Pennsylvania Department of Health
KINGSTON REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

KINGSTON REHABILITATION AND NURSING CENTER
Inspection Results For:

There are 175 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.


KINGSTON REHABILITATION AND NURSING CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a revisit survey and abbreviated complaint survey completed on May 15, 2024, it was determined that Kingston Rehabilitation and Nursing Center failed to correct the federal deficiencies cited during the survey of March 15, 2024, and continued to be out of 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.

Plan of Correction:

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

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.

§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Plan of Correction - To be completed: 06/05/2024

1.

This is to confirm that the facility does not admit to any wrongdoing as related to F0600 although citation was delivered. Companion to resident 2, made an allegation of verbal abuse against an aide while caring for resident.

Resident was made safe, and CNA was removed from facility once reported to NHA and DON. Resident was interviewed and does not recall the incident. She was pleasant at time of interview.

2.

The CNA was removed from the building. Abuse education was started with all staff along with electronic use policy in resident care areas.

Entire facility interviews were conducted with residents the CNA has cared for with BIMS 12-15, to ensure no other residents experienced this issue.

3.

Current facility staff have been educated on the abuse policy and the binder at every station that indicates exactly what is to be done if there is an abuse situation. They have been educated on how to identify abuse and how to report it. Staff will be educated on the following POC with assist level.

Agency staff entering the building to work have been educated on the abuse policy of the building and the electronic use policy of the building prior to going to the floor and will continue.

4.

DON/scheduler will monitor schedule for the next day and identify employees who need to be educated on the abuse and electronic use policy. This will occur at the daily staffing meetings; on Friday's the weekend will also be reviewed.

5.

Completion Date 06/05/2024

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, select facility policy review and staff interview, it was determined that the facility failed to implement procedures to ensure acceptable storage and use by dates for multi-dose medications on two of four medication carts observed (B hall and C hall).

Findings include:

A review of facility policy titled "Administering Medications" last reviewed by the facility November 2023, revealed the procedure for staff to check the expiration date on the medication label. When opening a multi-dose container, place the date on the container.

Observation of the B Hall medication cart on May 15, 2024, at 9:40 AM in the presence of Employee 1 (licensed practical nurse), revealed a vial of Lantus injectable 100 ml (a medication used to treat diabetes), a vial of Novolog injectable 100 ml (a medication used to treat diabetes), and a vial of Levemir injectable (a medication used to treat diabetes) opened and used, but not dated when initially opened.

Observation of the C Hall medication cart on May 15, 2024, at 9:55 AM in the presence of Employee 2 (licensed practical nurse), revealed a vial of Lantus injectable opened and in use, but not dated when initially opened.

Interview with the Nursing Home Administrator on May 15, 2024, at approximately 11:20 AM, confirmed that medications were to be dated when initially opened and put into use.

28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services

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

Plan of Correction - To be completed: 06/05/2024

1.

The multidose vials, 2 lantus, novolog, and Levemir were discarded immediately.

2.

All multidose vials were checks and ensured they were dated.

3.

11p-7a LN's will check all multidose vials q night to ensure all open vials are dated.

Nurse Educator will educate current facility LN's on labeling of multidose vials, and 11p-7a LN audit of multidose vials.

4.

DON/designee will audit multidose vials 5 times a week x 2 weeks, 3 times a week x 2 weeks and weekly x 2 weeks.

5. Completion Date: 06/05/2024

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on review of clinical records and select facility policy and resident and staff interviews it was determined that the facility failed to provide necessary supervision and effective safety measures to prevent an elopement by one resident (Resident 1) out of 10 sampled residents

Findings include:

A review of a select facility policy for "Leave of Absence (LOA)", reviewed April 1, 2024 revealed It is the policy of the facility to coordinate, when appropriate, the preparation for nd return from a leave of absence but not limited to physical, medical and medication needs. The purpose of the policy is to ensure resident's are met during their absence from the facility and to ensure sfety of the wheelchair user and other individuals while out in the community.

Procedures to include:

- the licensed nurse will ensure that there is a physician's order and perform any needed education.
-having a personal cell phone to use during LOA is recommended
-when the resident is ready to leave the facility, the nurse will initiate the LOA form, including destination, telephone number and expected time of return.

A review of the clinical record revealed that Resident 1 was admitted to the facility on May 3, 2024, with diagnoses, which included, recent diagnosis of lung cancer, bipolar disease, tardive dyskinesia and a history of substance abuse. The resident was cognitively intact with a BIMS score of 15 (13-15 indicates cognitively intact) and independently ambulatory.

Review of Resident 1's Elopement Risk initial Assessment dated May 3, 2024, indicated that the resident was cognitively intact, had a pertinent diagnosis (bipolar disorder), was independently mobile, did not demonstrate exit seeking behavior, and that the resident was homeless prior to admission to the facility. With respect to the question "Does the resident use illicit drugs or have Substance Use Disorder" asked during the assessment, "no" was incorrectly answered, as the resident did have a known substance use disorder as a documented diagnosis for Resident 1. The following was noted on the assessment "If any question above was answered as "YES", the resident has the potential to be at risk for elopement. Admitting nurse should implement interventions as appropriate until IDT(interdisciplinary team) reviews for final decision.

A review of an initial, 3 day care plan dated May 3, 2024 revealed that Resident 1 was identified as an elopement risk, but no planned interventions were identified.

A review of the Medbridge unit LOA binder (a book kept at the nurses station in which residents /family signed before leaving the facility) revealed that the sign out form included, date and time leaving the facility, anticipated time of return, signature of resident/family and the same for "signing" back into the facility on return from LOA. In addition to this Sign in and sign out form, the "LOA" form must be completed and placed into the binder. After signing out at the nurses station, the resident and/or family member are to stop at the front of the building reception desk. The receptionist then calls the resident unit nurses station to confirm the LOA and opens the front door for the resident to leave.

A review of the current LOA sign out sheet (at the Medbridge nursing station) revealed that Resident 1 signed out May 5, 2024 at 12:45 P.M. with the estimated time of return, 1 hour. The resident signed the time back in as returning at 1:34 P.M. She signed herself out on May 7, 2024 at 1:45 P.M., with an estimated to return in one half hour, but the signature on form was illegible with the time in scratched out.

There were no "LOA forms" completed for these 2 noted LOAs from the facility as noted in facility policy.

There was no evidence at the time of the survey that nursing had obtained a physician order approving Resident 1 to go LOA as noted in facility policy.

A review of nurses notes dated May 8, 2024 at 4:56 P.M., revealed, Resident 1 was inquiring about leaving the facility to go walk down the street to a grocery store .02 miles away. Nursing noted that a call was placed to CRNP (certified Registered Nurse Practitioner). A New order was received that resident may go LOA with family/friends but may not leave the facility property unsupervised. Resident updated of the same.

A Nurses Note dated May 9, 2024 at 8:00 A.M. revealed that "\ requesting to go LOA this AM, unsupervised. Call placed to CRNP, gave new order, LOA order that resident may leave the facility unsupervised."

A physician order dated May 9, 2024, (no time indicted) was noted "May go LOA." This physician order did not indicate that the resident could leave the facility unsupervised.

A review of a physical therapy skilled services note dated May 9, 2024, and signed as completed at 3:08 P.M. indicated a summary of daily skilled services to include, gait training over outside surfaces over concrete, grass, curbs with cane No loss of balance with any mobility indoors as well as outdoors.

During an interview May 15, 2024 at approximately 2 P.M., the Director of Therapy stated that the assessment was completed on May 9, 2024. She stated that she sometimes completed her therapy documentation at home, later in the day. She could not remember what time the therapy evaluation was completed on May 9, 2024. She stated that she thought it was in the morning that day.

A review of the Medbridge unit leave of absence sign out/in form indicated that Resident 1 signed out LOA on May 9, 2024 at 8:15 AM. She did not include the estimated time of return. The time in and return signature was not on the form. There was LOA form in the Medbridge nursing unit indicating where this resident planned to go when she left the facility.

During an interview on May 15, 2024 at 12 PM, Resident 1 stated that she had been leaving the facility unsupervised since she was admitted, to go to the grocery store for "her snacks." She stated that she did sign out and back in on the sheet in the binder, but did not fill out any other forms. She stated that the facility did not tell her about any other forms that needed to filled out to leave. She stated that on May 9, 2024 at around 8 A.M she left the facility and at about 8:30 AM, she saw the county bus stop sign outside the grocery store and decided to get on the bus and return to her home town for a visit. She had her "bus pass" in her wallet. The town is approximately 8.5 miles from the facility. She stated that the social services director called her while she was on the bus and told the resident that she had to return to the facility. She stated that she just decided to get on the bus when she got to the grocery store.

There was no documentation in the resident's clinical record concerning this incident when reviewed at the time of the survey ending May 15, 2024.

During an interview May 15, 2024 at approximately 1 P.M., the director of social services (SW) stated that on May 9, 2024, "sometime in the morning" she was informed that Resident 1 had left the facility. The SW stated that she called Resident 1 on her cell phone and told her that she had to return to the facility, that she could not leave and go on a bus by herself. The SW did not relay any additional information concerning this event. She confirmed that no additional assistance was given to this resident, and that the staff just waited for her to return to the facility by herself.

During an interview May 15, 2024 at 2 P.M., the Director of Nursing (DON) stated that on May 9, 2024, during morning IDT meeting (she could not state a time) she was informed by nursing staff that Resident 1 could not be located in the facility. The DON then called "code orange" indicating a resident elopement from the facility. The resident was not located and the SW called her cell phone at which time the resident informed her that she was on a bus, traveling to a nearby town.

There was no evidence that a physician order was obtained prior to this resident leaving the facility LOA. The resident was assessed as an elopement risk at the time of admission and left the facility unaccompanied multiple times prior to her getting on public transportation without facility staff's knowledge.

Interview with the Director of Nursing on May 15, 2024, at approximately 2:00 PM, confirmed that the facility did not implement their LOA policy and was unaware that the resident had left the facility without authorization.

28 Pa. Code 211.10 (a)(d) Resident care policies

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

Plan of Correction - To be completed: 06/05/2024

1.

Resident 1 LOA order was in place at the time of survey and was further clarified to add LOA independently to the order. Care plan was reviewed and revised.

2.

Current facility residents who have triggered as potential risk for elopement on the Elopement UDA, will be reviewed by the IDT to ensure care planned interventions are in place to address the risk factors.

Current facility residents were reviewed for LOA orders. Order classifications will be obtained if needed. Care plans to be updated to reflect changes as needed.

3.

Nurse Educator will educate current facility staff on current LOA policy, sign out sheets, and elopement assessment.

4.

DON/designee will review any resident that triggers for elopement in clinical stand up 5 x's a week to verify any triggered elopement risk have care plan with interventions. LOA orders will be reviewed upon admissions 5x a week during the clinical stand up process to verify accuracy. Results to QAPI to determine audit frequency.

5.Completion Date 06/05/2024

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Observations:

Based on review of clinical records, the facility's abuse prohibition policy and staff witness statements, and staff and family interview, it was determined that the facility failed to timely and thoroughly investigate an allegation of resident abuse and prevent the potential for further abuse during the course of the investigation for one resident out of 10 resident sampled (Resident 2).

Findings include:

A review of the facility's Abuse prohibition policy last reviewed by the facility on March 2024, indicated that the objective of the abuse policy is to comply with the seven-step approach to abuse and neglect detention and prevention. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within hearing distance, regardless of their age, ability to comprehend, or disability. It is the policy of this facility that reports of "abuse" are promptly and thoroughly investigated. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The information gathered is given to administration. Employees accused of "abuse" will be immediately removed from the facility and will remained removed pending the results of a thorough investigation.

Review of the clinical record revealed Resident 2 was admitted to the facility on January 11, 2023, with diagnoses, which included dementia.

Review of a Quarterly MDS Assessment dated March 31, 2024, revealed that the resident was severely cognitively impaired with a BIMS score of 1 (Brief Interview for Mental Status (BIMS section of the MDS which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 1-7 equates to being severely, cognitively impaired) and required assistance of two staff for bed mobility and toileting.

Review of Resident 2's current care plan, initially dated January 11, 2023, indicated that the resident required the assistance of two staff for bed mobility and toileting.

A review of a witness statement dated April 16, 2024, (no time indicated) Employee 1 (companion) stated, "on Friday April 12, 2024, at approimately 2 PM Employee 2, a nurse aide, answered the resident's call light, on her phone (ear buds). The aide remained on her phone having a conversation with her brother using profanity. The resident became disoriented and upset and began yelling "Are you talking to me?, What is going on? Employee 2 got in Resident 2's face and said "I don't need to speak to you to clean shit out of your vagina, I'm having a convo with my brother." The resident responded "stop breathing on me." The aide repeatedly made comments about the resident being covered in shit while on the phone. After the incident I (Employee 1, companion) told Employee 3 (LPN supervisor), "Please don't ever send that aide (Employee 2) in the room again. Employee 3 (LPN supervisor) advised me to write statement. I declined for fear of retaliation. Later that night (April 12, 2024) around 7 P.M. I asked Employee 4 (RN Supr) if Employee 3 (LPN supervisor) told him not to let Employee 1, nurse aide, care for the resident. He said no, but will pass the message on. On Saturday April 13, 2024, at approximately 10 AM I arrived at the facility. Resident 2 asked who her aide was. The resident stated that the aide was not nice and barely fed her breakfast, but what she did feed her, did it forcefully and almost made her choke. I found out the aide was the same women from Friday (April 12, 2024, Employee 2 na). I reported the situation again to Employee 5 (RN Supr) who, at that time, removed Employee 1 from the resident's room for the remainder of the shift.

A review of a facility investigation report dated April 12, 2024, at 2 PM revealed that on Tuesday April 16, 2024 at 11 AM, Resident 2's personal companion, Employee 1 (employed by the resident's family) called the Nursing Home Administrator to report an incident that occurred on Friday April 12, 2024. She stated that there was a tall black aide (identified as Employee 2) that entered Resident 2's room at 2 PM after she rang the call bell because the resident had a bowel movement (BM). The aide came into the resident's room, while on her cell phone with ear buds in the aide's ears, using profanity on the phone to whomever she was speaking to while caring for Resident 2. Resident 2, who is hard of hearing and blind, asked the aide if she was speaking to her (the resident). The aide responded, per Employee 1 (companion) "I don't need to speak to you to clean shit out of her vagina, I'm having a convo with my brother." Employee 1 (companion) stated that the aide repeatedly made comments about the resident being covered in shit while on the cellphone.

The facility did not obtain written or telephone statements from any staff or residents regarding this allegation of verbal abuse Employee 1 made on April 12, 2024, until April 16, 2024 after Employee 1 (companion) notified the facility's administrator. The facility failed to timely investigate and protect residents, including Resident 2 from the potential for further abuse perpetrated by Employee 2.

According to written employee statements and interviews, Employee 1 (companion) informed nursing staff on both Friday April 12, 2024, and Saturday April 13, 2024, that Employee 2 verbally abused Resident 2. The facility did not initiate an investigation to rule out potential abuse, or mistreatment when the allegation was received by Employee 3, LPN. Employee 2 remained on duty, providing care to residents, on the resident units allowing the potential for further abuse to occur.

During an interview on May 15, 2023, at 2 PM the DON (director of nursing) was unable to provide evidence that the facility conducted a timely and thorough investigation and protected residents from the potential for further abuse during the course of an abuse investigation.

Refer F600

28 Pa. Code 201.14 (a) Responsibility of Licensee

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

28 Pa. Code 211.12 (c) Nursing services

28 Pa. Code 201.29 (a)(c) Resident rights

Plan of Correction - To be completed: 06/05/2024

1.

Facility obtained statements and investigation regarding verbal abuse allegation when NHA and DON made aware 4/16.

2.

Abuse education was conducted with all staff. Abuse binder with step by step instructions on how to report abuse and who to report it to have been placed on every nurse's station.

3.

Nurse Educator educated current facility staff on abuse policy, reporting, and abuse binders on every station.

4.

DON/NHA will review all abuse allegations when made aware of any potential allegations.

5. Completion date: 06/05/2024

51.3 (g)(1-14) LICENSURE NOTIFICATION:

51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.

Observations:

Based on a review of clinical records and interview with facility staff, it was determined that the facility failed to notify the State Licensing Agency, Department of Health, Division of Nursing Care Facilities of an event with the potential to compromise resident health and safety as evidenced by one of four residents sampled (Resident 1).

Findings include:

Under the 28 PA Code 201.3 an elopement is defined as when a resident leaves the premises or a safe area without authorization.

A review of the clinical record revealed that Resident 1 was admitted to the facility on May 3, 2024, with diagnoses, which included lung cancer, bipolar disease, tardive dyskinesia and a history of substance abuse. The resident was cognitively intact with a BIMS score of 15 (13-15 indicates cognitively intact) and ambulated independently.

An interview conducted on May 15, 2024 at 12 PM with Resident 1 revealed that the resident stated that she has been leaving the facility without supervision since she was admitted, to go to the grocery store for "her snacks." She stated that on May 9, 2024, at around 8 AM she left the facility. While out out of the facility, at about 8:30 AM, she saw the county bus stop sign outside the grocery store and decided to get on the bus and return to her home town for a visit. She had her "bus pass" in her wallet. The town is approximately 8.5 miles from the facility. She stated that the social services director called her while she was on the bus and told the resident that she had to return to the facility. She stated that she just decided to get on the bus when she got to the grocery store.

There was no documentation in the clinical record concerning this incident when reviewed during the survey on May 15, 2024.

During an interview May 15, 2024 at approximately 1 P.M., the director of social services (SW) stated that on May 9, 2024, "sometime in the morning" she was informed that Resident 1 had left the facility. The SW stated that she called Resident 1 on her cell phone and told her that she had to return to the facility, that she could not leave and go on a bus by herself. The SW did not give any additional information concerning this event. She confirmed that the facility waited for her to return ot the facility by herself.

During an interview May 15, 2024 at 2 P.M., the Director of Nursing (DON) stated that on May 9, 2024, during morning IDT meeting (she could not state a time) she was informed by nursing staff that Resident 1 could not be located in the facility. The DON then called "code orange" indicating a resident elopement from the facility. The resident was not located and the SW called the resident's cell phone and the resident informed her that she was on a bus, traveling to a nearby town.

The resident was assessed as an elopement risk at the time of admission and left the facility unaccompanied multiple times prior to getting on public transportation without facility staff's knowledge.

Interview with the Director of Nursing on May 15, 2024, at approximately 2:00 PM, confirmed that the facility did not report the elopement to the State Licensing Agency, Division of Nursing Care Facilities because they did not consider the event as an elopement even though the facility implemented a "code orange" indicating a resident elopement.

Plan of Correction - To be completed: 06/05/2024

1. Incident involving resident 1 was reported into the PA DOH ERS system.

2. A 3 day look back will be completed of any incidents that occurred to compromise resident health and safety to ensure it was reported to the State Licensing Agency.

3. Staff educator/designee will educate the IDT team, nursing supervisors, and administrator on criteria that would indicate a report to the State Licensing Agency including elopement.

4. The staff educator/designee will audit reportable events to the State Licensing Agency including elopement to ensure it was completed. An audit will be completed 5 days a week x 2 weeks, 3 times a week x 2 weeks and 1 x a week for 1 month with results to QAPI for further auditing

Completion date 06/05/2024

§ 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.

Observations:

Based on review of nursing time schedules and staff interviews, it was determined that the facility failed to provide a minimum of one nurse aide per 12 residents during the evening shifts, and one nurse aide per 20 residents during the night shift on two of seven days (May 10, 2024, May 12, 2024.

Findings include:

Review of facility census data indicated that on May 10, 2024, the facility census was 123, which required 10.25 nurse aides during the day shift.

Review of the nursing time punch detail documentation revealed only 9.78 nurse aides provided care on the day shift on May 10, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 12, 2024, the facility census was 123, which required 10.25 nurse aides during the day shift.

Review of the nursing time schedules and time punch documentation revealed that only 9.13 nurse aides worked on the day shift on May 12 2024. No additional excess higher-level staff were available to compensate this deficiency.

An interview May 15, 2024 at 2 PM., the Director of Nursing confirmed that the facility did not meet state minimum staffing for nurse aides.

Plan of Correction - To be completed: 06/05/2024

1.

The facility cannot retroactively correct deficiency for ratio staffing with nurse's aide

2.

Facility did two week look back to ensure proper staffing for nurses aide and compliance.

3.

Nursing Home Administrator will educate Staffing Coordinator, Nursing Administration, and RN supervisors on correct staffing ratios for nurse's aide on all shifts and procedure for addressing call offs and staff replacement

4.

Staffing coordinator will monitor weekly ratios for nurse aides on all shifts to assure compliance with ratio regulation. Findings will be reported during quality assurance

5. Completion Date: 06/05/2024

§ 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 nursing time schedules and staff interviews, it was determined that the facility failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift, 1 LPN per 30 residents on the evening shifts, and one LPN per 40 residents during the night shift on seven of seven days (May 8, 2024, May 9, 2025, May 10, 2024, May 11, 2024, May 12, 2024 May 13, 2024 and May 14, 2024).

Findings include:

Review of facility census data indicated that on May 8,2024, the facility census was 121, which required 3.03 LPNs during the night shift.

Review of the nursing time schedules and time punch card documentation revealed 2.94 LPNs provided care on May 8, 2024, provided care on the night shift.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 9, 2024, the facility census was 124, which required 3.10 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed 2.88 LPN worked the night shift on May 9, 2024.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 10, 2024, the facility census was 123, which required 3.08 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed 2.88 LPNs worked the night shift on May 10, 2024.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 11, 2024, the facility census was 122, which required 3.05 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed 3 LPN worked the night shift on May 11,2024.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 12, 2024, the facility census was 123, which required 3.08 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed 1.88 LPN worked the night shift on May 12, 2024.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 13, 2024, the facility census was 125, which required 3.13 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed 2.97 LPN worked the night shift on May 13, 2024.

No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on May 14, 2024, the facility census was 125, which required 3.13 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed 2.91 LPN worked the night shift on May 14, 2024.

No additional excess higher-level staff were available to compensate this deficiency.

An interview May 15, 2024, at 2 P.M., the Director of Nursing confirmed that the facility did not meet the state minimum nursing ratios for LPNs

Plan of Correction - To be completed: 06/05/2024

1.

The facility cannot retroactively correct deficiency for ratio staffing with Licensed Practical Nurses

2.

Facility did two week look back to ensure proper staffing for LPN's and compliance.

3.

Nursing Home Administrator will educate Staffing Coordinator, Nursing Administration, and RN supervisors on correct staffing ratios for Licensed Practical Nurses on all shifts and the procedure for addressing call offs and staff replacement.

4.

Staffing coordinator will monitor weekly ratios for Licensed Practical Nurses on all shifts to assure compliance with ratio regulation. Findings will be reported during quality assurance.

5.

Completion Date: 06/05/2024

§ 211.12(i)(1) LICENSURE Nursing services.:

(1) Effective July 1, 2023, 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 2.87 hours of direct resident care for each resident.

Observations:

Based on a review of nurse staffing and resident census and staff interview, it was determined that the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse staffing of 2.87 hours of general nursing care to each resident:

A review of the facility's calculated total nursing care hours per resident day for May 12, 2024, was at 349.75 total hours for a maximum resident census of 123 and the facility required 353.01 total hours for a maximum resident census of 123.

Further review of PPD for May 12, 2023, revealed that the facility had 2.85 hours of direct nursing care and failed to provide the minimum of 2.87 hours of direct nursing care daily.

An interview with the Nursing Home Administrator (NHA) on May 15, 2024, at 2:35 PM, confirmed that the facility failed to provide the minimum of 2.87 hours of direct nursing care daily for each resident.

Plan of Correction - To be completed: 06/05/2024

1.

The facility cannot retroactively correct the facility nursing ppd for the dates cited.

2.

The NHA will complete an audit of the nursing schedule for the next 2 weeks to review projected ppd and implement staffing plans accordingly.

3.

To prevent this from recurring, the NHA will provide education to Nursing Admin, RN Supervisors, and Scheduling Coordinator relating to calculating and monitoring PPD to maintain the minimum 2.87 hours requirement.

4.

To monitor and maintain ongoing compliance the NHA/designee will review the nursing schedules daily as an ongoing process to ensure minimum ppd of 2.87 is maintained. Results of the audits will be brought to Quality Assurance Committee for review and revision as needed and the committee will determine continued need/frequency of audits.

5. Completion Date: 06/05/2024

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