Pennsylvania Department of Health
 LAKESIDE AT WILLOW VALLEY
Patient Care Inspection Results

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LAKESIDE AT WILLOW VALLEY
Inspection Results For:

There are  46 surveys for this facility. Please select a date to view the survey results.

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LAKESIDE AT WILLOW VALLEY - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare Recertification, State Licensure and Civil Rights Compliance Survey completed on January 4, 2024, at Lakeside at Willow Valley, it was determined that one deficiency was identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Nursing Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations for the Health portion of the survey process.


 Plan of Correction:


§ 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 review of nursing time schedules and staff interviews, it was determined that the facility administrative staff failed to provide a minimum of one Licensed Practical Nurse per 40 residents during the night shift on 11 of 21 days (7/2/23, 7/3/23, 7/4/23, 7/5/23, 7/6/23, 7/7/23, 7/8/23, 10/15/23, 10/20/23, 10/21/23, 12/31/23).

Findings include:

Review of facility census data indicated that on 7/2/23, the facility census was 72, which required two Licensed Practical Nurses (LPN) during the night shift.
Review of facility census data indicated that on 7/3/23, the facility census was 72, which required two Licensed Practical Nurses (LPN) during the night shift.
Review of facility census data indicated that on 7/4/23, the facility census was 73, which required two Licensed Practical Nurses (LPN) during the night shift.
Review of facility census data indicated that on 7/5/23, the facility census was 73, which required two Licensed Practical Nurses (LPN) during the night shift.
Review of facility census data indicated that on 7/6/23, the facility census was 73, which required two Licensed Practical Nurses (LPN) during the night shift.
Review of facility census data indicated that on 7/7/23, the facility census was 72, which required two Licensed Practical Nurses (LPN) during the night shift.
Review of facility census data indicated that on 7/8/23, the facility census was 72, which required two Licensed Practical Nurses (LPN) during the night shift.
Review of facility census data indicated that on 10/15/23, the facility census was 76, which required two Licensed Practical Nurses (LPN) during the night shift.
Review of facility census data indicated that on 10/20/23, the facility census was 76, which required two Licensed Practical Nurses (LPN) during the night shift.
Review of facility census data indicated that on 10/21/23, the facility census was 76, which required two Licensed Practical Nurses (LPN) during the night shift.
Review of facility census data indicated that on 12/31/23, the facility census was 74, which required two Licensed Practical Nurses (LPN) during the night shift.

Review of the nursing time schedules revealed one LPN provided care on the night shift during the dates listed above. No additional excess higher-level staff were available to compensate this deficiency.




 Plan of Correction - To be completed: 03/01/2024

1) Required Staffing Ratios will be reviewed with Nursing Supervisors, Nursing Team Leaders and Supportive Living Schedulers.
2) The schedule will be monitored by the Clinical Managers, Director of Nursing and/or Scheduler daily for appropriate staffing levels for CNAs, LPNs and RNs.
3) The Facility will be staffed with required staffing ratios each shift.
4) The Facility will be in compliance by March 1st, 2024.


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