Pennsylvania Department of Health
GARDENS AT WYOMING VALLEY, THE
Patient Care Inspection Results

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GARDENS AT WYOMING VALLEY, THE
Inspection Results For:

There are  127 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.
GARDENS AT WYOMING VALLEY, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Findings of revist an abbreviated complaint survey completed on December 13, 2023, at The Gardens at Wyoming Valley identified no deficient practice, related to the reported complaint allegations, under the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities but remained out of compliance with the following requirements under the 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 a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 21 shifts out of 54 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse aide staff of 1:12 on the day and evening shifts and 1:20 on the night shift based on the facility's census.

November 25, 2023 - 7 nurse aides on the day shift, versus the required 8 for a census of 86.
November 25, 2023 - 7 nurse aides on the evening shift, versus the required 8 for a census of 86.
November 25, 2023 - 3 nurse aides on the night shift, versus the required 5 for a census of 86.
November 26, 2023 - 6 nurse aides on the day shift, versus the required 8 for a census of 86.
November 26, 2023 - 3 nurse aides on the night shift, versus the required 5 for a census of 86.
November 27, 2023 - 7 nurse aides on the day shift, versus the required 8 for a census of 86.
November 27, 2023 - 7 nurse aides on the evening shift, versus the required 8 for a census of 87.
November 27, 2023 - 4 nurse aides on the night shift, versus the required 5 for a census of 87.
November 28, 2023 - 4 nurse aides on the night shift, versus the required 5 for a census of 86.
November 29, 2023 - 7 nurse aides on the evening shift, versus the required 8 for a census of 87.
November 29, 2023 - 4 nurse aides on the night shift, versus the required 5 for a census of 87.
November 30, 2023 - 4 nurse aides on the night shift, versus the required 5 for a census of 87.
December 1, 2023 - 6 nurse aides on the evening shift, versus the required 8 for a census of 87.
December 2, 2023 - 6 nurse aides on the evening shift, versus the required 8 for a census of 87.
December 2, 2023 - 4 nurse aides on the night shift, versus the required 5 for a census of 87.
December 3, 2023 - 6 nurse aides on the evening shift, versus the required 8 for a census of 87.
December 3, 2023 - 4 nurse aides on the night shift, versus the required 5 for a census of 87.
December 4, 2023 - 7 nurse aides on the day shift, versus the required 8 for a census of 87.
December 4, 2023 - 4 nurse aides on the night shift, versus the required 5 for a census of 87.
December 7, 2023 - 4 nurse aides on the night shift, versus the required 5 for a census of 87.
December 9, 2023 - 4 nurse aides on the night shift, versus the required 5 for a census of 84.

An interview with the Nursing Home Administrator on December 13, 2023, at approximately 2:50 PM, confirmed the facility had not met the required nurse aide to resident ratios on all three shifts on the above dates.



 Plan of Correction - To be completed: 01/24/2024

Correction does not constitute an admission of or agreement with the facts and conclusions set forth in the survey report. Our plan of correction is prepared and executed to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

Facility cannot retroactively correct this deficiency.

Recruitment of nursing staff will continue via facility website, Indeed, social media websites, job fairs, off site recruiters and instant interviews from walk-in candidates. Agency staff will be utilized for open shifts if available.

Retention efforts will be made in earnest. Referral bonuses are offered to current employees. The facility is currently offering a significant sign-on bonus for all new nursing staff.

The Director of Nursing/designee will review the ratio daily for compliance.

All efforts will be made to meet certified aide staffing ratios. If a call off occurs all efforts will be made to fill that position.

The Director of Nursing/designee will audit the certified aide ratio 1x/week for 4 weeks then monthly for 2 months.

Staffing will be following the revised ratio methodology beginning January 1, 2024

Results will be presented to QA committee for review and recommendation.

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

Based on a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum licensed practical nurse staff to resident ratio was provided on each shift for 8 shifts out of 54 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:25 on the day shift and 1:40 on the night shift based on the facility's census.

November 25, 2023 - 2 LPNs on the night shift, versus the required 3 for a census of 86.
November 26, 2023 - 2 LPNs on the night shift, versus the required 3 for a census of 86.
November 27, 2023 - 2 LPNs on the night shift, versus the required 3 for a census of 87.
November 28, 2023 - 2 LPNs on the night shift, versus the required 3 for a census of 86.
November 29, 2023 - 2 LPNs on the night shift, versus the required 3 for a census of 87.
December 3, 2023 - 2 LPNs on the night shift, versus the required 3 for a census of 87.
December 4, 2023 - 2 LPNs on the night shift, versus the required 3 for a census of 87.
December 10, 2023 - 3 LPNs on the day shift, versus the required 4 for a census of 84.

An interview with the Nursing Home Administrator on December 13, 2023, approximately 2:50 PM, confirmed the facility had not met the required LPN to resident ratios on the above dates.



 Plan of Correction - To be completed: 01/24/2024

Facility cannot retroactively correct this deficiency.

Recruitment of nursing staff will continue via facility website, Indeed, social media websites, job fairs, off site recruiters and instant interviews from walk-in candidates. Agency staff will be utilized for open shifts if available.

Retention efforts will be made in earnest. Referral bonuses are offered to current employees. The facility is currently offering a significant sign-on bonus for all new nursing staff.

The Director of Nursing/designee will review the ratio daily for compliance.
All efforts will be made to meet LPN staffing ratios. If a call off occurs all efforts will be made to fill that position.

The Director of Nursing/designee will audit the LPN ratio 1x/week for 4 weeks then monthly for 2 months.

Staffing will be following the revised ratio methodology beginning January 1, 2024

Results will be presented to QA committee for review and recommendation.

211.12(f.1)(5) LICENSURE Nursing services. :State only Deficiency.
(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.
Observations:

Based on a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum Registered nurse staff to resident ratio was provided on each shift for 24 shifts out of 54 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum Registered nurse (RN) staff of 1:250 on the day, evening, and night shift based on the facility's census.

November 25, 2023 - 0 RNs on the evening shift, versus the required 1 for a census of 86.
November 25, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 86.
November 26, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 86.
November 27, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 87.
November 28, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 86.
November 29, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 87.
November 30, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 87.
December 1, 2023 - 0 RNs on the day shift, versus the required 1 for a census of 87.
December 1, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 87.
December 2, 2023 - 0 RNs on the day shift, versus the required 1 for a census of 87.
December 3, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 87.
December 4, 2023 - 0 RNs on the day shift, versus the required 1 for a census of 87.
December 4, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 87.
December 5, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 87.
December 6, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 87.
December 7, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 87.
December 8, 2023 - 0 RNs on the day shift, versus the required 1 for a census of 86.
December 8, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 84.
December 9, 2023 - 0 RNs on the day shift, versus the required 1 for a census of 84.
December 9, 2023 - 0 RNs on the evening shift, versus the required 1 for a census of 84.
December 9, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 84.
December 10, 2023 - 0 RNs on the evening shift, versus the required 1 for a census of 84.
December 10, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 84.
December 11, 2023 - 0 RNs on the night shift, versus the required 1 for a census of 84.

An interview with the Nursing Home Administrator on December 13, 2023, at approximately 2:50 PM, confirmed the facility had not met the required RN to resident ratios on the above dates.




 Plan of Correction - To be completed: 01/24/2024

Facility cannot retroactively correct this deficiency.

Per the Department of Health regulation 211.12 (nursing services) "Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts" is required. On the following dates listed in the DOH 2567; November 25-30, 2023, and December 1-11, 2023 the facility did in fact have 1 RN on duty during all shifts.

Recruitment of nursing staff will continue via facility website, Indeed, social media websites, job fairs, off site recruiters and instant interviews from walk-in candidates. Agency staff will be utilized for open shifts if available.

Retention efforts will be made in earnest. Referral bonuses are offered to current employees. The facility is currently offering a significant sign-on bonus for all nursing staff.

The Director of Nursing/designee will review the ratio daily for compliance. All efforts will be made to meet RN staffing ratios. If a call off occurs all efforts will be made to fill that position.

The Director of Nursing/designee will audit the RN ratio 1x/week for 4 weeks then monthly for 2 months.

Staffing will be following the revised ratio methodology beginning January 1, 2024

Results will be presented to QA committee for review and recommendation.

211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(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, 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 levels revealed that on the following date the facility failed to provide minimum nurse staffing of 2.87 hours of general nursing care to each resident:

November 25, 2023 -2.63 direct care nursing hours per resident
November 27, 2023 -2.74 direct care nursing hours per resident
November 29, 2023 -2.75 direct care nursing hours per resident
December 3, 2023 -2.77 direct care nursing hours per resident
December 4, 2023 -2.82 direct care nursing hours per resident

The facility's general nursing hours were below minimum required levels on the date noted above.

An interview with the Nursing Home Administrator on December 13, 2023, at approximately 2:50 PM confirmed the facility failed to consistently provide minimum general nursing care hours to each resident daily.



 Plan of Correction - To be completed: 01/24/2024

The Facility cannot retroactively correct this deficiency.

Recruitment of nursing staff will continue via facility website, Indeed, social media websites, job fairs, off site recruiters and instant interviews from walk-in candidates. Agency staff will be utilized for open shifts if available.

Retention efforts will be made in earnest. Referral bonuses are offered to current employees. The facility is currently offering a significant sign-on bonus for all nursing staff.

The Director of Nursing/designee will review the PPD daily for compliance. All efforts will be made to meet the required PPD of 2.87. If a call off occurs all efforts will be made to achieve the PPD.

The Director of Nursing/designee will audit the PPD 1x/week for 4 weeks then monthly for 2 months.

Results will be presented to QA committee for review and recommendation.


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