Pennsylvania Department of Health
TULIP SPECIAL CARE, LLC
Patient Care Inspection Results

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TULIP SPECIAL CARE, LLC
Inspection Results For:

There are  55 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.
TULIP SPECIAL CARE, LLC - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey and a State Licensure Survey, completed on December 21, 2023, it was determined that Tulip Special Care, LLC, was not in compliance with the 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 related to the health portion of the survey process.





 Plan of Correction:


483.20(g) REQUIREMENT Accuracy of Assessments: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.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:

Based on observations, clinical record review and interviews with staff, it was determined that the facility failed to ensure that resident assessments accurately reflected residents' status related to restraints for one of two residents reviewed on restraints (Resident R36).

Findings include:

Observation, on December 18, 2023, at 11:30 a.m. revealed that Resident R36 was wearing hand mitts (a type of physical restraint) on both of his hands.

Continued observation, on December 19, 2023, at 12:29 p.m. revealed that Resident R36 continued to wear hand mitts on both of his hands.

Review of Resident R36's care plan, dated initiated May 16, 2022, revealed that the resident used physical restraints bilateral hand mitts secondary to pulling at tracheostomy (a surgically created hole in your trachea that allows for breathing) and tubing putting self at high risk for decannulation (removal of tracheostomy tube) related to confusion.

Review of Resident R36's physician orders revealed that the resident had ongoing orders for the bilateral hand mitts from May 16, 2022, through December 19, 2023.

Review of Resident R36's quarterly MDS assessment, dated August 8, 2023, revealed that the assessment did not indicate that the resident used any types of restraints.

Review of Resident R36's Quarterly MDS assessment, dated November 6, 2023, revealed that the assessment did not indicate that the resident used any types of restraints.

Review of Resident R36's quarterly Physical Restraint Evaluation, dated December 6, 2023, revealed that the resident continued to require restraints and that trial periods without the hand mitts were ineffective.

Interview on December 21, 2023, at 12:06 p.m. Employee E9, RNAC (Registered Nurse Assessment Coordinator), confirmed that the above MDS assessments for Resident R36 did not accurately reflect the resident's use of physical restraints.

28 Pa Code 201.14(a) Responsibility of licensee




 Plan of Correction - To be completed: 02/19/2024

1. On day of survey an audit was completed to determine which residents with orders for restraints were missed on the resident assessments (MDS)
2. Resident assessment not in compliance has been modified to reflect use of restraints.
3. RNAC has been inserviced on importance of ensuring timely, accurate resident assessments.
4. An audit will be completed by the NHA monthly to ensure residents with orders for restraints are reflected on the resident assessments and results will be reported to the QAPI Committee monthly.

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service: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.
§483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).
Observations:

Based on review of personnel records and interviews with staff, it was determined that the facility failed to complete annual performance reviews for nurse aide staff as required for three of three nurse aide personnel files reviewed (Employees E11, E12 and E13).

Findings include:

Review of Employee E11's personnel filed revealed that she was hired by the facility on August 20, 2018, as a nurse aide. Continued review revealed than an annual performance review had not been completed for the employee.

Review of Employee E12's personnel filed revealed that she was hired by the facility on August 24, 2022, as a nurse aide. Continued review revealed than an annual performance review had not been completed for the employee.

Review of Employee E13's personnel filed revealed that she was hired by the facility on October 18, 2021, as a nurse aide. Continued review revealed than an annual performance review had not been completed for the employee.

Interview on December 19, 2023, the Nursing Home Administrator stated that no annual performance reviews had been completed for any nursing staff.

Interview on December 20, 2023, at 12:38 p.m. Employee E5, Human Resources Director, provided a template of the facility's performance review process. Review of the form revealed that employees are rated on a scale of one to five based on the quality, productivity, job knowledge, reliability, attendance, initiative, teamwork, policy compliance, customer service and decision-making skills. The form also included areas to review the employee's accomplishments, goals and comments. Employee E5 confirmed that this process had not been completed for Employees E11, E12 and E13.

28 Pa. Code 201.19(2) Personnel policies and procedures





 Plan of Correction - To be completed: 02/19/2024

1. Employees E11, E12 and E13 annual performance review was completed.
2. A report was provided to NHA and DON of outstanding annual evaluations needed.
3. A plan was put in place to ensure all outstanding employee annual evaluations will be completed. 5 evaluations will be completed weekly until the facility is in compliance.
4. Once all evaluations are up to date an audit will be completed monthly thereafter to ensure compliance and results will be reported to the QAPI Committee monthly.

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills: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.
§483.25(g)(4)-(5) Enteral Nutrition
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

§483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.
Observations:


Based on observations, review of facility policy and interview with staff, it was determined that the facility failed to ensure that physican orders were followed related to one of seven residents reviewed with a gastrostomy tube. (Resident R31)

Findings include:

Review of facility's 'Tube feeding/Enteral nutrition' policy, effective 2020, states the following:
"6. Tube placement will be checked each shift prior to each feeding, flush or medication pass.
7. The licensed nurse will not check residuals routinely. A residual should only be checked if the patient presents with signs/symptoms not tolerating enteral feedings, for example: nausea, vomiting, abdominal distention, discomfort, fullness, or bloating.
8. Check residual prior to feeding or with med pass > 250ml hold feeding for 1 hour and recheck, if still > 250 ml contact MD and document.
9. The licensed nurse will assess the following prior to initiating the tube feeding: security of the tube and the appearance of the insertion site."

Review of Resident R31's psych evaluation dated November 17, 2023, revealed history of cardiac arrest, trach intubation, gastrostomy status, hypoxic ischemic autoimmune encephalopathy (brain injury that occurs when the brain experiences a decrease in oxygen or blood flow) nonverbal at baseline, does not respond to sound.

Review of physician's orders revealed an order dated on July 11, 2023, to "Check for residual prior to feeding or with med pass. If 250mL (milliliters) or over, hold feeding for 1 hour and recheck. If residual 250mL or over again, notify MD. Document amount of residual in mL." Continued review of physician orders revealed another order dated on July 11, 2023, to "Check tube placement prior to each feeding, flush or medication."

During observation of medication administration on December 19, 2023 at 12:15 p.m. with licensed nurse, Employee E6 it was observed that Employee E6 administered Levsin 0.125 mg enterally without checking tube placement and without checking residual volume.

28 Pa. Code 201.14(a)Responsibility of licensee

28 Pa. Code 211.12(d)(1)(2)(5)Nursing services






 Plan of Correction - To be completed: 02/19/2024

1. On the day of survey resident R31 was assessed by DON for appropriate tube placement and residual volume to ensure there were no complications. Employee E6 was educated on the importance of following physician orders and facility policy as it pertains to checking for proper tube placement and residual volume prior to administering medication.
2. All Nurses scheduled for that shift were educated on the importance of following physician orders and facility policy as it pertains to checking for proper tube placement and residual volume prior to administering medication.
3. All nursing staff will be inserviced on the importance of following physician orders and facility policy as it pertains to checking for proper tube placement and residual volume prior to administering medication.
4. An audit will be completed by the DON/designee weekly x 1-month, and then monthly thereafter to ensure compliance with physician orders and facility policy as it pertains to checking tube placement and residual volume prior to medication pass, and results will be reported to the QAPI Committee monthly.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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.
§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:

Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to adequately monitor the nutritional and hydration status for one of two residents reviewed related to nutrition (Resident R1).

Findings include:

Review of facility policy, "Significant Weight Gain" dated 2019, revealed that, "Appropriate members of the interdisciplinary team (IDT) will: Identify individuals with significant weight gain ... reweigh to assure accurate weight ... assess for recent weight loss ... consider food intake ... [and] assess for possible fluid imbalances." Continued review revealed that "Significant Weight Gain" is considered as five percent gain in one month and that "Severe Weight Gain" is considered as greater than five percent gain in one month.

Review of Resident R1's Admission MDS assessment (Minimum Data Set - a mandatory periodic resident assessment tool), dated September 26, 2023, revealed that the resident was admitted to the facility September 19, 2023, and had diagnoses including end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), cerebrovascular accident (damage to the brain from interruption of its blood supply), anoxic brain damage (brain damage caused by lack of oxygen to the brain), malnutrition (lack of sufficient nutrients in the body) and respiratory failure (not enough oxygen passes from your lungs to your blood). Continued review revealed that the resident required a feeding tube, invasive mechanical ventilation (machines that act as bellows to move air in and out of the lungs) and dialysis (the process of removing waste products and excess fluid from the body; dialysis is necessary when the kidneys are not able to adequately filter the blood).

Review of Resident R1's care plan, dated initiated September 20, 2023, revealed that the resident was identified by the facility as being at nutritional risk due to NPO (nothing by mouth) status and required a feeding tube to meet his nutritional requirements. Interventions included to weight the resident as ordered and to notify the dietician of significant changes.

Continued review of Resident R1's care plan, dated September 26, 2023, revealed that the resident required dialysis due to end stage renal disease, with interventions including to document the resident's body weight pre/post dialysis treatments as directed.

Review of documented weights for Resident R1 revealed the following:
On December 4, 2023, Resident R1 weighed 220.2 pounds;
On December 5, 2023, Resident R1 weighed 252 pounds;
On December 11, 2023, Resident R1 weighed 256.6 pounds;
On December 14, 2023, Resident R1 had two weights noted: 264 and 274.2 pounds;
This represents a 24.52 percent weight gain between December 4 to December 14, 2023.

Review of nursing notes for Resident R1 revealed no indication that the dietician or physician were aware or notified of the resident's significant weight change.

Interview on December 20, 2023, at 2:16 p.m. with Employee E4, dietician, and Employee E10, Medical Director, revealed that the employees were not aware of Resident R1's recent weight gain. Employee E4, dietician, stated that she did not know why she was not notified of the resident's significant weight change. Employee E4, dietician, also stated that she needed to obtain an accurate weight for the resident and implement a new process to ensure that accurate weights are consistently obtained. Employee E10, Medical Director, stated that the resident's documented weights were most likely inaccurate, agreed that the resident's weights showed a large trend of weight gain and stated that he would assess the resident.

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



 Plan of Correction - To be completed: 02/19/2024

1. Resident R1's was reweighed for accuracy, the dietitian reviewed the weight pattern and documented interventions as appropriate.
2. A review of all resident's weights was completed by the dietitian to ensure all recommended interventions were in place.
3. The Dietitian has been inserviced on the importance of monitoring weights to ensure appropriate interventions are in place in a timely manner.
4. An audit will be completed by the Dietitian weekly x 1-month, and then monthly thereafter to ensure all weights are completed, accurate and interventions are in place as appropriate, and results will be reported to the QAPI Committee monthly.

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan: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.
§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
Observations:

Based on observations, clinical record review and interviews with staff, it was determined that the facility failed to develop a baseline care plan within 48 hours of a resident's admission related to ventilators for two of three residents with ventilators reviewed (Resident R1 and Resident R97).

Findings include:

Observation, on December 18, 2023, at 11:24 a.m. revealed that Resident R97 was connected to a ventilator (machines that act as bellows to move air in and out of the lungs) to help him breathe.

Continued observation, on December 19, 2023, at 12:29 p.m. revealed that Resident R97 continued to use a ventilator.

Review of progress notes for Resident R97 revealed a respiratory note, dated December 4, 2023, at 5:29 p.m. which indicated that the resident was a new admission, and that upon his arrival to the facility the resident was placed on a ventilator.

Continued review of progress notes for Resident R97 revealed a pulmonary (branch of medicine specializing in lung and breathing disorders) physician consultation note, dated December 6, 2023, at 6:30 p.m. which indicated that the resident had a diagnosis of respiratory failure (not enough oxygen passes from your lungs to your blood) and continued to require the use of a ventilator.

Review of Resident R97's care plan, dated initiated December 4, 2023, revealed that no care pan had been developed related to the resident's use of a ventilator.

Interview on December 20, 2023, at 3:04 p.m. the Director of Nursing confirmed that no care plan had been developed related to Resident R97's use of a ventilator.

Review of Resident R1's Admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool) dated September 26, 2023, revealed that the resident was admitted to the facility on September 19, 2023, and had diagnoses including respiratory failure (not enough oxygen passes from your lungs to your blood), cerebrovascular accident (damage to the brain from interruption of its blood supply), quadriplegia (paralysis of all four limbs) and anoxic brain damage (brain damage caused by lack of oxygen to the brain). Continued review revealed that the resident used a ventilator (machines that act as bellows to move air in and out of the lungs).

Observation, on December 18, 2023, at 11:02 a.m. revealed that Resident R1 was connected to a ventilator to help him breathe.

Continued observation, on December 19, 2023, at 12:31 p.m. revealed that Resident R1 continued to use a ventilator.

Review of progress notes for Resident R1 revealed a pulmonary (branch of medicine specializing in lung and breathing disorders) physician consultation note, dated December 17, 2023, at 4:30 p.m. which indicated that the resident had a diagnosis of respiratory and continued to require the use of a ventilator.

Review of Resident R1's care plan revealed that on September 21, 2023, a focus area noting that the resident was ventilator dependent was initiated. Continued review revealed that no further care plan related to the resident's ventilator use was developed; there were no goals or interventions listed.

Interview on December 20, 2023, at 2:43 p.m. the Director of Nursing confirmed that no care plan had been developed related to Resident R1's use of a ventilator.

28 Pa Code 201.14(a) Responsibility of licensee

28 Pa Code 211.12(d)(1) Nursing services

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







 Plan of Correction - To be completed: 02/19/2024

1. Resident R1 and R97's respiratory care plans were updated to include ventilator use.
2. A review of all residents' respiratory care plans was completed to ensure accuracy and are in compliance.
3. The Respiratory Director has been inserviced on the importance of completing an accurate baseline care plan within 48 hrs. of admission.
4. An audit will be completed by the NHA weekly x 1-month, and then monthly thereafter to ensure all respiratory baseline care plans are completed timely and accurately, and results will be reported to the QAPI Committee monthly.

483.20(f)(1)-(4) REQUIREMENT Encoding/Transmitting Resident Assessments:Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.
§483.20(f) Automated data processing requirement-
§483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility:
(i) Admission assessment.
(ii) Annual assessment updates.
(iii) Significant change in status assessments.
(iv) Quarterly review assessments.
(v) A subset of items upon a resident's transfer, reentry, discharge, and death.
(vi) Background (face-sheet) information, if there is no admission assessment.

§483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State.

§483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following:
(i)Admission assessment.
(ii) Annual assessment.
(iii) Significant change in status assessment.
(iv) Significant correction of prior full assessment.
(v) Significant correction of prior quarterly assessment.
(vi) Quarterly review.
(vii) A subset of items upon a resident's transfer, reentry, discharge, and death.
(viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment.

§483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS.
Observations:

Based on clinical record reviews and interviews with staff, it was determined that the facility failed to transmit a MDS assessment within the required timeframes for one of 16 residents reviewed (Resident R4).

Findings include:

Review of Resident R4's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated November 10, 2023, revealed that it was not signed by the RNAC (Registered Nurse Assessment Coordinator) until December 17, 2023, and that it was not transmitted until December 17, 2023.

Interview on December 21, 2023, at 12:06 p.m. Employee E9, RNAC, stated that Resident R4's assessment was late and confirmed that it was not transmitted within the required timeframes.

28 Pa. Code 201.14(a) Responsibility of licensee






 Plan of Correction - To be completed: 02/19/2024

I hereby acknowledge the CMS 2567-A, issued to TULIP SPECIAL CARE, LLC for the survey ending 12/21/2023, AND attest that all deficiencies listed on the form will be corrected in a timely manner.
§ 201.19(2) LICENSURE Personnel policies and procedures.:State only Deficiency.
(2) Employee performance evaluations, including documentation of any monitoring, performance, or disciplinary action related to the employee.

Observations:

Based on review of personnel records and interviews with staff, it was determined that the facility failed to complete annual performance reviews for staff as required for two of two licensed nurse personnel files reviewed (Employees E14 and E15).

Findings include:

Review of Employee E14's personnel filed revealed that she was hired by the facility on May 17, 2022, as an LPN (licensed practical nurse). Continued review revealed than an annual performance review had not been completed for the employee.

Review of Employee E15's personnel filed revealed that she was hired by the facility on November 29, 2021, as a RN (registered nurse) Supervisor. Continued review revealed than an annual performance review had not been completed for the employee.

Interview on December 19, 2023, the Nursing Home Administrator stated that no annual performance reviews had been completed for any nursing staff.

Interview on December 20, 2023, at 12:38 p.m. Employee E5, Human Resources Director, provided a template of the facility's performance review process. Review of the form revealed that employees are rated on a scale of one to five based on the quality, productivity, job knowledge, reliability, attendance, initiative, teamwork, policy compliance, customer service and decision-making skills. The form also included areas to review the employee's accomplishments, goals and comments. Employee E5 confirmed that this process had not been completed for Employees E14 and E15.






 Plan of Correction - To be completed: 02/19/2024

1. Employees E11, E12 and E13 annual performance review was completed.
2. A report was provided to NHA and DON of outstanding annual evaluations needed.
3. A plan was put in place to ensure all outstanding employee annual evaluations will be completed. 5 evaluations will be completed weekly until the facility is in compliance.
4. Once all evaluations are up to date an audit will be completed monthly thereafter to ensure compliance and results will be reported to the QAPI Committee monthly.

§ 211.12(f.1)(5) LICENSURE Nursing services. :State only Deficiency.
(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.
Observations:

Based on review of nursing staff schedules and interviews with staff, it was determined that the facility failed to maintain required staffing ratios, including one RN (registered nurse) per every 250 residents, on four of twenty-one days reviewed (August 28, November 20, December 18 and December 19, 2023).

Findings include:

Review of facility nursing staffing schedules revealed that on August 28, 2023, on the evening shift (3:00 p.m. to 11:00 p.m.), the resident census was 33. Continued review revealed there was no RN on duty.

Continued review of facility nursing staffing schedules revealed that on November 20, 2023, on the evening shift, the resident census was 42. Continued review revealed there was no RN on duty.

Continued review of facility nursing staffing schedules revealed that on December 18, 2023, on the day shift (7:00 a.m. to 3:00 p.m.), the resident census was 43. Continued review revealed there was no RN on duty.

Continued review of facility nursing staffing schedules revealed that on December 18, 2023, on the evening shift, the resident census was 43. Continued review revealed there was no RN on duty.

Continued review of facility nursing staffing schedules revealed that on December 19, 2023, on the day shift, the resident census was 43. Continued review revealed there was no RN on duty.

Continued review of facility nursing staffing schedules revealed that on December 19, 2023, on the evening shift, the resident census was 43. Continued review revealed there was no RN on duty.

Interview on December 21, 2023, at 11:13 a.m. the Nursing Home Administrator confirmed that the facility did not meet the required RN staffing ratios for the above shifts.





 Plan of Correction - To be completed: 02/19/2024

1. On the day of survey all upcoming schedules were reviewed by the NHA and DON to ensure an RN was scheduled for all shifts.
2. NHA, DON and staffing scheduler met to discuss the requirement to have an RN scheduled and barriers preventing the compliance.
3. A plan was put in place to ensure compliance by reviewing our hiring practices, staffing needs, flexing schedules, on-call for call out replacements, agency needs and better communication between NHA, DON and Staffer to ensure compliance.
4. NHA/DON will review/audit the schedule daily for compliance and results will be reported to the QAPI Committee monthly.


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