Pennsylvania Department of Health
LAKEVIEW HEALTHCARE AND REHAB
Patient Care Inspection Results

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LAKEVIEW HEALTHCARE AND REHAB
Inspection Results For:

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LAKEVIEW HEALTHCARE AND REHAB - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Complaint Survey completed on January 3, 2024, at Lakeview Healthcare and Rehab it was determined that there were no federal deficiencies identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities as it relates to the Health portion of the survey process; however, the facility was not in compliance with 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.





 Plan of Correction:


51.3 (g)(1-14) LICENSURE NOTIFICATION:State only Deficiency.
51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.

Observations:

Based upon review of facility policy, and staff interviews, it was determined that the facility failed to report an incident to the Department of Health (DOH) in a timely manner.

Findings include:

Review of facility policy entitled "Fire Watch" dated 3/20/2023, revealed that "Our local fire department and state licensing agency shall be immediately notified when there is an unforeseen disablement ... of our fire detection ..."

Review of information submitted by the facility dated 12/20/23, for disruption of the wander guard system (alarming system to alert staff if a resident was exiting the building unattended) not working properly starting on 12/14/23, revealed the information submitted was six days after the incident occurred.

During an interview on 12/27/23, at 11:25 a.m. the Maintenance Director revealed that it was the fire alarming system that was not functioning from 12/14/23, through 12/22/23.

During an interview on 12/27/23, at 11:40 a.m. the Director of Nursing revealed that on 12/14/23, staff placed tabs monitors on the doors that remained unlocked due to the fire system not functioning which would alarm to notify staff if the door was opened.

During an interview on 12/27/23, at 11:58 a.m. the Nursing Home Administrator revealed that it was the fire system not functioning properly not the wander guard system from 12/14/23, through 12/22/23. He/she also confirmed on 12/27/23, at 11:58 a.m. that the Department of Health (DOH) was not notified of the incident in a timely manner.

28 Pa. Code 201.14(a) Responsibility of licensee



 Plan of Correction - To be completed: 02/05/2024

1. Administrator reported as soon as he/she was made aware that this was a fire alarming system issue and reported through the ERS system on 12/20/2023. CertaSite repair service was immediately called for repairs. "Fire Watch" policy was implemented on 12/14/2023 and continued until fire alarm system was fixed and doors were secured on 12/22/2023. There was no harm to any residents.

2. The Administrator will correct the deficiency by educating all pertinent staff on policy of WHAT IS REPORTABLE, how it is reported, why it is reported, when it should be reported and whom should be reporting through the ERS system to avoid further occurrences.

3. Will review 3 months back of all facility events and incidents to ensure requirements of reporting were met. Will review and discuss ongoing at morning meetings with management staff all facility events and incidents to ensure we are not missing any reporting requirements for further occurrences and to sustain compliance.

4. Findings will be reported to QA committee for further review and monitoring.
§ 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 review of the facility staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one Nurse Aide (NA) per 12 residents on daylight shift for two of 28 days reviewed (12/26/23, and 12/29/23); one NA per 12 residents on evening shift for five of 28 days reviewed (12/9/23, 12/21/23, 12/25/23, 12/28/23, and 1/1/24); and one NA per 20 residents on overnight shift for three of 28 days reviewed (12/9/23, 12/10/23, and 12/17/23).

Findings include:

Review of facility staffing ratio information from 12/5/23, through 1/1/24, revealed the following NA staffing shortages for daylight shift:

12/26/23census of 31 residentstwo NAs scheduled and three NAs were required.
12/29/23census of 31 residentstwo NAs scheduled and three NAs were required.

Review of facility staffing ratio information from 12/5/23, through 1/1/24, revealed the following NA staffing shortage for evening shift:

12/9/23census of 33 residentstwo NAs scheduled and three NAs were required.
12/21/23census of 31 residentstwo NAs scheduled and three NAs were required.
12/25/23census of 31 residentstwo NAs scheduled and three NAs were required.
12/28/23census of 31 residentstwo NAs scheduled and three NAs were required.
1/1/24census of 31 residentstwo NAs scheduled and 2.58 NAs were required.

Review of facility staffing ratio information from 12/5/23, through 1/1/24, revealed the following NA staffing shortage for the overnight shift:

12/9/23census of 33 residentsone NA scheduled and two NAs were required.
12/10/23census of 32 residentsone NA scheduled and two NAs were required.
12/17/23census of 31 residentsone NA scheduled and two NAs were required.

During an interview on 1/3/24, at approximately 11:48 a.m. the Nursing Home Administrator confirmed that the facility failed to meet the required NA ratios for the above dates and shifts.






 Plan of Correction - To be completed: 02/09/2024

1. Nursing Home Administrator will re-educate Director of Nursing and Scheduler on staffing ratios regulation effective July 1, 2023.

2. Director of Nursing/Designee will complete a 4 week look out daily for 8 weeks to identify that the NA ratio is being met.

3. Bonuses will be offered as an incentive to pick up NA shifts. HR will continue to work on hiring additional NA nursing staff by placing ads on Indeed and monitoring open NA positions as they apply and processing applicants in a timely manner. HR will also offer a sign on bonus as well as referral bonus if applicable. Will ask for volunteers to stay over or come in early for their shifts. Will also implement a volunteer sign-up sheet for employees that would like extra shifts that we can call for call offs. If employees will not voluntarily pick up shifts due to call offs, then we will implement our mandating policy.

4.Director of Nursing/Designee will monitor the daily /weekly staffing sheet and will be ongoing to sustain compliance.

5.Findings will be reported to QA Committee for further review and monitoring.

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