Pennsylvania Department of Health
CORRY MANOR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CORRY MANOR
Inspection Results For:

There are 84 surveys for this facility. Please select a date to view the survey results.

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CORRY MANOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Follow-up Survey completed on January 27, 2025, it was determined that Corry Manor corrected the federal deficiencies cited, however, failed to correct all the deficiencies cited during the survey of November 8, 2024, and continued to be out of compliance with the following requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 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 the facility nursing staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one Nurse Aide (NA) was met per 10 residents for the day shift for three of 14 days (1/11/25, 1/12/25, and 1/19/25); and failed to ensure a minimum of one NA per 11 residents for the evening shift for four of 14 days (1/10/25, 1/11/25, 1/13/25, and 1/20/25); and failed to ensure a minimum of one NA per 15 residents for the overnight shift for nine of 14 days reviewed (1/10/25, 1/11/25, 1/12/25, 1/13/25, 1/15/25, 1/16/25, 1/17/25, 1/18/25, and 1/19/25).

Findings include:

Review of facility nursing staffing documents for the time period from 1/08/25, through 1/21/25, revealed the following NA staffing shortages for the day shift where the NA ratios were not met:

1/11/25census of 108 residents8.69 NA worked and 10.80 were required.
1/12/25census of 108 residents9.51 NA worked and 10.80 were required.
1/19/25census of 107 residents9.71 NA worked and 10.70 were required.

Review of facility nursing staffing documents for the time period from 1/08/25, through 1/21/25, revealed the following NA staffing shortages for the evening shift where the NA ratios were not met:

1/10/25census of 109 residents9.63 NA worked and 9.91 were required.
1/11/25census of 108 residents8.83 NA worked and 9.82 were required.
1/13/25census of 108 residents9.76 NA worked and 9.82 were required.
1/20/25census of 107 residents9.35 NA worked and 9.73 were required.

Review of facility nursing staffing documents for the time period from 1/08/25, through 1/21/25, revealed the following NA staffing shortages for the overnight shift where the NA ratios were not met:

1/10/25census of 109 residents6.47 NA worked and 7.27 were required.
1/11/25census of 108 residents5.33 NA worked and 7.20 were required.
1/12/25census of 108 residents5.39 NA worked and 7.20 were required.
1/13/25census of 108 residents5.47 NA worked and 7.20 were required.
1/15/25census of 107 residents7.01 NA worked and 7.13 were required.
1/16/25census of 105 residents6.37 NA worked and 7.00 were required.
1/17/25census of 105 residents4.80 NA worked and 7.00 were required.
1/18/25census of 107 residents5.60 NA worked and 7.13 were required.
1/19/25census of 107 residents6.60 NA worked and 7.13 were required.

During a telephone interview on 1/27/25, at 10:45 a.m. the Nursing Home Administrator confirmed the NA ratios were not met for the above days and shifts.

Plan of Correction - To be completed: 03/03/2025

Plan of Correction:
P 5520 Nursing Services
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice.
Nursing home administrator/NHA or designee to in-service staffing coordinator, director of nursing, staff educator and assistant director of nursing and charge nurses on the state required minimum staffing ratios for nursing assistants.
2. How the care community will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
Nursing Home Administrator/NHA or designee to conduct staffing meetings 3 times/week to ensure the state required minimum staffing ratios for nursing assistants are met throughout the week, weekends and holidays.
3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur?
NHA/ designee to review staffing sheets 3x weekly to ensure the state required minimum staffing ratios for nursing assistants are met for the day/ shifts prior. Staffing meeting includes discussion of open shifts, vacation coverage, review of current nursing staff schedule and what is needed to meet state required nurses aide ratio and PPD, interviews scheduled, new hires and orientation date.
NHA/ designee to utilize corporate hiring and recruitment platform and Indeed for job applicants, attend job fairs, corporate talent acquisition specialist, newspaper ads, employee referral bonus program and tuition reimbursement for recruitment efforts. STNA's are offered call-in bonus pay and incentive programs for picking up additional shifts.
NHA or designee will host open interview hours to increase recruitment efforts.
The admission team will review potential admissions based on the ability to meet the care needs of the resident and meet minimum staffing needs.
4. How will the corrective action(s) be monitored to ensure that deficient practice will not recur, i.e., what quality assurance program will be put into place; and
NHA/designee to meet 3x weekly with director of nursing/DON or designee and staffing coordinator to review nursing assistant ratios, staffing meeting and audit will continue to ensure sustained compliance.
All audits will be reviewed through the quality and performance improvement process.
5. Dates when corrective action will be completed.
March 3, 2025

§ 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 review of facility nursing staffing documents and staff interview, it was determined that the facility failed to ensure the Licensed Practical Nurse (LPN) ratios were met of one LPN per 25 residents on the day shift for two of 14 days (1/15/25, and 1/20/25), and one LPN per 40 residents on the overnight shift for four of 14 days (1/11/25, 1/12/25, 1/13/25, and 1/19/25).

Findings include:

Review of facility nursing staffing documents for the time period from 1/08/25, through 1/21/25, revealed the following LPN staffing shortages for the day shift where the LPN ratios were not met:

1/15/25 census of 107 residents4.05 LPNs worked and 4.28 were required.
1/20/25 census of 107 residents4.27 LPNs worked and 4.28 were required.

Review of facility nursing staffing documents for the time period from 1/08/25, through 1/21/25, revealed the following LPN staffing shortages for the overnight shift where the LPN ratios were not met:

1/11/25 census of 108 residents2.13 LPNs worked and 2.70 were required.
1/12/25 census of 108 residents2.13 LPNs worked and 2.70 were required.
1/13/25 census of 108 residents2.13 LPNs worked and 2.70 were required.
1/19/25 census of 107 residents1.07 LPNs worked and 2.68 were required.

During a telephone interview on 1/27/25, at 10:45 a.m. the Nursing Home Administrator confirmed that the facility did not meet the minimum LPN ratio for the above days and shifts.

Plan of Correction - To be completed: 03/03/2025

Plan of Correction:
P 5530 Nursing Services
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice.
Nursing Home Administrator/NHA or designee to in-service staffing coordinator, director of nursing/DON, staff educator and assistant director of nursing and charge nurses on the state required minimum staffing ratios for licensed practical nurses.
2. How the care community will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
NHA/ designee to conduct staffing meetings 3 times/week to ensure the state required minimum staffing ratios for licensed practical nurses are met throughout the week, weekends and holidays.
3. What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur?
NHA/designee to review staffing sheets 3x weekly to ensure the state required minimum staffing ratios for licenses practical nurses are met for the day/ shifts prior. Staffing meeting includes discussion of open shifts, vacation coverage, review of current nursing staff schedule and coverage needed to meet state required LPN ratio and PPD, interviews scheduled, new hires and orientation date.
NHA/designee to utilize corporate recruitment platform and Indeed for job applicants, attend job fairs, corporate talent acquisition specialist, newspaper ads, employee referral bonus program and tuition reimbursement for recruitment efforts. Licensed Nurses are offered call-in bonus pay and incentive programs for picking up additional shifts.
NHA or designee will host open interview hours to increase recruitment efforts.
The admission team will review potential admissions based on the ability to meet the care needs of the resident and meet minimum staffing needs.
4. How will the corrective action(s) be monitored to ensure that deficient practice will not recur, i.e., what quality assurance program will be put into place; and
NHA/designee to meet 3x weekly with DON/designee and staffing coordinator to review licenses practical nurse's ratios. Staffing meetings will continue to ensure sustained compliance
All audits will be reviewed through the quality and performance improvement process.
5. Dates when corrective action will be completed.
March 3, 2025

§ 211.12(f.1)(5) LICENSURE Nursing services. :

(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.

Observations:

Based on review of facility nursing staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one Registered Nurse (RN) per 250 residents during the evening shift for one of 14 days reviewed (1/18/25).

Findings include:

Review of facility nursing staffing documents for the time period from 1/08/25, through 1/21/25, revealed the following RN staffing shortages for the evening shift where the RN ratios were not met:

1/18/25 census of 107 residents0.49 RNs worked and 1.00 was required.

During a telephone interview on 1/27/25, at 10:45 a.m. the Nursing Home Administrator confirmed that the facility did not meet the minimum RN ratio for the above day and shift.

Plan of Correction - To be completed: 03/03/2025

Plan of Correction:
P 5540 Nursing Services
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice.
Nursing Home Administrator/NHA or designee to in-service staffing coordinator, staff educator, DON/director of nursing and assistant director of nursing and charge nurses on the state required minimum staffing ratios for registered nurses.
2. How the care community will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
NHA/designee to conduct staffing meetings 3 times/week to ensure the state required minimum staffing ratios for registered nurses are met throughout the week, weekends and holidays.
3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur
NHA/designee to review staffing sheets 3x weekly to ensure the state required minimum staffing ratios for registered nurses are met for the day/ shifts prior. Staffing meeting includes discussion of open shifts, vacation coverage, review of current nursing staff schedule and coverage needed to meet state required registered nurse ratio and PPD, the interviews scheduled, new hires and orientation date.
NHA/ designee to utilize corporate recruitment platform and Indeed for job applicants, attend job fairs, corporate talent acquisition specialist, newspaper ads, employee referral bonus program and tuition reimbursement for recruitment efforts. Registered Nurses are offered call-in bonus pay and incentive programs for picking up additional shifts.
NHA or designee will host open interview hours to increase recruitment efforts.
The admission team will review potential admissions based on the ability to meet the care needs of the residents and meet minimum staffing needs.
4. How will the corrective action(s) be monitored to ensure that deficient practice will not recur, i.e., what quality assurance program will be put into place; and
NHA/designee to meet 3x weekly with DON/designee and staffing coordinator to review registered nurse's ratios. Staffing meetings will continue to ensure sustained compliance.
All audits will be reviewed through the quality performance and improvement process.
5. Dates when corrective action will be completed.
March 3, 2025

§ 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 facility nursing staffing documents and staff interview, it was determined that the facility failed to provide the minimum number of general nursing care hours of 3.2 hours of direct resident care hours per resident in a 24-hour period for 10 of 14 days reviewed (1/10/25, 1/11/25, 1/12/25, 1/13/25, 1/14/25, 1/15/25, 1/17/25, 1/18/25, 1/19/25, and 1/20/25.

Findings include:

Review of nursing staffing documents for the time period from 1/08/25, through 1/21/25, revealed that the hours of direct resident care was below 3.2 minimum per patient per day (PPD) on the following dates:

1/10/25 3.14
1/11/25 2.62
1/12/25 2.73
1/13/25 3.00
1/14/25 3.16
1/15/25 3.08
1/17/25 2.94
1/18/25 3.01
1/19/25 2.81
1/20/25 3.19

During a telephone interview on 1/27/25, at 10:45 a.m. the Nursing Home Administrator confirmed the facility did not meet the 3.2 minimum hours of direct resident care on the above dates.

Plan of Correction - To be completed: 03/03/2025

Plan of Correction:
P 5640 Nursing Services
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice.
Nursing Home Administrator/NHA or designee to in-service staffing coordinator, staff educator, Director of Nursing/DON and assistant director of nursing and charge nurses on the state required minimum staffing levels of 3.2 hours per patient day.
2. How the care community will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
NHA/designee to conduct staffing meetings 3 times weekly to ensure the state required minimum number of general nursing care hours are met through the week, weekends and holidays.
3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur
NHA/designee to review staffing sheets 3x weekly to ensure adequate nursing coverage is scheduled to meet the minimum number of general nursing care hours. Staffing meeting includes discussion of open shifts, vacation coverage, review of current nursing staff schedule and coverage needed to meet state required minimum staffing hours of 3.2, interviews scheduled, new hires and orientation date.
NHA/ designee to utilize corporate recruitment platform and Indeed for job applicants, attend job fairs, corporate talent acquisition specialist, newspaper ads, employee referral bonus program and tuition reimbursement for recruitment efforts. Nursing staff are offered call-in- bonus pay and incentive programs for picking up additional shifts.
NHA or designee will host open interview hours to increase recruitment efforts.
The admission team will review potential admissions based on the ability to meet the care needs of the residents and meet minimum staffing needs.
4. How the corrective action(s) will be monitored to ensure that deficient practice will not recur, i.e., what quality assurance program will be put into place; and
NHA/designee to meet 3x weekly with DON/designee and staffing coordinator to review nursing schedule and projected daily minimum number of general nursing care hours to ensure the minimum 3.2 hours are met. Staffing meetings will continue to ensure sustained compliance.
All audits will be reviewed through the quality and performance improvement process.
5. Dates when corrective action will be completed.
March 3, 2025

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