Pennsylvania Department of Health
 SOMERSET HEALTHCARE & REHABILITATION CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SOMERSET HEALTHCARE & REHABILITATION CENTER
Inspection Results For:

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SOMERSET HEALTHCARE & REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Based on an abbreviated complaint survey completed on February 23, 2026, it was determined that Somerset Healthcare and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.
 Plan of Correction:


483.10(c)(1)(4)(5) REQUIREMENT Right to be Informed/Make Treatment Decisions: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(c) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:

§483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

§483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.

§483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.
Observations:

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to inform the resident/resident representative in advance of the risks and benefits of psychotropic medications (medications that affect the persons mental state, emotions and behavior) and the treatment alternatives prior to initiating the administration of the medication for one of 6 residents reviewed (Resident 4).

Findings include:

A facility policy related to psychotropic medications, dated February 4, 2026, indicated that prior to initiating or increasing psychotropic medications, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications (psychotropic medications used to treat mental health disorders), in advance of such initiation or increase. The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated January 28, 2026, revealed that the resident was cognitively impaired, was sometimes understood and was able to usually understand others, had no behavioral symptoms, received hospice services, received psychotropic medications, including antipsychotic and antidepressant medications and had diagnoses that included anxiety, depression and dementia.

A nursing note for Resident 4, dated October 30, 2025, at 7:30 p.m. indicated that the resident had a new order per hospice to increase his Seroquel (an antipsychotic medication) to 50 milligrams (mg) twice daily for behaviors.

Physician's orders for Resident 4, dated October 31, 2025, included an order for the resident to receive 50 mg of Seroquel twice daily.

Physician's orders for Resident 4, dated January 27, 2026, included an order for the resident to receive 100 mg of Seroquel twice daily.

There was no documented evidence in Resident 4's clinical record to indicate that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased doses of Seroquel.

Interview with the Director of Nursing on February 19, 2026, at 3:17 p.m., confirmed that there was no documented evidence in Resident 4's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased doses on Seroquel.

28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(b)(2) Management.

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





 Plan of Correction - To be completed: 03/27/2026

A medication review has been completed for Resident # 4 for any antipsychotic medication(s). Consent(s) have been obtained. Resident # 4 has not had adverse consequences from not having a signed consent for the antipsychotic medication(s) while in the facility.

Audit of residents on antipsychotic medications has been completed to ensure that consents have been obtained for all new antipsychotic medications and any changes in antipsychotic medications.

Audits will be completed by the Director of Nursing (DON)/Designee for all new antipsychotic medication orders and any dose changes of antipsychotic medications twice weekly for 2 weeks, then weekly for 2 weeks, then monthly for 2 months.

Education will be provided to the licensed nursing staff on obtaining informed consent for antipsychotic medications and any changes in antipsychotic medications.

Results of audits will be presented to the Quality Assurance and Performance Improvement Committee for review and recommendations.
483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).
Observations:

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident representative was notified timely about a change in condition for one of six residents reviewed (Resident 2).

Findings include:

The facility's policy regarding notification of changes, dated February 4, 2026, indicated that the facility will notify the resident's representative when there is a change requiring notification.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 26, 2025, indicated that the resident was cognitively impaired and required assistance from staff for daily care needs. The resident's care plan, updated July 26, 2025, revealed that the resident was at risk for falls.

A nursing note for Resident 2, dated August 1, 2025, revealed that the resident fell in his room. A nursing note dated August 9, 2025, revealed that Resident 2 was found on his knees in his room and that he had a bruised elbow. A nursing note dated August 15, 2025 revealed that the resident was found on the floor in his room and that he had tripped over the oxygen tubing.

There was no documented evidence that Resident 2's daughter/power of attorney was notified regarding the falls on August 1, August 9, or August 15.

Interview with the Director of Nursing on February 19, 2026 at 1:34 p.m. revealed that Resident 2's daughter was not notified regarding the falls and that she should have been.

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





 Plan of Correction - To be completed: 03/27/2026

Resident #2 has been discharged from the facility therefore the resident's daughter/Power of Attorney (POA) will not be notified at this time of falls from August 2025.

Current residents are reviewed in a daily morning meeting, 5 times per week, for any falls and to ensure that the resident's representative is notified of the resident's fall.

Education will be provided to licensed nursing staff on family/resident representative/POA to include notification within 2 hours of a serious fall or within 24 hours of a minor incident without injury. Education will include that notification must include the time and circumstances of the fall, any injuries sustained, medical interventions provided, and the planned follow-up care.

Director of Nursing/Designee will complete an audit of family/resident representative/POA notification of the occurrence of a fall 2 times per week for 2 weeks, the weekly for 2 weeks, then monthly for 2 months.

Results of audits will be presented to the Quality Assurance and Performance Improvement Committee for review and recommendations.

483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of six residents reviewed (Resident 2).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 2, dated July 26, 2025, revealed that the resident was cognitively impaired, required assistance with care needs, and had diagnoses that included a gastrointestinal bleed (stomach).

Physician's orders for Resident 2, dated August 7, 2025, included an order for staff to obtain the residents stool three times and check for hidden blood.

A review of Resident 2's Treatment Administration Record, dated August 2025, revealed that staff did not obtain and test any stool samples from the resident as ordered.

Interview with the Director of Nursing on February 19, 2026 at 1:34 p.m. revealed that staff did not obtain any stool samples and check the for blood for Resident 2 and that they should have.

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





 Plan of Correction - To be completed: 03/27/2026

Resident #2 has been discharged from the facility and the facility is unable to obtain the laboratory (lab) work that was ordered in August 2025.

Lab orders of current residents have been reviewed to ensure no other missed hemoccult stools.

Education will be provided to licensed nursing staff on placing lab orders in the electronic medical record, and in the lab book that is on each unit of the facility.

Director of Nursing/Designee will audit labs that hemoccult stools were completed and results were obtained 2 times per week for 2 weeks, the weekly for 2 weeks, then monthly for 2 months.

Results of audits will be presented to the Quality Assurance and Performance Improvement Committee for review and recommendations.
483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(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 facility policies, clinical records, observations and staff interviews, it was determined that the facility failed to ensure that a resident's environment remained free of accident hazards by failing to ensure care-planned interventions were in place and that fall risk assessments were completed for one of six residents reviewed (Resident 1), and failed to implement interventions after a fall for one of six residents reviewed (Resident 4).

Findings include:

The facility's policy regarding fall prevention dated February 4, 2026, indicated that each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. A fall risk assessment is to be completed every 90 days and as indicated when a resident has a change in condition. The nurse will indicate the residents fall risk and initiate interventions on the care plan in accordance with residents' level of risk.

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 20, 2025, revealed that the resident was severely cognitively impaired, was dependent on staff for daily care needs and assistance of one staff for transfers. A care plan for Resident 1 dated September 25, 2025, revealed that the resident was a fall risk and was to be provided with a weighted blanket to help decrease anxiety/ restlessness.

A fall investigation report for Resident 1, dated September 24, 2025, revealed that the resident had an unwitnessed fall with prevention interventions in place. A weighted blanket to decrease anxiety and restlessness was added as a new intervention to prevent future falls, and the care plan was updated.

A review of Resident 1's clinical record revealed that fall risk assessments were completed on January 2 and September 5, 2025. There was no documented evidence that fall risk assessments were completed every 90 days per facility policy.

Observation of Resident 1 on February 19, 2026, at 11:30 a.m. revealed that the resident was lying in bed and did not have a weighted blanket.

Interview with Licensed Practical Nurse 1 on February 19, 2025, at 2:47 p.m. revealed that she was not aware that Resident 1 was supposed to have a weighted blanket.

Interview with the Nursing Home Administrator on February 19, 2026, at 2:52 p.m. confirmed that the resident should have had fall risk assessments completed every 90 days and that she should have a weighted blanket.

A quarterly MDS assessment for Resident 4, dated January 28, 2026, revealed that the resident was cognitively impaired, was sometimes understood and was able to usually understand others, was dependent with transfers, had a history of falls and had a diagnosis of dementia.

A nursing note for Resident 4, dated October 20, 2025, at 10:28 p.m. revealed that the resident had an assisted fall at approximately 10:15 p.m. while staff was assisting him in a transfer. The resident was going from his recliner, to his bed and became weak during the transfer. He was lowered to the floor and assessed for injury. The resident was assisted to his bed for p.m. care. Review of Resident 4's transfer status at the time of the fall revealed that the resident was a two assist for transfers with the use a pivot disc (designed to make transfers easier for individuals who are able to stand but cannot readily move their legs).

An incident report for Resident 4, dated October 20, 2025, indicated that no witness statements were found and there was no fall investigation completed post fall to identify contributing factors related to the fall. There was no documented evidence that a thorough investigation was completed to ensure that staff were transferring Resident 4 appropriately at the time of his fall, and there was there was no documented evidence that fall interventions were implemented after his fall to minimize his risk of further falls.

Interview with the Director of Nursing on February 19, 2026, at 4:30 p.m. confirmed that she did not have any witness statements or any further investigation reports completed post fall that ensured staff were transferring Resident 4 correctly at the time of his fall on October 20, 2025, and confirmed that there was no documented evidence that fall interventions were implemented after his fall to minimize his risk of further falls.

28 Pa. Code 211.12(d)(1)(5) Nursing Services.






 Plan of Correction - To be completed: 03/27/2026

Resident #1 was reviewed to ensure that current fall care plan interventions were in place and weighted blanket is in use.
Resident #4 was reviewed to ensure that new fall prevention interventions were placed following most recent fall.

Residents' Fall Prevention Assessments were reviewed and updated by the Director of Nursing/designee and the care plans were reviewed and updated as needed.

Nursing staff will be educated by the Director of Nursing/designee on importance of following fall prevention interventions, assigning new fall prevention interventions post-fall and completing the Fall Prevention Assessment for residents on admission/readmission, following a fall and quarterly.

Director of Nursing/designee will perform random audits on residents' fall prevention interventions, fall prevention assessments, and completed investigations to include witness statements 3 times a week for 2 weeks, weekly for 2 weeks and then monthly for 2 months.

Results of Audits will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
§ 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 review of nursing schedules, staffing information furnished by the facility, and staff interviews, it was determined that the facility failed to provide one nurse aide (NA) per 10 residents on the day shift for seven of 21 days, failed to provide one NA per 11 residents on the evening shift for 12 of 21 days, and failed to provide one NA per 15 residents on the night shift for seven of 21 days reviewed for January 19 through January 25, 2026; February 5 through February 11, 2026; and February 12 through 18, 2026. Findings include: Review of facility census data revealed: On February 8, 2026, the facility census was 70, during the day shift, which required 7.00 NA's during the day shift. Review of the nursing time schedules revealed 5.26 NA's provided care on the day shift. On February 9, 2026, the facility census was 69, during the day shift, which required 6.90 NA's during the day shift. Review of the nursing time schedules revealed 6.80 NA's provided care on the day shift. On February 10, 2026, the facility census was 71, during the day shift, which required 7.10 NA's during the day shift. Review of the nursing time schedules revealed 6.85 NA's provided care on the day shift. On February 15, 2026, the facility census was 71, during the day shift, which required 7.10 NA's during the day shift. Review of the nursing time schedules revealed 5.72 NA's provided care on the day shift. On February 16, 2026, the facility census was 71, during the day shift, which required 7.10 NA's during the day shift. Review of the nursing time schedules revealed 5.79 NA's provided care on the day shift. On February 17, 2026, the facility census was 71, during the day shift, which required 7.10 NA's during the day shift. Review of the nursing time schedules revealed 6.85 NA's provided care on the day shift. On February 18, 2026, the facility census was 71, during the day shift, which required 7.10 NA's during the day shift. Review of the nursing time schedules revealed 6.50 NA's provided care on the day shift. On February 5, 2026, the facility census was 69, during the evening shift, which required 6.27 NA's during the evening shift. Review of the nursing time schedules revealed 6.00 NA's provided care on the evening shift. On February 6, 2026, the facility census was 71, during the evening shift, which required 6.45 NA's during the evening shift. Review of the nursing time schedules revealed 5.98 NA's provided care on the evening shift. On February 8, 2026, the facility census was 70, during the evening shift, which required 6.36 NA's during the evening shift. Review of the nursing time schedules revealed 6.06 NA's provided care on the evening shift. On February 9, 2026, the facility census was 69, during the evening shift, which required 6.27 NA's during the evening shift. Review of the nursing time schedules revealed 5.48 NA's provided care on the evening shift. On February 10, 2026, the facility census was 71, during the evening shift, which required 6.45 NA's during the evening shift. Review of the nursing time schedules revealed 5.95 NA's provided care on the evening shift. On February 11, 2026, the facility census was 71, during the evening shift, which required 6.45 NA's during the evening shift. Review of the nursing time schedules revealed 6.44 NA's provided care on the evening shift. On February 13, 2026, the facility census was 71, during the evening shift, which required 6.45 NA's during the evening shift. Review of the nursing time schedules revealed 4.51 NA's provided care on the evening shift. On February 14, 2026, the facility census was 70, during the evening shift, which required 6.36 NA's during the evening shift. Review of the nursing time schedules revealed 5.42 NA's provided care on the evening shift. On February 15, 2026, the facility census was 71, during the evening shift, which required 6.45 NA's during the evening shift. Review of the nursing time schedules revealed 5.66 NA's provided care on the evening shift. On February 16, 2026, the facility census was 72, during the evening shift, which required 6.55 NA's during the evening shift. Review of the nursing time schedules revealed 5.34 NA's provided care on the evening shift. On February 17, 2026, the facility census was 71, during the evening shift, which required 6.45 NA's during the evening shift. Review of the nursing time schedules revealed 6.41 NA's provided care on the evening shift. On February 18, 2026, the facility census was 71, during the evening shift, which required 6.45 NA's during the evening shift. Review of the nursing time schedules revealed 5.81 NA's provided care on the evening shift. On January 19, 2026, the facility census was 66, during the night shift, which required 4.40 NA's during the night shift. Review of the nursing time schedules revealed 4.19 NA's provided care on the night shift. On January 20, 2026, the facility census was 66, during the night shift, which required 4.40 NA's during the night shift. Review of the nursing time schedules revealed 4.34 NA's provided care on the night shift. On January 21, 2026, the facility census was 66, during the night shift, which required 4.40 NA's during the night shift. Review of the nursing time schedules revealed 4.31 NA's provided care on the night shift. On January 22, 2026, the facility census was 67, during the night shift, which required 4.47 NA's during the night shift. Review of the nursing time schedules revealed 3.78 NA's provided care on the night shift. On January 25, 2026, the facility census was 65, during the night shift, which required 4.33 NA's during the night shift. Review of the nursing time schedules revealed 4.25 NA's provided care on the night shift. On February 17, 2026, the facility census was 71, during the night shift, which required 4.73 NA's during the night shift. Review of the nursing time schedules revealed 4.66 NA's provided care on the night shift. On February 18, 2026, the facility census was 71, during the night shift, which required 4.73 NA's during the night shift. Review of the nursing time schedules revealed 4.13 NA's provided care on the night shift. However, there were no additional excess higher-level staff available to compensate for these deficiencies. Interview with the Nursing Home Administrator on February 23, 2026, at 9:46 a.m. confirmed that the facility did not meet the required NA-to-resident staffing ratios for the days listed above.
 Plan of Correction - To be completed: 03/27/2026

The facility will make every attempt to staff a minimum of one nurse aide (NA) per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Education will be provided to the scheduler by the Nursing Home Administrator (NHA) to ensure that they understand the regulatory staffing ratio requirements.

In the event of call-offs by staff, other staff/agency will be contacted to cover any open shifts to ensure staffing requirements are met.

Staffing ratio will be discussed during stand up morning meeting with regards to meeting staffing ratio.

Director of Nursing/Designee will log ratio on audit sheet 5 times per week for 2 weeks then weekly for 2 times per week for 2 weeks, then monthly for 2 months.

Findings will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
§ 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 review of nursing schedules, review of staffing information furnished by the facility, and staff interviews, it was determined that the facility failed to provide a minimum of one licensed practical nurse (LPN) per 30 residents on the evening shift for nine of 21 days and failed to provide one LPN per 40 residents on the night shift for one of 21 days reviewed for January 19 through January 25, 2026; February 5 through February 11, 2026; and February 12 through 18, 2026. Findings include: Review of facility census data revealed: On January 19, 2026, the facility's census was 66 during the evening shift, which required 2.20 LPN's on the evening shift. Review of the nursing time schedules revealed that 2.06 LPN's provided care during the evening shift. On January 24, 2026, the facility's census was 66 during the evening shift, which required 2.20 LPN's on the evening shift. Review of the nursing time schedules revealed that 1.91 LPN's provided care during the evening shift. On February 5, 2026, the facility's census was 69 during the evening shift, which required 2.30 LPN's on the evening shift. Review of the nursing time schedules revealed that 2.22 LPN's provided care during the evening shift. On February 7, 2026, the facility's census was 70 during the evening shift, which required 2.33 LPN's on the evening shift. Review of the nursing time schedules revealed that 2.16 LPN's provided care during the evening shift. On February 8, 2026, the facility's census was 70 during the evening shift, which required 2.33 LPN's on the evening shift. Review of the nursing time schedules revealed that 2.16 LPN's provided care during the evening shift. On February 11, 2026, the facility's census was 71 during the evening shift, which required 2.37 LPN's on the evening shift. Review of the nursing time schedules revealed that 2.16 LPN's provided care during the evening shift. On February 16, 2026, the facility's census was 72 during the evening shift, which required 2.40 LPN's on the evening shift. Review of the nursing time schedules revealed that 2.22 LPN's provided care during the evening shift. On February 17, 2026, the facility's census was 71 during the evening shift, which required 2.37 LPN's on the evening shift. Review of the nursing time schedules revealed that 2.31 LPN's provided care during the evening shift. On February 18, 2026, the facility's census was 71 during the evening shift, which required 2.37 LPN's on the evening shift. Review of the nursing time schedules revealed that 2.19 LPN's provided care during the evening shift. On January 22, 2026, the facility's census was 67 during the night shift, which required 1.68 LPN's on the night shift. Review of the nursing time schedules revealed that 1.66 LPN's provided care during the night shift. However, there were no additional excess higher-level staff available to compensate for these deficiencies. Interview with the Nursing Home Administrator on February 23, 2026, at 9:46 a.m. confirmed that the facility did not meet the required LPN-to-resident staffing ratios for the days listed above.
 Plan of Correction - To be completed: 03/27/2026

The facility will make every attempt to staff a minimum of one Licensed Practical Nurse (LPN) per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Education will be provided to the scheduler by the Nursing Home Administrator (NHA) to ensure that they understand the regulatory staffing ratio requirements.

In the event of call-offs by staff, other staff/agency will be contacted to cover any open shifts to ensure staffing requirements are met.

Staffing ratio will be discussed during stand up morning meeting with regards to meeting staffing ratio.

Director of Nursing/Designee will log ratio on audit sheet 5 times per week for 2 weeks then weekly for 2 times per week for 2 weeks, then monthly for 2 months.

Findings will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations: Based on review of nursing schedules and staff interviews, it was determined that the facility failed to provide 3.20 hours of direct resident care for each resident for eight of 21 days (24-hour periods) reviewed for January 19 through January 25, 2026; February 5 through February 11, 2026; and February 12 through 18, 2026. Findings include: Review of the nursing time schedules provided by the facility revealed that the facility provided 2.94 hours of direct care for each resident on February 8; 3.14 hours of direct care for each resident on February 9; 3.17 hours of direct care for each resident on February 10; 2.97 hours of direct care for each resident on February 13; 3.04 hours of direct care for each resident on February 15; 2.97 hours of direct care for each resident on February 16; 3.14 hours of direct care for each resident on February 17; and 3.00 hours of direct care for each resident on February 18; Interview with the Nursing Home Administrator on February 23, 2026, at 9:46 a.m. confirmed that the facility did not meet the required daily hours of direct resident care for each resident on the days listed above.
 Plan of Correction - To be completed: 03/27/2026

The facility will make every attempt to staff a minimum of 3.2 hours of direct resident care for each resident.

Education will be provided to the scheduler by the Nursing Home Administrator (NHA) to ensure that they understand the regulatory staffing requirements of 3.2 hours of direct resident care for each resident.

In the event of call-offs by staff, other staff/agency will be contacted to cover any open shifts to ensure staffing requirements are met.

The staffing calculator spreadsheet used by the Department of Health will be completed by the scheduler 5 times per week for 4 weeks, then weekly x 2 weeks, to ensure that 3.2 hours of direct resident care was met each day.

Findings will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.

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