Pennsylvania Department of Health
MARYWOOD HEIGHTS
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
MARYWOOD HEIGHTS
Inspection Results For:

There are  50 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.
MARYWOOD HEIGHTS - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on January 31, 2024, it was determined that Marywood Heights was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care Facilities and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on review of clinical records and facility provided documentation and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of practice for one resident (Resident 1) out of 5 residents reviewed by failing to show ongoing monitoring, identification and documentation of changes in resident condition to assure prompt and necessary treatment of fracture.

Findings included:

According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals.

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement 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. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records.

According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care:
Assessments
Clinical problems
Communications with other health care professionals regarding
the patient
Communication with and education of the patient, family, and the patient ' s designated support person and other third parties.

A review of clinical record revealed Resident 31 was admitted to the facility on February 26, 2013, with diagnoses, which included moderate intellectual disabilities and a history of falling.

A review of a quarterly MDS (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated November 20, 2023, revealed that Resident 1 was moderately cognitively impaired with a BIMS score of 9 (Brief Interview for Mental Status tool used to screen cognitive condition of residents) and required staff assistance with activities of daily living and had a history of falls.

A nurses notes dated October 20, 2023 at 11:07 AM revealed that the report of the resident's Dexa scan (an imaging test to measure the bone density) was received and that the resident was identified to be at risk for fractures.

A review of nursing documentation dated November 7, 2023 indicated that Resident 1 had pain in her left shoulder.

There was no further nursing documentation of a nursing assessment of the resident's left shoulder at that time or follow-up nursing documentation regarding the status of the resident's left shoulder pain.

The nurse's notes dated November 23, 2023, at 9:43 PM revealed that Resident 1 complained of discomfort to the left arm and told her family about the discomfort. The entry noted that the resident recently, July 21, 2023, received tetanus vaccine to that arm and Tylenol was offered to the resident.

On November 24, 2023 at 7:26 PM revealed that nursing "Received call from resident's niece/POA, with concerns for resident complained of pain and limited mobility in left upper extremity. Resident told her that she fell in her bathroom "last month" but states that she has very poor short term memory and is not cognizant of time. The POA thinks that maybe resident overstretched arm. Resident able to move left arm out to a 90 degree angle but did not complained of pain for me. She had received Tdap vaccine on July 21, 2023 but niece states that it started about two weeks ago, requests ibuprofen and MRI. Nursing left voicemail at Dr. the Physician's office. Updated the resident's POA on leaving message(with the Physician) and waiting on call back."

A physician order was noted November 27, 2023, for Voltaren arthritis pain external gel 1% ( a nonsteroidal anti-inflammatory drug (NSAID) for pain management; apply to left shoulder area, twice a day for pain in the left shoulder.

Following surveyor during the survey ending January 31, 2024, the facility provided physician documentation dated December 11, 2023, revealed that the physician noted that Resident 1 was having arm pain. "The POA (Resident 1's niece) called to discuss. Will evaluate next week and call in Medrol (steroid medication)."

A physician order was noted December 12, 2023, at 3:40 PM, for a Medrol Pak, 4 mg (an oral steroid for inflammation) until December 18, 2023.

A nurses note dated December 14, 2023, at 9:43 PM revealed that "Resident continues on Medrol dose pack for Left shoulder. She complained of occasional pain, which is manageable with current pain medication. She denies having any radiating pain at this time. Resident able to perform range of motion with minimal difficulty."

A review of a nurses note dated December 15, 2023 at 5:20 PM revealed "Resident sitting in dining room. She continues on Medrol dose pack for Left shoulder pain. Resident able to perform range of motion with minimal assistance. Resident encouraged to rest periodically throughout the day/evening to aide in lessening her pain, as well. Resident continues to walk through hallways with walker frequently."

A physician's assistant note dated December 29, 2023, at 2:25 PM revealed that the resident had upper respiratory symptoms. The entry included a note " note; to the primary care physician as an FYI, the resident's niece was asking about Resident 1's shoulder and asked if an x-ray was done. No notes documented that she was evaluated (by the physician) but per your note, you were going to see her."

A nurse's note dated January 12, 2024, revealed that Resident 1 was seen by attending Physician and an order was received for an x-ray of the left shoulder.

A review of an x-ray report dated January 12, 2024, revealed a mildly comminuted, non-displaced, non united fracture of the lateral left humeral head (shoulder), likely acute.

A late entry nurses note written on January 18, 2024 at 10:45 A.M. for January 15, 2024 at 10:44 A.M., revealed "multiple attempts to contact Ortho physicians office to schedule an orthopedic appointment. Left message to return call to facility."

A review of a nurses note dated January 18, 2024, at 11:02 AM., revealed that Resident 1 had an ortho appointment on January 31, 2024 at 8:30 AM

There was no evidence that Resident 1's left shoulder pain, first reported by the resident on November 23, 2023, was timely and fully evaluated, assessed and treated. There was no documented evidence that nursing staff timely consulted with the physician regarding the resident's ongoing complaints of left shoulder pain.

During an interview on January 26, 2024, at approximately 9:00 a.m., the Director of Nursing confirmed that Resident 1's fracture was not timely identified and treated.


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

28 Pa. Code 211.5 (f) Medical records








 Plan of Correction - To be completed: 03/12/2024

1. Resident 1 is receiving follow up orthopedic care.
2. Nursing documentation will be reviewed during morning clinical meeting to ensure physicians are contacted when residents are experiencing new or worsening pain.
3. Licensed Nurses will be re-educated regarding the Nurse's responsibility for ongoing monitoring, identification, and documentation when new onset or worsening of pain occurs to ensure prompt and necessary treatment is received.
4. DON/Designee will randomly audit nursing documentation to confirm residents with new onset re worsening pain receive ongoing monitoring, identification, and documentation of changes in resident condition to assure prompt and necessary treatment is received. Random audits will be conducted weekly x 4 weeks, then monthly x 3 months. Findings of audits will be reported to the Quality Assurance/Performance Improvement Committee monthly.

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).
Observations:

Based on review of clinical records and grievances lodged with the facility and staff interview, it was determined that the facility failed to notify a resident's representative of an unwitnessed fall incurred by one resident out of five sampled (Resident 4).

Findings include:

A review of the clinical record revealed that Resident 4 was admitted into the facility on October 18, 2023, with diagnoses including chronic kidney disease and dementia.

A nurse's note dated December 23, 2023, at 4:30 PM, but entered into the record on December 24, 2023, at 7:33 PM revealed that the resident had an unwitnessed fall and staff found the resident on the floor. The entry noted that the resident's physician and responsible party were notified of the fall.

A review of a facility concern/grievance form dated January 15, 2024, revealed that Resident 4's responsible part stated that she was not notified of Resident 4's fall on December 23, 2023.

An interview with the Director of Nursing on January 31, 2024, at approximately 2 PM confirmed the facility failed to timely notify the resident's responsibility party of the resident's fall at the time of occurrence as noted in the resident's clinical record. She further confirmed that Employee 5 (LPN) wrote the nurses note indicating that she had contacted the resident's responsible party, but she had not contacted the responsible party at that time.



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

28 Pa. Code 201.29 (a) Resident rights









 Plan of Correction - To be completed: 03/12/2024

1. Resident #4 resides in the facility. Her most recent fall was January 15, 2024. Resident representative was notified of fall at time of occurrence and documented appropriately.
2. The twenty-four-hour report will be reviewed during morning clinical meeting to ensure resident representatives have been notified of falls timely.
3. "Resident Change in Condition Notification" policy will be reviewed. Licensed nurses will be in serviced on this policy.
4. DON/Designee will randomly audit nursing documentation to ensure resident representative have been notified when a fall occurs. Random audits will be conducted weekly x 4 weeks, then monthly x 3 months. Findings of audits will be reported to the Quality Assurance/Performance Improvement Committee monthly.

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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.
§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:

Based on a review of the facility's abuse prohibition policy, select investigative reports and clinical records, and interview with staff it was determined that the facility neglected to provide the care and services necessary to avoid physical harm and maintain physical health for one resident out of five residents sampled (Resident 2).


Findings include:

A review of the facility's Resident Abuse policy, last revised January 2023, revealed that the facility will provide each resident with the highest practicable physical, mental, and psychological services to meet their individual needs and to promote or maintain the resident at their highest level of well-being. This includes the protection of Resident's Rights. Each resident has the right to privacy, dignity and confidentiality for all aspects of care and services.

A review of the clinical record revealed that Resident 2 was admitted to the facility on June 2 24, 2022, with diagnoses, which included dementia, muscle weakness and the need for assistance with personal care

A quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated November 20, 2023, indicated that the resident required the assistance of staff for activities of daily living and and utilized a sit to stand lift for transfers.

A review of the resident's current plan of care, initially dated July 8, 2023, revealed a care plan in place for ADL (activities of daily living) self-care performance deficit. Planned interventions were that upon admission the resident needed to utilize a sit to stand lift (devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone).

A review of a facility investigation report dated December 19, 2023, at 9:55 PM revealed that Employee 3, an agency nurse aide, and Employee 4, an agency nurse aide, were transferring Resident 2 from the wheelchair to the bed via a sit to stand lift. The nurse aides placed the resident into the lift and had her "hovering" \ over her bed. Employee 3, an agency nurse aide, left the room to get a clean brief. At the same time, Employee 4, an agency nurse aide, left the resident in the lift to get a washcloth from the bathroom sink. When Employee 4 looked back from the bathroom, she observed Resident 2 opening the velcro ties to the sling (on the lift), falling onto the bed, and then onto the floor, hitting her buttocks and back. The RN supervisor assessed the resident. The Physician was contacted. No injuries were noted.

An interview with the Nursing Home Administrator and Director of Nursing on January 31, 2024, at approximately 2 PM confirmed that Employees 3 and 4 were aware that the resident's transfer was to performed with two people, utilizing a sit to stand lift, but both employees left the resident unattended in the lift sling resulting in the resident's fall.



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

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







 Plan of Correction - To be completed: 03/12/2024

1. Resident 2 currently utilizes a Hoyer lift for transfers. Employees 3 & 4 no longer work at the facility through their agency.
2. Current residents utilizing mechanical lifts will be identified. Physician Orders, care plans and kardexes will be reviewed to ensure information is consistent & accurate.
3. The facility's Abuse policy will be reviewed. Facility staff will be re-educated on the abuse policy, including the importance of ensuring care and services are provided with the correct level of assistance and that the residents' plans of care are followed appropriately.
4. DON/Designee will perform random audits to ensure residents utilizing hoyer and stand-up lifts are transferred appropriately as per their plan of care weekly x four weeks, then monthly x 3 months. Results will be forwarded to the QAPI Committee monthly.

483.12 REQUIREMENT Free from Misappropriation/Exploitation: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.
§483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.
Observations:


Based on a review of clinical records, select facility policy and investigative reports it was determined that the facility failed to ensure that one of five residents sampled were free from misappropriation of property, medications (Resident 3).

Findings include:

A review of the facility's Resident Abuse policy, last revised January 2023, revealed that misappropriation of Resident Property is the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Examples of misappropriation include, but are not limited to taking resident's monies, using their phone to make personal calls, administering a resident's medication to another resident, or eating food items off a resident's tray.

Clinical record review revealed Resident 3 was admitted to the facility on November 17, 2023, with diagnoses of peripheral vascular disease and chronic pain and readmitted to the facility after a hospital stay on December 22, 2023.

A physician order was noted, December 22, 2023, for Oxycodone -APAP ( an opioid narcotic combination pain medication) 5-325 mg, one tablet by mouth, as needed, every 4 hours for pain level rated 4-10.

A review of a prescription dated and signed by the resident's attending physician on December 22, 2023, revealed the order for Oxycodone-APAP 5-325 mg, one tablet by mouth as needed every 4 hours for pain. The prescription indicated that 180 pills were to be dispensed by the pharmacy and sent to the facility for the resident.

A review of a pharmacy delivery sheet dated December 22, 2023, revealed that 180 Oxycodone-APAP pills were dispensed for Resident 3 and received at the facility. Three separate cards of oxycodone-APAP, containing 60 pills each, were noted in the delivery received by the facility.

A review of a facility investigation dated January 11, 2024, revealed that the facility's pharmacy notified Employee 1 (RN Supervisor) that it was too soon to refill Resident 3's prescription for Percocet Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen); the pharmacy informing the facility that the pharmacy sent 180 tablets on December 22, 2023. Facility records revealed that only one card of 60 was present in the facility with only 11 doses remaining on January 11, 2024.

A review of an employee witness statement dated January 14, 2024, revealed that Employee 2 (LPN) stated that 3 cards of 60 pills were sent and received at the facility on December 22, 2023 on the 11 PM to 7 AM shift. The three cards of the opioid narcotic controlled medication were placed in the locked narcotic box in the med cart and the corresponding narcotic sign sheets were placed in the narcotic book according to Employee 2's statement.

The facility's investigation noted that the facility conducted an immediate search of med carts, med room, but no Percocet cards and corresponding narcotic reconciliation forms were found for Resident 3 to indicate the amount of opioid medication present in the med cart. Two of the three cards of 60 pills each could not be located, 120 doses of the Oxycodone-APAP 5-325 mg were missing.

During an interview January 31, 2024, the Director of Nursing and the Nursing Home Administrator confirmed that the facility confirmed that Resident 3's property, medications, had been misappropriated from the facility.

Refer F755

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

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


















 Plan of Correction - To be completed: 03/12/2024

1. Resident 3 no longer resides at the facility. Facility was invoiced to replace missing medications.
1. 2. A Master Narcotic Inventory Sheet has been implemented to ensure nurses are aware of all medications that are supposed to be present in each medication cart. The facility audited the controlled substance records and eMAR's for residents receiving narcotic pain medication and corresponding count records have been completed and no discrepancies were noted. A Master Narcotic Inventory Form has been initiated for each medication cart.

3. All facility staff will be educated regarding the Resident Abuse Policy. License Nursing Staff have been educated on the facility policy regarding reconciliation of controlled substances, including maintaining, filing, and forwarding completed reconciliation forms to the Director of Nursing for review when narcotic medication is completed or destroyed.

4. DON/Designee will audit controlled substance records and inventory sheets weekly x 4 weeks, then monthly x 3 to ensure misappropriation of narcotic medication is not occurring. Results will be reported to QAPI monthly.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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.
§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:

Based on review of controlled drug records and select facility policy and staff interview, it was determined that the facility failed to implement pharmacy procedures for reconciling controlled drugs and records accounting for their administration for one of five residents sampled (Resident 3).

Finding include:

Clinical record review revealed Resident 3 was admitted to the facility on November 17, 2023, with diagnoses of peripheral vascular disease and chronic pain. The resident was readmitted to the facility after a hospital stay on December 22, 2023.

A physician order was noted November 20, 2023, for Percocet (Oxycodone-APAP, an opioid narcotic combination pain medication) 5/325 mg, one tab every 4 hours as needed for pain.

A review of a pharmacy invoice dated November 20, 2023, revealed that 90 Oxycodone-APAP 5-325 mg were delivered to the facility for administration to Resident 3

A review of Medication Administration Records revealed that from November 22, 2023 through November 30 2023, revealed documented evidence that 36 doses of the Oxycodone-APAP 5-325 mg were administered to Resident 3.

A review of Medication Administration Records revealed that from December 1, 2023 through December 14, 2023, 39 doses of the Oxycodone-APAP 5-325 mg were administered to Resident 3. The documentation on the MARs indicated that a total of 75 pills of Oxycodone-APAP 5-325 mg were administered during November 2023 and December 2023.

However, at the time of the survey ending January 31, 2024, there was no evidence of the associated pharmacy provided controlled drug narcotic sign out record (accountability form) associated with Resident 3's supply of Oxycodone-APAP 5-325 mg 90 pills dispensed to the the facility on November 20, 2023, or of the disposition of the remaining 15 doses of the narcotic medication.

The resident was admitted to the hospital on November 30, 2023 and readmitted to the facility on December 22, 2023. There was no documented evidence of the remaining 15 doses of Resident 3's controlled medication at the time of the survey ending January 31, 2024.

During an interview January 1, 2023 t 2 P.M., the Director stated that Resident 3's controlled drug narcotic sign out sheet for the resident's supply of Oxycodone-APAP 5-325 mg dispensed to the facility on November 20, 2023, could not be located and facility was unable to account for the remaining 15 doses of the narcotic medication.

Refer F602


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

28 Pa Code 211.9 (a)(1)(j.1)(4)(k) Pharmacy services.














































 Plan of Correction - To be completed: 03/12/2024

1. Resident 3 no longer resides at the facility.
2. The facility audited the controlled substance records and eMAR's for residents receiving narcotic pain medication and corresponding count records have been completed and no discrepancies were noted. A Master Narcotic Inventory Form has been initiated for each medication cart.
3. Licensed professional staff have been educated on the facility policy regarding reconciliation of controlled substances, including maintaining, filing and forwarding completed reconciliation forms to the Director of Nursing for review when narcotic medication is completed or destroyed.
4. DON/Designee will review the Master Narcotic Inventory Forms to ensure narcotic reconciliation forms are present and narcotics are accounted for. Random audits will be conducted weekly x 4 weeks, then monthly x 3 months. Findings of audits will be reported to the Quality Assurance/Performance Improvement Committee monthly.

§ 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 resident census 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 on the night shift on three of seven days (January 9, 2024, January 10, 2024, and January 15, 2024 ).

Findings include:

Review of facility census data indicated that on January 09, 2023, the facility census was 58, which required 1.45 LPNs during the night shift.

Review of the nursing time schedules and time punch card documentation revealed 1.13 LPNs provided care on the night shift on January 09, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 10, 2024, the facility census was 58, which required 2.32 LPNs during day shift.

Review of the nursing time schedules and time punch documentation revealed 2 LPNs worked the day shift on January 10, 2024. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on January 15, 2024, the facility census was 60, which required 1.5 LPNs during the night shift.

Review of the nursing time schedules and time punch card documentation revealed only 1.19 LPNs provided care on the night shift on January 15, 2024. No additional excess higher-level staff were available to compensate this deficiency.

An interview January 31, 2024, at 1 PM the Director of Nursing confirmed that the facility did not meet the minimum nursing staff ratios for LPNs on the above shifts.
















 Plan of Correction - To be completed: 03/12/2024

1. The facility can not retroactively correct past ratios.
2. Licensed nurses will be reeducated regarding state ratio requirements. Deployment Sheets are reviewed in advance of upcoming shifts to ensure sufficient staff are scheduled for PPD/Ratios.
3. Efforts to continue to be made to recruit and maintain staff. Agency staff continue to be used to supplement facility staff. The RN Supervisor will be responsible to find replacements for late call-offs. NHA/Designee will conduct audits of schedules to ensure staffing ratios are met.
4. Random audits will be conducted weekly x 4 weeks, then monthly x 3 months to ensure staffing ratios are met. Findings of audits will be reported to the Quality Assurance/Performance Improvement Committee monthly.


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