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

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WILLIAM PENN NURSING AND REHAB
Inspection Results For:

There are  82 surveys for this facility. Please select a date to view the survey results.

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

Based on a Complaint Investigation completed on January 2, 2025, at William Penn Nursing and Rehab, it was determined that there were no federal deficiencies, related to the Health portion of the survey process, identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care as they relate to the Health portion of the survey process; however, the facility was not in compliance with 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(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 1 of 21 days reviewed, one NA per 11 residents during the evening shift for 3 of the 21 days reviewed, and one NA per 15 residents during the night shift for 7 of 21 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility for the weeks of December 1 - 7, 2024, December 15-21, 2024, and December 26, 2024 - January 1, 2025, revealed the following staff scheduled for resident census:

Day shift (requires one NA per 10 residents):

December 26, 2024, 10.67 NAs for a census of 112, requires 11.2 NAs

Evening shift (requires one NA per 11 residents):

December 2, 2024, 9.6 NAs for a census of 111, requires 10.09 NAs
December 6, 2024, 10.53 NAs for a census of 117, requires 10.64 NAs
December 7, 2024, 10.40 NAs for a census of 115, requires 10.45 NAs

Night shift (requires one NA per 15 residents):

December 3, 2024, 7.47 NAs for a census of 115, requires 7.67 NAs
December 4, 2024, 7.47 NAs for a census of 116, requires 7.73 NAs
December 16, 2024, 6.4 NAs for a census of 115, requires 7.67 NAs
December 18, 2024, 6.4 NAs for a census of 115, requires 7.67 NAs
December 21, 2024, 7.47 NAs for a census of 116, requires 7.73 NAs
December 28, 2024, 6.93 NAs for a census of 111, requires 7.4 NAs
December 31, 2024, 7.47 NA for a census of 113, requires 7.53 NAs

Interview with the Nursing Home Administrator and Director of Nursing on January 2, 2025, at 2:00 PM confirmed that the facility did not meet regulatory NA-to-resident ratios as evidenced above.


 Plan of Correction - To be completed: 01/27/2025

1. Facility will continue to take measures to adequately provide staff to ensure the needs of residents are met.
2. 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.
3. The Director of Nursing 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.
4. Audits will be completed weekly, and results of these audits will be reviewed at Quality Assurance and Process Improvement Meetings until substantial compliance is achieved.
5. Compliance Date: 1/27/2025

§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on a review of 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 during the night shift per 40 residents on six of 21 days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility for the weeks of December 1 - 7, 2024, December 15-21, 2024, and December 26, 2024, - January 1, 2025, revealed the following staff scheduled for the resident census:

Day Shift (requires one LPN per 25 residents):

December 27, 2024, 4.5 LPNs for a census of 113, requires 4.52 LPNs
December 29, 2024, 4 LPNs for a census of 111, requires 4.44 LPNs

Night Shift (requires one LPN per 40 residents)

December 4, 2024, 2.19 LPNs for a census of 116, requires 2.90 LPNs
December 7, 2024, 2.5 LPNs for a census of 115, requires 2.88 LPNs
December 18, 2024, 2 LPNs for a census of 115, requires 2.88 LPNs
December 21, 2024, 2.5 LPNs for a census of 116, requires 2.90 LPNs
December 26, 2024, 2 LPNs for a census of 113, requires 2.83 LPNs
December 30, 2024, 2 LPNs for a census of 111, requires 2.78 LPNs

Interview with Nursing Home Administrator and Director of Nursing January 2, 2025, at 2:00 PM confirmed that the facility did not meet regulatory licensed practical nurse-to-resident ratios as evidenced above.


 Plan of Correction - To be completed: 01/27/2025

1. Facility will continue to take measures to adequately provide staff to ensure the needs of residents are met.
2. 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.
3. The Director of Nursing 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.
4. Audits will be completed weekly, and results of these audits will be reviewed at Quality Assurance and Process Improvement Meetings until substantial compliance is achieved.
5. Compliance Date: 1/27/2025


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