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

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GARDENS AT EASTON, THE
Inspection Results For:

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GARDENS AT EASTON, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated survey in response to a complaint completed on January 6, 2024, it was determined that The Gardens at Easton 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, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for six of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from December 16, 2023 through January 5, 2024, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for 12 residents on day (7:00 a.m. to 3:00 p.m.) shift on December 20, 21, 23, and 25, 2023.

The facility failed to meet the minimum NA to resident ratio of one NA for 12 residents on evening (3:00 p.m. to 11:00 p.m.) shift on December 23 and 25, 2023.

In an interview conducted on January 6, 2024, at 12:10p.m., the Director of Nursing confirmed that the facility failed to meet the required staffing ratio for nurse aides on the previously mentioned dates and shifts.











 Plan of Correction - To be completed: 02/06/2024

1.Past CNA ratios for 12/20/23, 12/21/23, 12/23/23, and 12/25/23. cannot be corrected as this is a past event.

2. Calculation of shift CNA ratios will be completed and reviewed daily for accuracy by the scheduler.

3. The scheduler/designee will look ahead for a minimum of 1 week at projected staffing patterns to more effectively achieve appropriate CNA ratios as needed.

4. We will follow the new regulations and guidelines for ratios. CNA ratio will be audited by scheduler/designee and DON/designee daily for 4 weeks. Results presented to QAPI committee.


§ 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, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratio for 2 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from December 16, 2023 through January 5, 2024, 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 December 25, 2023 and January 1, 2024.

During an interview on January 6, 2024, at 12:10 p.m., the Director of Nursing confirmed that the facility did not meet the minimum required nursing staff to resident ratio on the days identified.



 Plan of Correction - To be completed: 02/06/2024

1.Past LPN ratios for 12/25/23 and 01/01/2024 cannot be corrected as this is a past event.

2. Calculation of shift LPN ratios will be completed and reviewed daily for accuracy by the scheduler.

3. The scheduler/designee will look ahead for a minimum of 1 week at projected staffing patterns to more effectively achieve appropriate LPN ratios as needed.

4. We will follow the new regulations and guidelines for ratios. LPN ratio will be audited by scheduler/designee and DON/designee daily for 4 weeks. Results presented to QAPI committee.



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