Pennsylvania Department of Health
MANOR AT ST. LUKE VILLAGE, THE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

MANOR AT ST. LUKE VILLAGE, THE
Inspection Results For:

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MANOR AT ST. LUKE VILLAGE, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a revisit survey completed on January 16, 2024, it was determined that The Manor at St Luke Village corrected the federal deficiencies cited during the survey of November 16, 2023, under the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities, but continued to be out of compliance with the following requirements of 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(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.

Plan of Correction - To be completed: 02/04/2024

1. The facility cannot retroactively correct the nurse aide ratios.

2. The facility is focusing on retention of existing nurse aides and recruitment of new nurse aides through efforts of the Staffing Committee.

3. To prevent this from recurring, The Scheduler and Nursing Supervisors re-educated by DON/Designee regarding the new ratio requirements for nurse aides.

4. To monitor and maintain compliance, the DON/designee will hold staffing meetings to review calculations of the nurse aide ratios for accuracy weekly x5 x 4 weeks then weekly x2.

5. Findings will be submitted to the QAPI committee for further recommendations.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(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 nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum licensed practical nurse (LPN) staff to resident ratio was provided on the day, evening, and night shifts for 7 shifts out of 42 reviewed.

Findings include:

A review of the facility's weekly staffing records from December 18, 2023, through December 24, 2023, and January 9, 2024, through January 15, 2024, revealed that on the following dates the facility failed to provide minimum LPN staff of 1:25 on the day shifts, 1:30 on the evening shifts and 1:40 on the night shift based on the facility's census.

Review of facility census data indicated that on December 24, 2023, the facility census was 94, which required 18.80 hours from LPNs during night shift.

Review of the nursing time schedules revealed two LPNs provided care on the night shift on December 24, 2023, for a total of 16.00 hours. No additional excess higher-level staff were used to compensate this deficiency.

Review of facility census data indicated that on January 9, 2024, the facility census was 94, which required 25.07 hours of LPNs during evening shift.

Review of the nursing time schedules revealed three LPNs provided care on the evening shift on January 9, 2024, for a total of 24.00 hours. No additional excess higher-level staff were used to compensate this deficiency.

Review of facility census data indicated that on January 10, 2024, the facility census was 95, which required 30.40 hours of LPNs during day shift.

Review of the nursing time schedules revealed three LPNs provided care on the day shift on January 10, 2024, for a total of 24.00 hours. No additional excess higher-level staff were used to compensate this deficiency.

Review of facility census data indicated that on January 11, 2024, the facility census was 95, which required 25.33 hours of LPNs during evening shift.

Review of the nursing time schedules revealed three LPNs provided care on the evening shift on January 11, 2024, for a total of 24.00 hours. No additional excess higher-level staff were used to compensate this deficiency.

Review of facility census data indicated that on January 12, 2024, the facility census was 94, which required 25.07 hours of LPNs during evening shift.

Review of the nursing time schedules revealed three LPNs provided care on the evening shift on January 12, 2024, for a total of 24.00 hours. No additional excess higher-level staff were used to compensate this deficiency.

Review of facility census data indicated that on January 15, 2024, the facility census was 95, which required 30.40 hours of LPNs during day shift.

Review of the nursing time schedules revealed three LPNs provided care on the day shift on January 15, 2024, for a total of 24.00 hours. No additional excess higher-level staff were used to compensate this deficiency.

Review of facility census data indicated that on January 15, 2024, the facility census was 95, which required 25.33 hours of LPNs during evening shift.

Review of the nursing time schedules revealed three LPN's provided care on the evening shift on January 15, 2024, for a total of 24.00 hours. No additional excess higher-level staff were used to compensate this deficiency.

An interview with the Nursing Home Administrator on January 16, 2024, at 12:45 PM, confirmed the facility had not met the required minimum licensed practical nurse (LPN) to resident ratios on the day, evening, and night shifts on the above dates.

Plan of Correction - To be completed: 02/04/2024

1. The facility cannot retroactively correct the LPN ratios.

2. The facility is focusing on retention of existing nurse aides and recruitment of LPNs through efforts of the Staffing Committee.

3. To prevent this from recurring, The Scheduler and Nursing Supervisors re-educated by DON/Designee regarding the new ratio requirements for LPNs.

4. To monitor and maintain compliance, the DON/designee will hold staffing meetings to review calculations of the LPN ratios for accuracy weekly x5 x 4 weeks then weekly x2.

5. Findings will be submitted to the QAPI committee for further recommendations.

§ 211.12(i)(1) LICENSURE Nursing services.:

(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:

Based on review of facility nurse staffing data, it was determined that the facility failed to maintain a minimum of 2.87 hours of direct resident care for each resident.

Findings include:

A review of facility nurse staffing data, including deployment sheets for the week of December 18, 2023, through December 24, 2023, and for January 9, 2024, through January 15, 2024, the facility's 24 hour daily nurse staffing nurse staffing was below 2.87 hrs per resident on the following days:

January 9, 2024, nursing hours of direct resident care for each resident was 2.72
January 10, 2024, nursing hours of direct resident care for each resident was 2.61
January 11, 2024, nursing hours of direct resident care for each resident was 2.73
January 12, 2024, nursing hours of direct resident care for each resident was 2.80
January 13, 2024, nursing hours of direct resident care for each resident was 2.85
January 15, 2024, nursing hours of direct resident care for each resident was 2.75

Interview with the Administrator on January 16, 2024, at 12:45 p.m. confirmed the nursing hours indicated above.

Plan of Correction - To be completed: 02/04/2024

1. The facility cannot retroactively correct the minimum direct resident care hours on the one identified date.

2. The facility is focusing on retention and recruitment of direct care staff through efforts of the Staffing Committee.

3. To prevent this from recurring, The Scheduler and Nursing Supervisors educated by the NHA/Designee regarding the new direct resident care hours.

To prevent this from recurring, the facility to include census management to coincide with staffing levels

4. To monitor and maintain compliance, the DON/designee will hold staffing meetings to review calculations of direct care workers hours 5x weekly x4 weeks then weekly x2.

5. Findings will be submitted to the QAPI committee for further recommendations.

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