Pennsylvania Department of Health
WILLIAM PENN NURSING AND REHAB
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WILLIAM PENN NURSING AND REHAB
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.


WILLIAM PENN NURSING AND REHAB - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, Civil Rights Compliance Survey, and an Abbreviated Survey to investigate a Complaint, completed on May 9, 2025, it was determined that William Penn Nursing and Rehab 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 Regulation as they relate to the Health portion of the survey process.

Plan of Correction:

483.20(g) REQUIREMENT Accuracy of Assessments:

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.

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected residents' status for six of 26 residents reviewed (Residents 4, 14, 20, 71, 75, and 81).

Findings include:

Clinical record review for Resident 75 revealed a Quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated February 2, 2025. The facility staff assessed the resident as taking an anticoagulant (a medication that prevents or reduces clotting time of the blood).

Further clinical record review revealed no evidence that Resident 75 was on an anticoagulant.

An interview with Employee 2, registered nurse assessment coordinator (RNAC), on May 7, 2025, at 10:50 AM confirmed that Resident 75 was not on an anticoagulant during the assessment period, and this was marked in error on the MDS.

The Nursing Home Administrator and Director of Nursing were informed of the above findings during a meeting on May 7, 2025, at 2:00 PM.

Clinical record review for Resident 4 revealed a quarterly MDS dated February 11, 2025. The facility staff assessed the resident as having used a limb restraint when in a chair less than daily.

Interview with Employee 2, RNAC, on May 7, 2025, at 9:20 AM revealed that Resident 4 never utilized a limb restraint, and this was an MDS coding error.

Clinical record review for Resident 20 revealed a quarterly MDS dated March 4, 2025. The facility staff assessed the resident as having an impairment of both of her lower extremities.

Clinical record review for Resident 71 revealed an annual MDS dated February 16, 2025. The facility staff assessed her as having an impairment of her bilateral lower extremities.

Interview with Employee 6, RNAC, on May 9, 2025, at 12:10 PM revealed that Residents 20 and 71 do not have an impairment of their bilateral lower extremities, and this was marked in error on the MDS.

The Director of Nursing was made aware of the concerns with Resident 20 and 71's MDS coding concerns on May 9, 2025, at 12:15 PM.

Clinical record review for Resident 14 revealed a quarterly MDS dated March 13, 2025. The facility staff assessed the resident as having used a trunk restraint in a chair or out of bed, less than daily.

Clinical record review for Resident 81 revealed a quarterly MDS dated March 12, 2025. The facility staff assessed the resident as having used a trunk restraint in a chair or out of bed, less than daily.

Interview with Employee 2 on May 7, 2025, at 9:06 AM revealed that Residents 14 and 81 never utilized a trunk restraint and that this was an MDS coding error.

The Director of Nursing was made aware of the concerns with Residents 14 and 81 MDS coding concerns on May 9, 2025, at 12:16 PM.

483.20(g) Accuracy of Assessments
Previously cited 6/25/2024

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 06/10/2025

Resident 4 – MDS modified for P0100F
Resident 14 and 81 – MDS modified for P0100E
Resident 20 and 71 – MDS modified for GG0115B
Resident 75 – MDS modified for N0415E

Registered Nurse Assessment Coordinator and/or Designee will complete a whole house audit of MDS items: GG0115B. N0415E, P0100E, and P0100F of the last submitted MDS.

The Regional Director of Clinical Reimbursement will educate the RNACs on completion of MDS Items: GG0115B. N0415E, P0100E, and P0100F.

Registered Nurse Assessment Coordinator and/or Designee will complete weekly random audits of MDS Items: GG0115B. N0415E, P0100E, and P0100F for 5 MDSs x 4 weeks.

Audits will be reviewed by the Quality Assessment Performance Improvement Committee monthly for further recommendations or systematic changes for 3 months.

483.80(d)(3)(i)-(vii) REQUIREMENT COVID-19 Immunization:

§483.80(d) (3) COVID-19 immunizations. The LTC facility must develop and implement policies and procedures to ensure all the following:
(i) When COVID-19 vaccine is available to the facility, each resident and staff member
is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized;
(ii) Before offering COVID-19 vaccine, all staff members are provided with education
regarding the benefits and risks and potential side effects associated with the vaccine;
(iii) Before offering COVID-19 vaccine, each resident or the resident representative
receives education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine;
(iv) In situations where COVID-19 vaccination requires multiple doses, the resident,
resident representative, or staff member is provided with current information regarding those additional doses, including any changes in the benefits or risks and potential side effects associated with the COVID-19 vaccine, before requesting consent for administration of any additional doses;
(v) The resident, resident representative, or staff member has the opportunity to accept or refuse a COVID-19 vaccine, and change their decision;
(vi) The resident's medical record includes documentation that indicates, at a minimum,
the following:
(A) That the resident or resident representative was provided education regarding the
benefits and potential risks associated with COVID-19 vaccine; and
(B) Each dose of COVID-19 vaccine administered to the resident; or
(C) If the resident did not receive the COVID-19 vaccine due to medical
contraindications or refusal; and
(vii) The facility maintains documentation related to staff COVID-19 vaccination that
includes at a minimum, the following:
(A) That staff were provided education regarding the benefits and potential risks
associated with COVID-19 vaccine;
(B) Staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; and
(C) The COVID-19 vaccine status of staff and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).

Observations:

Based on staff interview, it was determined that the facility failed to maintain COVID-19 vaccine status of staff and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network for one of one staff reviewed (Employee 3).

Findings include:

The surveyor requested information regarding the COVID-19 vaccination status for the facility's current employees during an interview with Employee 4 (Registered Nurse, Infection Preventionist), on May 9, 2025, at 11:00 AM. Employee 4 indicated that she has not been tracking vaccination status for staff. She also indicated that she had no evidence of offering COVID-19 vaccinations to staff because they do not ask each staff member individually as they post a sign by the time clock and in the employee breakroom indicating that if staff were interested in receiving a vaccine that they need to visit their primary care physician or local pharmacy.

The Nursing Home Administrator and Director of Nursing were made aware of concerns related to staff COVID-19 vaccinations on May 9, 2025, at 11:35 AM.

28 Pa. Code 211.5(f)(i)-(xi) Medical records

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 06/10/2025

Audit of 152 staff members completed to determine if each staff members Covid 19 vaccination status is indicated on the Covid 19 Vaccination Matrix.

Staff members Covid 19 vaccination status has been recorded on the Covid 19 Vaccination Matrix.

The Director of Human Resources will obtain new hire Covid vaccine acceptance, declination or record of current vaccine form at on-boarding orientation.
The Infection Preventionist, or designee, will receive new hire Covid vaccine acceptance, declination or record of current vaccine forms from the Director of Human Resources at time of hire.
The Covid 19 Staff Vaccination Matrix will be updated by the Infection Preventionist with each new hire and as new Covid vaccines are received.
The Infection Preventionist will obtain new acceptance, declination or record of current vaccine from staff as an updated Covid vaccine is available.
In-service signed by Infection Preventionist and Director of Human Resources.

Weekly audits will be completed by the Infection Preventionist to verify Covid 19 vaccination status is obtained/current for staff members. Nursing Home Administrator (NHA) or designee will review audits.

483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs:

§483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

§483.55(b) Nursing Facilities.
The facility-

§483.55(b)(1) Must provide or obtain from an outside resource, in accordance with §483.70(f) of this part, the following dental services to meet the needs of each resident:
(i) Routine dental services (to the extent covered under the State plan); and
(ii) Emergency dental services;

§483.55(b)(2) Must, if necessary or if requested, assist the resident-
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services locations;

§483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay;

§483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and

§483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.

Plan of Correction - To be completed: 06/10/2025

Resident 34 will see dental hygienist June 5 at the facility for routine cleaning, resident 50 will see dental hygienist June 5 at the facility for routine cleaning, resident 95 will see dental hygienist June 5 at the facility for routine cleaning, resident 4 is declining in health and family does not want her seen at this time and she is not having any dental issues , resident 20 resident and daughter are refusing dental care. Resident is not having any dental issues and does not want to be seen unless she has issues, resident 37 will see dental hygienist May 19 at the LIFE Geisinger center for routine cleaning. Resident 71 was seen 515 and has a follow up for teeth extraction.

An audit will be completed on all residents for dental services.

In-service education programs were conducted separately with licensed staff by the Director of Nursing Services (DON) or designee. Proper procedures for offering routine dental care as well as dental care and issues.

Nursing Home Administrator (NHA), or designee, will conduct weekly audits on new admissions.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations:
Based on review of select facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide dignity regarding covering urinary catheter bags for one of one resident reviewed for catheters (Resident 87).

Findings include:

Clinical record review for Resident 87 revealed a current physician's order for them to have a Foley urinary catheter to straight bag drainage for urinary retention.

Observation of Resident 87 on May 6, 2025, at 12:58 PM, May 7, 2025, at 11:02 AM, May 8, 2025, at 12:42 PM and May 9, 2025, at 10:15 AM revealed that they were in bed with the urinary catheter bag hanging on the side of the bed uncovered.

During the May 6, 2025, at 12:58 PM observation, the catheter bag was on the door side, in full view from the hallway, and visible to all passing. During the May 7, 2025, at 11:02 AM observation, the bag was on the window side of the bed, lying on the floor, in full view from the hallway, and visible to all passing. During the May 8, 2025, and May 9, 2025, observation, the catheter bag was on the window side and attached to the bed and remained uncovered.

Concurrent interview on May 9, 2025, at 10:15 AM with the Director of Nursing confirmed the findings.

28 Pa. Code 201.18(b)(1)(3) Management

28 Pa. Code 201.29(a) Resident rights

Plan of Correction - To be completed: 06/10/2025

Privacy cover placed on foley catheter bag and placed on frame of bed.

In house audit completed, 3 residents have foley catheters, all have privacy bags on foley catheter bags.

In-service education programs were conducted separately with licensed and non-licensed staff by the Director of Nursing Services (DON) and the MDS Coordinator. Proper procedures for addressing resident preferences obtained from interview information were discussed. Altering care to accommodate resident choice was also addressed to assure the maintenance of resident dignity and respect.

Nursing Home Administrator (NHA), or designee, will conduct weekly observations x 4 then monthly to ensure staff are promoting and maintaining resident dignity in accordance with resident preferences.
Findings of this audit will be discussed with the Resident Council.
This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based on observation and staff interview, it was determined that the facility failed to properly store resident medications on one of two nursing units reviewed (Station Two Nursing Unit; Honey Creek Hall).

Findings include:

Observation during the medication pass on the Station Two Nursing Unit (Honey Creek Hall) on May 9, 2025, at 9:35 AM revealed a medication cart being utilized by Employee 5, licensed practical nurse.

Observation of the medication cart revealed the following:

There was a significant accumulation of debris and dirt including hair in the bottom of the drawers.

There were several unsecured and unidentified medication tablets found in the drawer that contained the medication punch cards that included several unidentified pills: two white colored round pills, two orange colored round pills, a multi-colored capsule, and a large brown colored pill.

The above findings were reviewed in a meeting with the Director of Nursing on May 9, 2025, at 9:57 AM.

28 Pa. Code 201.18(b)(1) Management

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

Plan of Correction - To be completed: 06/10/2025

The Honey creek medication cart was immediately cleaned and free of dirt and loose pills.

All medication carts checked for loose pills and dirt and cleaned.

In-service education programs were conducted separately with licensed staff by the Director of Nursing Services (DON) or designee. Proper procedures for cleaning and maintaining medication carts education provided

Nursing Home Administrator (NHA) or designee, will conduct weekly observations x 4 then monthly to ensure staff are cleaning and maintaining the cleanliness of medication carts.

This plan of correction will be monitored at the monthly Quality Assurance meeting until such a time consistent substantial compliance has been met.

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

§483.35(a) Sufficient Staff.
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)(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:
Clinical record review and resident and staff interview, it was determined that the facility failed to have sufficient nursing staff to meet resident needs related to call bell response time for two of 26 residents reviewed (Residents 50 and 66).

Findings include:

In an interview with Resident 50 on May 6, 2025, at 12:56 PM she stated that she has waited an hour to go the bathroom. She stated that she is usually only incontinent when she rings her call bell and must wait a long time for staff to assist her. Resident 50 stated that the licensed practical nurse will come into her room and turn off her call bell stating they will let the nurse aide know but nobody comes back.

Clinical record review for Resident 50 revealed her most recent annual MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) assessment dated March 13, 2025, indicated Resident 50 was cognitively intact and occasionally incontinent of her bladder function.

Resident 50 filed a grievance on January 1, 2025, stating her call bell was on for over an hour, noting she was incontinent and embarrassed. Review of Resident 50's grievance revealed no resolution to her concern.

Interview with Employee 7 (social services) on May 9, 2025, at 10:43 AM confirmed these finding for Resident 50. There was no evidence of any call bell audits completed until January 14, 2025.

The above call bell response times were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on May 8, 2025, at 2:00 PM.

Interview with Resident 66 on May 6, 2025, at 12:15 PM revealed that he has concerns with the facility not having enough staff. He indicated that when he rings his bell to go to the bathroom or use the urinal there are not enough staff to answer it timely. He could not provide specific dates, but he indicated that it happens on all the shifts. He said that he is incontinent often because they "don't answer the call bell timely." He said the that often he has to wait over 30 minutes.

Review of Resident 66's MDS dated February 27, 2025, revealed that he is always continent of bowel and frequently incontinent of bladder.

The above noted concern related to Resident 66 was reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on May 8, 2025, at 2:30 PM.

28 Pa. Code 201.18(b)(1)(3) Management

28 Pa. Code 211.12(d)(1)(3)(4)(5) Nursing services

Plan of Correction - To be completed: 06/10/2025

Call bell audits completed on resident 50 and 66. Audits revealed sufficient time in call bell being answered timely.
Call bell audits completed throughout the facility
In-service education programs were conducted separately with licensed and non-licensed staff by the Director of Nursing Services (DON) or designee. Education includes prompt response to call bells and resident feedback on proper time for call bell to be answered and addressed.
Nursing Home Administrator (NHA), or designee, will conduct weekly observations x 4 then monthly to ensure staff are responding timely to residents call bell in accordance with resident preferences

483.35(g)(1)-(4) REQUIREMENT Posted Nurse Staffing Information:

Least serious 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 has the potential for causing no more than a minor negative impact on the resident.

§483.35(g) Nurse Staffing Information.
§483.35(g)(1) Data requirements. The facility must post the following information on a daily basis:
(i) Facility name.
(ii) The current date.
(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:
(A) Registered nurses.
(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).
(C) Certified nurse aides.
(iv) Resident census.

§483.35(g)(2) Posting requirements.
(i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift.
(ii) Data must be posted as follows:
(A) Clear and readable format.
(B) In a prominent place readily accessible to residents and visitors.

§483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

§483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.

Observations:

Based on observation and staff interview, it was determined that the facility failed to post the daily nurse staffing information at the beginning of each shift for two of two nursing units reviewed (Nursing Unit One and Nursing Unit Two).

Findings include:

Observation of the nurse staffing information posted on the wall adjacent to the main lobby of the facility on May 8, 2025, at 11:19 AM and 12:38 PM revealed a nurse staffing sheet dated May 7, 2025.

Observation at the Nursing Unit Two nurse station and concurrent interview with Employee 5, licensed practical nurse, on May 8, 2025, at 11:30 AM revealed that there was no nurse staffing information posted in a prominent place at or near the nurse's station.

Observation of Nursing Unit One nurse station and concurrent interview with Employee 6, social worker, on May 8, 2025, at 12:43 PM revealed that there was no nurse staffing information posted in a prominent place at or near the nurse station.

An interview with Employee 8, scheduler, on May 8, 2025, at 12:53 PM revealed that the posted nurse staffing information located near the main lobby was changed to reflect the correct date of May 8, 2025.

The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on May 8, 2025, at 2:15 PM.

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

Plan of Correction - To be completed: 06/10/2025

Immediate action taken in posting of nursing hours at 11:30am on 5/8/2025.

Posting of nursing hours will be done daily by 8:00am, verified by Nursing Home Administrator (NHA), or designee
.
Nursing Home Administrator (NHA) will educate staffing coordinator and Human Resources on the importance of posting daily nursing hours in a prompt and timely manner.

Posting of daily nursing hours will be audited daily 5x by Nursing Home Administrator (NHA) or designee, weekly 4x.

Findings of this audit will be discussed with the Resident Council.

This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.

§ 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 a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide (NA) per 10 residents during the day shift for one of 21 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility for February 16-22, 2025; March 9-15, 2025, and May 2-8, 2025, revealed the following nurse aides scheduled for the resident census:

Day shift (requires one NA per 10 residents):

February 19, 2025, 11.47 NAs for a census of 121; requires 12.10 NAs

An interview with Employee 8, scheduler, on May 9, 2025, at 12:41 PM confirmed the facility did not meet the regulatory NA-to-resident ratio as evidenced above.

The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on May 9, 2025, at 1:00 PM.

Plan of Correction - To be completed: 06/10/2025

Facility will continue to take measures to adequately provide staff to ensure the needs of residents are met. Specific measures to meet staffing needs include the use of agency staff, increasing bonuses for in house staff to incentivize shift pick ups, as well as increase recruiting efforts for staff.

The Director of Nursing or designee will provide re-education on minimum staffing ratios to RN Supervisors, Human Resources and Scheduling Coordinator who are responsible for maintaining adequate staffing and staffing ratios.

Nursing Home Administrator (NHA), or designee will audit the daily schedules to ensure the minimum number of staff to resident ratios have been scheduled and will audit that protocols were followed if a call off occurred.

Audits will be completed weekly, By Nursing Home Administrator (NHA) or designee, and results of these audits will be reviewed at Quality Assurance and Process Improvement Meetings until substantial compliance is achieved.

§ 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 licensed practical nurse (LPN) per 25 residents on the day shift for two of 21 days reviewed, and one LPN per 40 residents during the night shift on two of 21 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility for February 16-22, 2025; March 9-15, 2025, and May 2-8, 2025, revealed the following LPNs scheduled for the resident census:

Day Shift (requires one LPN per 25 residents):

March 14, 2025, 4.00 LPNs for a census of 116; requires 4.64 LPNs
March 15, 2025, 4.00 LPNs for a census of 116; requires 4.64 LPNs

Night Shift (requires one LPN per 40 residents):

March 13, 2025, 2.13 LPNs for a census of 115; requires 2.88 LPNs
May 2, 2025, 2.06 LPNs for a census of 113; requires 2.83 LPNs

An interview with Employee 8, scheduler, on May 9, 2025, at 12:41 PM confirmed the facility did not meet the regulatory LPN-to-resident ratio as evidenced above.

The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on May 9, 2025, at 1:00 PM.

Plan of Correction - To be completed: 06/10/2025

Facility will continue to take measures to adequately provide staff to ensure the needs of residents are met. Specific measures to meet staffing needs include the use of agency staff, increasing bonuses for in house staff to incentivize shift pick ups, as well as increase recruiting efforts for staff.

The Director of Nursing or designee will provide re-education on minimum staffing ratios to RN Supervisors, Human Resources and Scheduling Coordinator who are responsible to maintain adequate staffing and staffing ratios.

Nursing Home Administrator (NHA), or designee will audit the daily schedules to ensure the minimum number of staff to resident ratios have been scheduled and will audit that protocols were followed if a call off occurred.

Audits will be completed weekly, by Nursing Home Administrator (NHA), or designee, and results of these audits will be reviewed at Quality Assurance and Process Improvement Meetings until substantial compliance is achieved.

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