Pennsylvania Department of Health
WESBURY UNITED METHODIST COMM
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WESBURY UNITED METHODIST COMM
Inspection Results For:

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WESBURY UNITED METHODIST COMM - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Complaint Survey completed on April 9, 2024, at Wesbury United Methodist Community, it was determined that there were no federal deficiencies identified 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, the facility was not in compliance with 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 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 interview, it was determined that the facility to provide a minimum of one Licensed Practical Nurse (LPN) per 25 residents during the day shift for one of 21 days reviewed (3/31/24), and one LPN per 40 residents during the overnight shift for two of 21 days reviewed (3/17/24 and 4/1/24).

Findings include:

Review of the facility census revealed that on 3/31/24, the facility census was 150 which required a minimum of 6.0 LPNs during the day shift. Review of the nursing time schedules revealed that only 3.75 LPNs worked the day shift on 3/31/24; therefore not meeting the LPN ratio for that dates.

Review of the facility census revealed that on 3/17/24, the facility census was 150 which required a minimum of 3.75 LPNs during the overnight shift. Review of the nursing time schedules revealed that only 3.41 LPNs worked the overnight shift on 3/17/24; therefore not meeting the LPN ratio for that date.

Review of the facility census revealed that on 4/1/24, the facility census was 149 which required a minimum of 3.73 LPNs during the overnight shift. Review of the nursing time schedules revealed that only 3.00 LPNs worked the overnight shift on 4/1/24; therefore not meeting the LPN ratio for that date.

During an interview on 4/9/24, at approximately 7:55 a.m. the Nursing Home Administrator confirmed that the facility failed to meet the required LPN to resident ratio on the above dates and shifts.

Plan of Correction - To be completed: 05/03/2024

In an effort to maintain compliance with the regulation, the facility shall utilize the following process:

1. In an attempt to achieve appropriate staffing ratios for LPNs, each day the Director of Nursing or designee will review the deployment sheet for the upcoming day for compliance with required ratios.
2. When a call-off is received, the supervisor will make every effort to replace the hours fully.
3. Education will be provided to nursing supervisors on replacing staff, ratios, and ppd.
4. The facility shall complete a monitor of staffing ratios weekly utilizing the DOH staffing form for 1 month, then monthly for 2 months, and finally quarterly until such time is determined by the Quality Assurance Committee that the facility is maintaining compliance. This shall be the responsibility of the Director of Nursing or designee.

§ 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 review of nursing schedules and staffing information furnished by the facility, it was determined that the facility failed to ensure the total number of general nursing care hours provided in each 24-hour period be a minimum of 2.87 hours per patient day (PPD) of direct care for each resident for one of 21 days reviewed (3/31/24).

Findings include:

The staffing information furnished by the facility for the time period 3/14/24, through 4/2/24, revealed that on 3/31/24, the facility staffing level was 2.66 PPD hours of direct care for each resident; therefore not meeting the required minimum of 2.87 PPD hours.

During an interview on 4/9/24, at approximately 7:55 a.m. the Nursing Home Administrator confirmed that the facility failed meet 2.87 PPD hours of direct care for each resident on 3/31/24.

Plan of Correction - To be completed: 05/03/2024

In an effort to maintain compliance with the regulation, the facility will utilize the following process:

1. In an attempt to achieve the required ppd hours of a 2.87 the Director of Nursing or designee will review the deployment sheet for the upcoming day to review for compliance with the required ppd.
2. When a call off is received, the supervisor will make every effort to replace the hours fully if they impact the facility's ability to achieve a ppd of 2.87.
3. Education will be provided to nursing supervisors on replacing staff, ratios, and ppd.
4. The facility will complete a monitor of the facility's ppd weekly utilizing the DOH staffing calculation tool for 1 month, then monthly for 2 months, and finally quarterly until the Quality Assurance Committee has determined the facility is maintaining compliance.

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