2/8/26, 2/9/26, 2/10/26, 2/11/26, 2/12/26, 2/13/26, and 2/14/26).

Findings include:

Review of facility census data and nursing time schedules 1/25/26 through 2/14/26, revealed that the facility failed to maintain 3.20 hours of general nursing care (PPD) to each resident in a 24-hour period on the following dates:

1/25/26, Census 52, PPD 3.10
1/26/26, Census 52, PPD 3.12
1/28/26, Census 57, PPD 3.07
2/8/26, Census 56, PPD 3.17
2/9/26, Census 57, PPD 2.95
2/10/26, Census 58, PPD 3.13
2/11/26, Census 58, PPD 3.17
2/12/26, Census 57, PPD 3.03
2/13/26, Census 57, PPD 3.04
2/14/26, Census 58, PPD 3.13

During an interview on 2/19/26, at 10:57 a.m. the Nursing Home Administrator (NHA) confirmed that the facility was mistakenly using a staffing data calculator intended for outdated staffing regulations. Due to using the outdated staffing data calculator, the facility was unaware that they were not in compliance with current regulations regarding staffing ratios.

During an interview on 2/19/26, at 4:06 p.m. the NHA confirmed that the facility failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on ten of 21 days as required.

Plan of Correction - To be completed: 03/14/2026

Administrator and Director of Nursing, educated by Regional Director of Clinical Operations by 3.4.26 on required state PPD.

In an attempt to achieve appropriate PPD, the facility has implemented a daily assignment grid that designates the required PPD needed to meet state requirements. Assignment grids will be reviewed during labor meetings no less than 3x per week for 3 weeks.

When a call off is received, the nursing supervisor will make every effort to fully replace staff hours. In the event it cannot be covered, the Director of Nursing will be notified so that administrative staff can reach out to employees for coverage. Administrative coverage will be obtained should we not find staff coverage.

The facility will continue with recruitment and retention efforts to include enforcing the attendance policy.

The facility will monitor PPD utilizing the DOH Staffing Calculator tool 3x per week for 3 weeks. The results will be reviewed in future QAPI meetings to determine further need for audits.

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