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

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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:

Findings of an abbreviated complaint survey completed on April 8, 2024 at Somerset Healthcare and Rehabilitation Center identified no deficient practice under the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities as it relates to the Health portion of the survey process; however, deficient practice was identified under 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(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 schedules, review of staffing information furnished by the facility, and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide (NA) per 12 residents on the evening shift for four of 21 days, and failed to ensure a minimum of one NA per 20 residents on the overnight shifts for three of 21 days (24-hour periods) reviewed.

Findings Include:

Review of facility census data indicated that on March 16, 2024, the facility census was 79, which required 6.58 (79 residents divided by 12) NA's during the evening shift. Review of the nursing time schedules revealed 4.19 NA's provided care on the evening shift on March 16, 2024.

On March 17, 2024, the facility census was 80, which required 4.0 NA's during the night shift; however, review of the time schedule revealed that 3.28 NA's provided care on the night shift.

On March 23, 2024, the facility census was 79, which required 6.58 NA's on the evening shift; however, review of the time schedule revealed that 5.91 NA's provided care on the evening shift. The night shift census was 79, which required 3.95 NA's; however, review of the time schedule revealed that 3.94 NA's provided care on the night shift.

On March 30, 2024, the facility census was 74, which required 6.17 NA's during the evening shift; however, review of the time schedule revealed that 5.44 NA's provided care on the evening shift.

On March 31, 2024, the facility census was 75, which required 6.25 NA's during the evening shift; however, review of the time schedule revealed that 3.28 NA's provided care during the evening shift. The night shift census was 75, which required 3.75 NA's; however, review of the time schedule revealed that 3.53 NA's provided care on the night shift.

No additional excess higher-level staff were available to compensate for these deficiencies.

Interview with the Nursing Home Administrator on April 8, 2024, at 11:51 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: 04/12/2024

1. The Administrator immediately educated the Director of Nursing (aka DON) and the scheduler on ratios and Hours Per Patient Day (aka HPPD). The Administrator, DON and scheduler addressed the scheduling concerns of Certified Nurse Aide (aka CNA) Ratio to ensure that the facility will be meeting current ratios for resident care. Admissions will be adjusted accordingly.
2. The scheduler, DON, and Administrator will monitor staffing ratios and HPPD daily. Acuity of the residents and nursing workload will also be included. Nursing staff are expected to work another shift when calling off on the weekend as per policy and call offs will progressively be disciplined as per policy. Staff education will be completed on all shifts on the importance of coming to work when scheduled. Continue to recruit additional talent.
3. Flexible scheduling, floating nursing staff, and involving the nursing staff in staffing decisions will also be included when reviewing staffing ratios and HPPD.
4. The management team will review the staffing day prior to ensure adequate HPPD/Ratios are met. The DON will review staffing levels at our monthly Quality Assurance Performance Improvement Meeting.

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 ensure a minimum of one licensed practical nurse (LPN) per 30 residents on the evening shift for one of 21 days, and failed to ensure a minimum of one LPN per 40 residents on the overnight shifts for two of 21 days (24-hour periods) reviewed.

Findings Include:

Nursing time schedules provided by the facility for the days of March 12 through April 1, 2024, revealed that the facility census was 74, which required 1.88 LPN's; however, review of the facility's time record revealed that 1.13 LPN's provided care on the night shift.

On March 30, 2024, the facility census was 74, which required 2.47 LPN's on the evening shift; however, review of the facility's time record revealed 2.25 LPN's provided care. On night shift the facility census was 75, which required 1.85 LPN's; however, review of the facility's time record revealed that 1.19 LPN's provided care on the night shift.

Interview with the Nursing Home Administrator on April 8, 2024, at 11:51 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: 04/12/2024

1. The Administrator immediately educated the Director of Nursing (aka DON) and the scheduler on ratios and Hours Per Patient Day (aka HPPD). The Administrator, DON and scheduler addressed the scheduling concerns of Licensing Practical Nurse (aka LPN) ratio to ensure that the facility will be meeting current ratios for resident care. Admissions will be adjusted accordingly.
2. The scheduler, DON, and Administrator will monitor staffing ratios and HPPD daily. Acuity of the residents and nursing workload will also be included. Nursing staff are expected to work another shift when calling off on the weekend as per policy and call offs will progressively be disciplined as per policy. Staff education will be completed on all shifts on the importance of coming to work when scheduled. Continue to recruit additional talent.
3. Flexible scheduling, floating nursing staff, and involving the nursing staff in staffing decisions will also be included when reviewing staffing ratios and HPPD.
4. The management team will review the staffing day prior to ensure adequate HPPD/Ratios are met. The DON will review staffing levels at our monthly Quality Assurance Performance Improvement Meeting.

211.12(f.2)(1) LICENSURE Nursing services. :State only Deficiency.
(1) A facility may substitute an LPN or RN for a nurse aide but may not substitute a nurse aide for an LPN or RN

Observations:


Based on review of nursing schedules and staff interviews, it was determined that the facility failed to provide 2.87 hours of direct resident care for each resident for four of 21 days (24-hour periods) reviewed.

Findings include:

Nursing time schedules provided by the facility for the days of March 12 through April 1, 2024, revealed that the facility provided only 2.75 hours of direct care for each resident on March 16, 2024; only 2.80 hours of direct care for each resident on Mary 23, 2024; only 2.83 hours of direct care for each resident on March 30, 2024; and only 2.53 hours of direct care for each resident on March 31, 2024.

Interview with the Nursing Home Administrator on April 8, 2024, at 11:51 a.m. confirmed that staffing was below the required minimum number of nursing care hours for the days listed above.


 Plan of Correction - To be completed: 04/12/2024

1. The Administrator immediately educated the Director of Nursing (aka DON) and the scheduler on ratios and Hours Per Patient Day (aka HPPD). The Administrator, DON and scheduler addressed the scheduling concerns of Registered Nurses (aka RNs) Licensing Practical Nurses (aka LPNs) and Certified Nursing Assistants (aka CNAs) HPPD to ensure that the facility will be meeting current HPPD for resident care. Admissions will be adjusted accordingly.
2. The scheduler, DON, and Administrator will monitor staffing ratios and HPPD daily. Acuity of the residents and nursing workload will also be included. Nursing staff are expected to work another shift when calling off on the weekend as per policy and call offs will progressively be disciplined as per policy. Staff education will be completed on all shifts on the importance of coming to work when scheduled. Continue to recruit additional talent.
3. Flexible scheduling, floating nursing staff, and involving the nursing staff in staffing decisions will also be included when reviewing staffing ratios and HPPD.
4. The management team will review the staffing day prior to ensure adequate HPPD/Ratios are met. The DON will review staffing levels at our monthly Quality Assurance Performance Improvement Meeting.



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