Pennsylvania Department of Health
COMPLETE CARE AT BERKSHIRE LLC
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
COMPLETE CARE AT BERKSHIRE LLC
Inspection Results For:

There are  77 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.
COMPLETE CARE AT BERKSHIRE LLC - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Special Monitoring Survey completed on February 5, 2024, it was determined that Complete Care at Berkshire was not in compliance with the following requirements of 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 nursing time schedules and staff interview, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for four of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from June 1 to 7, 2023, September 17 to 23, 2023, and December 6 to 12, 2023, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for 12 residents on evening shift (3:00 p.m. to 11:00 p.m.) on September 22, 2023.

The facility failed to meet the minimum NA to resident ratio of one NA for 20 residents on night shift (11:00 p.m. to 7:00 a.m.) on September 20, 2023, and December 9 and 10, 2023.

In an interview at 11:40 a.m. on December 15, 2023, the Administrator confirmed that the facility did not meet minimum nurse aide to resident ratios on the identified dates.



 Plan of Correction - To be completed: 02/29/2024

Staffing Manager or designee will staff the daily nursing staff to meet the minimum ratios of 1 CNA per 12 residents during 7AM-3PM shift, 1 CNA per 12 residents 3PM-11PM shift, and 1 CNA per 20 residents during 11PM-7AM shifts.

Nursing staff ratio audits will be conducted by DON or designee daily as well as running the actual hours worked report from timeclock software.

Reports will be reviewed at monthly QAPI meetings.
§ 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 nursing time schedules and staff interview, it was determined that the facility failed to meet the minimum Licensed Practical Nurse (LPN) to resident ratio for three of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from June 1 to 7, 2023, September 17 to 23, 2023, and December 6 to 12, 2023, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on night shift (11:00 p.m. to 7:00 a.m.) on September 18, 2023, and December 6 and 7, 2023.

In an interview at 11:40 a.m. on December 15, 2023, the Administrator confirmed that the facility did not meet minimum LPN to resident ratio on the identified dates.



 Plan of Correction - To be completed: 02/29/2024

Staffing Manager or designee will staff the daily nursing staff to meet the minimum ratios of 1 LPN per 25 residents during 7AM-3PM shift, 1 LPN per 30 residents 3PM-11PM shift, and 1 LPN per 40 residents during 11PM-7AM shifts.

Nursing staff ratio audits will be conducted by DON or designee daily as well as running the actual hours worked report from timeclock software.

Reports will be reviewed at monthly QAPI meetings.

Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port