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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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MEADOW VIEW REHABILITATION & HEALTHCARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a revisit and abbreviated complaint survey completed on March 15, 2024, it was determined that Meadow View Rehabilitation & Healthcare Center failed to correct the federal deficiencies cited during the surveys of December 14, 2024, and February 7, 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:

483.10(g)(4)(i)-(vi) REQUIREMENT Required Notices and Contact Information:

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)(4) The resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands, including:
(i) Required notices as specified in this section. The facility must furnish to each resident a written description of legal rights which includes -
(A) A description of the manner of protecting personal funds, under paragraph (f)(10) of this section;
(B) A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment of resources under section 1924(c) of the Social Security Act.
(C) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies, resident advocacy groups such as the State Survey Agency, the State licensure office, the State Long-Term Care Ombudsman program, the protection and advocacy agency, adult protective services where state law provides for jurisdiction in long-term care facilities, the local contact agency for information about returning to the community and the Medicaid Fraud Control Unit; and
(D) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community.
(ii) Information and contact information for State and local advocacy organizations including but not limited to the State Survey Agency, the State Long-Term Care Ombudsman program (established under section 712 of the Older Americans Act of 1965, as amended 2016 (42 U.S.C. 3001 et seq) and the protection and advocacy system (as designated by the state, and as established under the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15001 et seq.)
(iii) Information regarding Medicare and Medicaid eligibility and coverage;
(iv) Contact information for the Aging and Disability Resource Center (established under Section 202(a)(20)(B)(iii) of the Older Americans Act); or other No Wrong Door Program;
(v) Contact information for the Medicaid Fraud Control Unit; and
(vi) Information and contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community.

Observations:

Based on a review of clinical records, CMS guidance and facility documentation, and staff interviews, it was determined the facility failed to develop policies and procedures in accordance with CMS (Center for Medicare and Medicaid Services) guidance to protect residents from unacceptable practices of disenrolling residents from the Medicare Health Plans and to ensure all risks of disenrolling are fully explained, both verbally and in writing to the residents, and if applicable, the residents' representative.

Finding include:

A review of a CMS guidance titled "Memo to Long Term Care (LTC) Facilities on Medicare Health Plan Enrollment" dated October 2021 revealed CMS continues to hear reports of the unacceptable practice of nursing facilities or skilled nursing facilities (collectively, long-term care or LTC facilities) disenrolling beneficiaries from Medicare health plans (Medicare Advantage plans with and without Part D, Medicare-Medicaid plans, or Programs of All-Inclusive Care for the Elderly (PACE) without the beneficiary's or the beneficiary's representative's request, consent, knowledge, and/or complete understanding. Only a Medicare beneficiary, the beneficiary's authorized or designated representative, or the party authorized to act on behalf of the beneficiary under state law can request enrollment in or voluntary disenrollment from a Medicare health or drug plan. Further it is indicated changes in a beneficiary's health care coverage generally must be initiated by the beneficiary or their representative. If a beneficiary or their legal representative requests assistance from the LTC facility in changing the beneficiary's health care coverage, the LTC facility should take the following steps to help ensure changes to a beneficiary's health care coverage comply with regulations regarding enrollment/disenrollment and resident rights:

1)Explain orally and in writing the impact to the beneficiary if they change coverage (e.g., to a stand-alone prescription drug plan (PDP) and Original Medicare, or to a different Medicare health plan).
2) Develop written policies and procedures regarding the process of assisting beneficiaries with changing their health care coverage. At a minimum, information should include the circumstances under which the facility can assist a beneficiary with a plan change. The need to obtain a document signed by the beneficiary or representative that acknowledges that the specific information regarding the impact of a change in coverage was provided to them orally and in writing, and that that the beneficiary and/or the representative understand the information. The need to obtain an attestation signed by the facility staff member that assisted with the change in enrollment, attesting that the beneficiary or representative requested the change and that the beneficiary or representative (as applicable) received and understood the minimum required information listed above. In cases where beneficiaries request disenrollment from PACE, LTC facilities that are contracted with PACE organizations should work directly with the PACE organization and the participant's interdisciplinary team to ensure the PACE participant receives the information required under the PACE regulations and to coordinate the transition of care, including as specified in their contract requirements.

According to the CMS memo if a LTC facility cannot provide documentation of a beneficiary's request to change enrollment, this may suggest that the enrollment action was not initiated by the beneficiary or their legal representative and therefore was not legally valid. Lastly, If the facility has the beneficiary sign documentation regarding their understanding of an enrollment change, CMS will expect to find that the beneficiary's assessed cognitive function also supports an ability to understand this type of information. If CMS becomes aware of enrollment actions that the beneficiary alleges were taken without their request, consent, knowledge, and/or complete understanding, CMS will expect the facility to provide the above noted documentation to support that it appropriately assisted the beneficiary with their choice to change coverage, including that the beneficiary's cognitive function supports such decision-making.

Interview with the Nursing Home Administrator on March 15, 2024, at 1:18 PM, confirmed that the facility may initiate discussions about making changes in Medicare Health plans for its residents. The NHA was unable to provide established facility policies and procedures in place at the time of the survey, that outline the facility's process of assisting beneficiaries and their representatives with changing their Medicare health plans, and that assure that residents possess the cognitive ability to make such changes at the given time, and that these changes are initiated by the resident or their representative.

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

28 Pa. Code 201.18 (b)(2)(c)(e)(1)(2) Management

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

1. The facility has a policy and procedure in place if a resident or their representative wishes to make changes to their Medicare Health Plan.
2. Nursing Home Administrator or Designee will conduct an initial audit to validate that any changes made to current residents Medicare Health Plans follow the facilities policy.
3. Nursing Home Administrator of Designee will re-educated Business Office Manager and Social Service Director regarding Medicare Health Plan Enrollment Policy and Procedure.
4. Nursing Home Administrator or Designee will conduct random audits weekly for four weeks and then monthly audits for two months thereafter to validate that current residents who have recently elected to change their Medicare Health Plan is following the facility policy. Results of the audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.

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 a review of clinical records and select investigation reports and staff interview, it was determined that the facility failed to implement effective fall prevention interventions including timely and necessary staff supervision of resident with a history of falls with injury, known unsafe restless behaviors that increased the resident's risk for falls, to prevent a fall with minor injury for one resident out of six sampled (Resident B1).

Findings include:

A review of the clinical record revealed that Resident B1 was admitted to the facility on February 9, 2024, with diagnoses of dementia, muscle weakness and a history of repeated falls.

An admission Minimum Data Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated February 23, 2024, revealed that the resident was severely cognitively impaired with a BIMS score of 2 and required extensive staff assistance with activities of daily living.

The resident's care plan, initially dated February 9, 2024, indicated that the resident was at risk for falls related to a history of falling with planned interventions of the placement of an alarm to broda chair when out of bed, a bed alarm-check placement and function every shift, education on transfer and ambulation techniques, keep bed in lowest position, keep environment free of clutter, keep personal belongings within reach, low Bed, matt to floor next to both sides of bed when occupied, place alarm boxes out of resident reach and a PT/OT evaluation as needed

Nursing documentation dated February 9, 2024, through February 11, 2024, revealed that the resident displayed restless behaviors, continuing attempts to stand up and out of the wheelchair, bending over while in the chair, displaying unsafe actions of leaning forward in the chair and episodes of agitation during all shifts of nursing duty. The resident was placed at the nurses' stations repeatedly for close staff observation according to nursing documentation, which included nursing entries dated February 10, 2024, at 11:31 AM when nursing noted that the "Resident attempted to self transfer and bend over in wheelchair despite several attempts at redirecting, when attempting to redirect, resident becomes agitated and begins yelling, "leave me alone", currently at nurses station." A nurses note dated February 11, 2024 at 10:50 PM revealed that the resident was at nurses station sitting in a wheelchair, stood up, the was alarm sounding, multiple staff members shouted for her to sit down as they ran toward her however she fell backwards onto floor striking occipital area of head on floor. She was laying on her right side crying and began rubbing her left groin and hip area. As a result of this fall from the wheelchair on February 11, 2024, when the resident was at the nurse's station for observation, she sustained a comminuted right introchanteric femur fracture (right hip fracture).

Following hospitalization for treatment of the hip fracture, Resident B1 was readmitted to the facility on February 16, 2024 at 12:05 PM.

A nurses note dated February 16, 2024 at 6 PM, revealed that "While resident was sitting in her Broda chair in the lobby by the nurses station, she leaned forward and the chair tipped over and she fell out landing on her L (left) side, hitting the left side of her forehead. Assessed for injuries. Large hematoma (similar to a bruise, but the damage that causes it occurs in larger blood vessels. It can lead to swelling, discoloration) L side of forehead seen. Clip alarm pulled off when she leaned forward and was not sounding. The physician was called and made aware of fall. new order noted to give Seroquel (an antipsychotic medication) 25 mg po now then Seroquel 25 mg po BID for anxiety/agitation." It was noted that Resident B1 just returned to the facility from the hospital this afternoon (February 16, 2024 at 12:05 PM). and that "She is confused and not easily redirected."

A nurses note dated February 16, 2024 at 6:41 PM, after the resident's fall with minor injury, revealed that the new interventions to prevent further falls implemented were the placement of a Pommel Cushion on the Broda chair along with front Anti-Tippers by maintenance man. Nursing noted that the resident was resting quietly at present under close observation.
Along with a physician order dated February 16, 2024 at 5:15 PM, for Seroquel Oral Tablet, Give 25 mg by mouth two times a day for agitation/anxiety and Give 25 mg by mouth one time only for anxiety/agitation now.

A review of a February Medication Administration Record revealed that Seroquel 25 mg was given to Resident B1 on February 16, 2024 at 7:04 PM, after the resident's fall. After the resident's fall on February 16, 2024, the resident's care plan was updated to include,
Anti-Tippers to front of broda chair along with elevating leg rests and a pommel
cushion

The resident had a fall on February 11, 2024, while seated in a wheelchair at the nurse's station, which resulted in a fractured hip. Following hospitalization for treatment of the resident's hip fracture, and upon the resident's return to the facility on February 16, 2024, the resident was placed in a Broda chair, in the the lobby by the nurse's station, and sustained another fall resulting in a hematoma. The facility was aware that placing the resident at the nurse's station proved ineffective in preventing the resident's fall on February 11, 2024, but employed the same intervention on the day the resident returned to the facility on February 16, 2024, and the resident leaned forward in the chair and fell.

The facility failed to demonstrate the provision of individualized effective fall prevention measures, including sufficient staff supervision, at the level and frequency required, to prevent another fall, with minor injury under similar circumstances as a prior recent fall. At the time of the survey ending March 15, 2024, the DON and NHA were unable to provide evidence that the facility had provided effective safety measures and staff supervision to prevent his resident's fall on February 16, 2024.

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

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

1. R1 care plan has been updated to reflect appropriate fall interventions.
2. Director of Nursing or Designee will conduct an initial audit or current residents that exhibit restless behaviors to confirm interventions were care planned and initiated.
3. Director of Nursing or Designee will educate nursing staff on implementing resident specific and effective fall prevention interventions including timely and necessary staff supervision of resident with a history of falls with injury and known unsafe restless behaviors that increases their risk for falls. Staff will be educated on the fall management and prevention system which includes strategies/ interventions and fall checklist.
4. Director of Nursing or Designee will conduct random audits of current residents with restless behaviors weekly for four weeks and monthly for two months thereafter to confirm appropriate interventions and supervision is in place. Results of the audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.

483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff:

§483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

§483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

§483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

Observations:

Based on a review of clinical records, employee records, nurse staffing, and incident reports and staff interview, it was determined that the facility failed to provide nursing staff with the necessary skills and competencies to fully assess and monitor a resident for signs of injury after an unwitnessed fall for one resident out of six sampled (Residents B2).

Findings include:

According to the Commonwealth of Pennsylvania, Pennsylvania code, Title 49. Professional and vocational standards, Chapter 21, State Board of Nursing, 21.145 functions of the LPN;
(a) The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgment based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place.

A review of the clinical record revealed that Resident B2 was admitted to the facility on October 9, 2023, with diagnoses of type 2 diabetes, hypertension and atrial fibrillation.

A physician orders dated November 9, 2023, was noted for Eliquis (an anticoagulant medication) 2.5 mg by mouth twice a day for atrial fibrillation (a rapid, irregular heart rhythm)

A review of the resident's quarterly minimum data set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 22, 2023, revealed Resident B2 was cognitively intact with a BIMS score (The Brief Interview for Mental Status (BIMS) is a structured evaluation aimed at evaluating aspects of cognition in elderly patients) of 13, required limited assistance from staff for activities of daily living and utilized a walker for ambulation.

A nursing note dated February 27, 2024, at 02:40 AM revealed that "Staff heard a loud noise, nurse aide and writer (Employee 1, agency LPN) responded and found resident on the floor at the entrance of her room, lying on the floor with her head and left shoulder against the door blocking entrance to the room. On observation, no open areas, resident was awake and alert with episodes of confusion, not her baseline. Vital signs were obtained and emergency medical services was notified, order to transfer to ED obtained by MD, resident being monitored by staff while awaiting for EMS."

A review of a SNF to hospital transfer form dated February 27, 2024 at 2:40 AM revealed that after the fall, Employee 1 (agency LPN) obtained vital signs but did not conduct neuro check data collection in response to an unwitnessed fall (assess an individual ' s neurological functions, motor and sensory response, and level of consciousness).

An incident report dated February 27, 2024, at 2:40 AM, but noted as a late entry and completed February 28, 2024 at 1:17 PM by the DON revealed "Staff heard a loud noise, nurse aide and Employee 1 (agency LPN) responded and found resident on the floor at the entrance of her room, lying on the floor with her head and left shoulder against the door blocking entrance to the room. On observation, no open areas, resident was awake and alert with episodes of confusion, not her baseline. Vital signs were obtained and EMS(emergency medical service) was notified, the Physician was notified. Resident being monitored by staff while awaiting for EMS. According to the incident investigation report, Employee 1, agency LPN, assessed Resident B2 for injury, complaints of left upper arm pain, and noted no dislocation, malformation or injury. The report noted that the resident's "Neuros were intact but initially the resident appeared altered and actually appeared to pass out for a few minutes." The resident was transferred to the hospital for evaluation.

There was no evidence at the time of the survey ending March 15, 2024, that neuro checks were conducted after Resident B2's unwitnessed fall until the time of transfer to the hospital or that a Registered Nurse had assessed the resident for potential injury and checked the resident's neurological status.

Employee 1 contacted the director of nursing (DON) at the resident's time of the fall since the facility had no RN on duty during the night shift of duty. A review of facility nurse staffing documents revealed that two agency licensed practical nurses were on duty February 27, 2024 11 PM to 7 AM shift. The DON did not come to the facility to conduct a professional nursing assessment of the resident when Employee 1 contacted her regarding the resident's fall. Resident assessment is outside the scope of practice of an LPN, according to their practice act.

A review of facility documentation, Agency staff orientation guidelines, revealed that Employee 1 (agency LPN) read and signed the form as reviewed and confirming orientation d on November 17, 2023, her first date of employment in the facility.

A review of a licensed nurse skills competency checklist provided to the facility by the nurse staffing agency, dated January 20, 2024, indicated that Employee 1 (agency LPN) was proficient in nursing areas to include "care of head injuries."

There was no documented evidence at the time of the survey ending March 15, 2024, that Employee 1 had conducted neurological monitoring after the fall until the resident's transfer to the ED or that a registered nurse assessed the resident after the fall to include a neurological assessment after Resident B2's unwitnessed fall.

An interview on March 15, 2024, at approximately 1:00 P.M. the Director of Nursing (DON) stated that Employee 1, an agency LPN, called her at the time of Resident B2's fall. The DON confirmed that there were two agency LPNs on duty on the 11 PM to 7AM shift when Resident B2 fell. The DON stated that she did not come into the facility to assess Resident B2 and stated that Employee 1 should have completed the neurological assessment, to include neuro checks and Employee 1 should also have completed the incident investigation.

During an interview March 15, 2024, at approximately 1:15PM, The Nursing Home Administrator and Director of Nursing confirmed that Employee 1 failed to demonstrate competency regarding neurological data collection after an unwitnessed fall or that a professional nursing assessment of the resident was conducted after the fall.

28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services

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

1. Facility cannot retroactively correct deficiency cited.
2. Director of Nursing or Designee will conduct an audit of falls within the past seven days to confirm that neurological checks have been completed at time of fall.
3. Director of Nursing or Designee will re-educate Licensed Nursing Staff on completion of neurological checks post fall according to policy. Falls will be reviewed in morning meeting to verify that policy has been followed.
4. Director of Nursing or Designee will audit random falls to verify neurological assessments are completed weekly for four weeks and monthly for two months thereafter. Results of the audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:

§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Observations:

Based on clinical record review and staff interviews, it was determined that the facility failed to demonstrate the clinical necessity for initiation of an antipsychotic drug for one resident (Resident B1) out of six reviewed.

Findings included:

A review of the clinical record revealed that Resident B1 was admitted to the facility on February 9, 2024, with diagnoses of dementia, muscle weakness and a history of repeated falls.

An admission Minimum Data Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated February 23, 2024, revealed that the resident was severely cognitively impaired with a BIMS score of 2 and required extensive staff assistance with activities of daily living.

A review of nursing documentation revealed that the resident displayed unsafe restless behaviors, repeatedly attempting to self-rise and leaning out of her wheelchair from the time of admission February 9, 2024, through the time the resident fell from her wheelchair sustaining a fractured hip on February 11, 2024. The resident was readmitted to the facility from the hospital on February 16, 2024 at 12:05 PM. The resident had another fall on February 16, 2024, at 5:44 PM falling from a Broda chair after again displaying unsafe leaning and attempted self rising.

A physician order dated February 16, 2024, at 5:15 PM was noted for Seroquel Oral Tablet, give 25 mg by mouth two times a day for agitation/anxiety and give 25 mg by mouth one time only for anxiety/agitation now.

A review of the resident's February 2024 Medication Administration Record revealed that Seroquel 25 mg was given to Resident B1 on February 16, 2024 at 7:04 PM and twice a day thereafter through the time of the survey.

There was no documented evidence at the time of the survey ending March 15, 2024, of the clinical indicator, psychiatric diagnosis, or had been prescribed an antipsychotic medication prior to initiation of the antipsychotic drug on February 16, 2024, prescribed for anxiety and agitation. There was no physician documentation of a resident specific information which detailed the clinical justification for the use of the antipsychotic drug was clinically indicated.

At the time of the survey ending March 15, 2024, there was no documented evidence of the clinical necessity or clinically supporting diagnosis for use of this antipsychotic medication prescribed for dementia with anxiety/agitation.

28 Pa. Code 211.9(a)(1)(d) Pharmacy services

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

28 Pa. Code 211.2 (d)(8) Medical director

28 Pa. Code 211.5 (f) Medical records

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

1. B1 sequel has been reviewed by medical director and has been updated.
2. Director of Nursing or Designee will conduct an initial audit to validate current residents who have a physician order for Seroquel, have proper diagnosis and clinical necessity documented.
3. Director of Nursing or Designee will re-educate licensed staff and prescribing physicians and extenders on proper diagnosis and clinical documentation needed for the use of Seroquel.
4. Director of Nursing or Designee will conduct random weekly audits for four weeks and monthly for two months thereafter to validate current residents who have a physician order for Seroquel, proper diagnosis is documented. Results of the audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.

§ 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 7 of 7 days (March 8, 2024, March 9, 2024, March 10, 2024, March 11, 2024, March 12, 2024, March 13, 2024, March 14, 2024).

Findings include:

Review of facility census data indicated that on March 8, 2024, the facility census was 52, which required 1.3 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed 1.01 LPN worked the night shift on March 8, 2024.

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

Review of facility census data indicated that on March 9, 2024, the facility census was 53, which required 1.39 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed .33 LPN worked the night shift on March 9, 2024.

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

Review of facility census data indicated that on March 10, 2024, the facility census was 53, which required 1.33 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed .42 LPN worked the night shift on March 10, 2024.

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

Review of facility census data indicated that on March 11, 2024, the facility census was 52, which required 1.30 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed 1.02 LPN worked the night shift on March 11, 2024.

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

Review of facility census data indicated that on March 12, 2024, the facility census was 52, which required 1.30 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed .44 LPN worked the night shift on March 12, 2024.

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

Review of facility census data indicated that on March 13, 2024, the facility census was 53, which required 1.33 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed .92 LPN worked the night shift on March 13,2024.

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

Review of facility census data indicated that on March 14, 2024, the facility census was 53, which required 1.33 LPNs on the night shift.

Review of the nursing time schedules and time punch documentation revealed .33 LPN worked the night shift on March 14, 2024.

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

The facility substituted one of the LPNs on duty for an RN during the overnight shift on each of the above noted dates but another LPN was not available to meet the LPN ratio requirement.

An interview March 15, 2024 at 1 PM the Nursing Home Administrator confirmed that the facility did not meet the state minimum nursing ratios for LPNs

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

1. Facility cannot retroactively correct deficiency cited.
2. Nursing Home Administrator or Designee will conduct an initial audit to validate that Licensed Practical Nursing hours and ratios are being met.
3. Nursing Home Administrator or Designee will re-educate nursing administration and Human Resources/Scheudler on maintaining the proper minimum staffing hours and ratios. The facility will conduct daily labor meetings to review staffing and allocate proper resources when needed. The facility will review past, present and future hours and ratios at this meeting.
4. Nursing Home Administrator or Designee will conduct random weekly audits for four weeks and monthly for two months thereafter to validate that Licensed Practical Nursing hours and ratios are being met. Results of the audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.

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