Pennsylvania Department of Health
TRANSITIONS HEALTHCARE SHOOK HOME
Patient Care Inspection Results

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TRANSITIONS HEALTHCARE SHOOK HOME
Inspection Results For:

There are  70 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.
TRANSITIONS HEALTHCARE SHOOK HOME - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated survey completed on February 15, 2024, it was determined that Transitions Healthcare Shook Home was not in 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:


§ 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 document review and staff interview, it was determined that the facility failed to ensure a required minimum of one Licensed Practical Nurse (LPN) per 40 residents on overnights shifts for ten of 21 overnight shifts reviewed (December 31, 2023; January 1, 5, and 6, 2024; February 1, 6, 9, 10, 11, and 12, 2024).

Findings include:

Review of facility provided staffing ratio information for December 31, 2023; January 1, 5, and 6, 2024; February 1, 6, 9, 10, 11, and 12, 2024, on the overnight shift, revealed a resident census of 42-55 residents. The information also revealed an LPN ratio of one; therefore, the facility did not meet the minimum LPN ratio required for the facility census of residents on those shifts.

During an interview with the Nursing Home Administrator (NHA) on February 14, 2024, at approximately 2:00 PM, the NHA said they are making an effort to recruit an LPN for the overnight shift, but have been unsuccessful with filling the vacancy or finding an agency person.


 Plan of Correction - To be completed: 03/26/2024

1. Facility identified no adverse
outcome from days identified.
2. Education will be provided by the
Administrator to the Nursing
Administration, scheduler, and
charge nurses on calculation of the
ratios and replacement of staff if
indicated.
3. A staffing ratio document will be
completed daily by the scheduler
and reviewed at morning meetings.
The ratio document will be updated
with any changes in the schedule
and reviewed with the DON/Admin Nurse
to ensure proper coverage. If a shortage is discovered, will call Part Time and PRN staff, and contract agency staffing to meet staffing ratios.
4. An audit of the ratio document
against the deployment sheet will be
completed daily for 1 week, weekly
for 2 weeks and then biweekly X 2
weeks. Results of the audit will be
taken to QAPI for review of findings
and further interventions if
warranted.


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