Pennsylvania Department of Health
 SOUTHWESTERN NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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SOUTHWESTERN NURSING AND REHABILITATION CENTER
Inspection Results For:

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SOUTHWESTERN NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Findings of an abbreviated survey, in response to four complaints, completed on February 21, 2024 at Southwestern Nursing and Rehabilitation Center identified no deficient practice 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, deficient practice was identified under 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


§ 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 nursing time schedules and staff interview it was determined that the facility administrative staff failed to provide a minimum of one nurse aide (NA) per twelve residents during the day and/or evening shift, and/or one nurse aid per 20 residents during the night shift for 10 of 21 days (2/1, 2/2, 2/3, 2/4, 2/5, 2/6, 2/13, 2/15, 2/16, and 2/18/24).

Findings include:

Review of the facility census data, nursing time schedules, and deployment sheets from 1/30/24 through 2/19/24, revealed the following nurse aide staffing shortages:

On 2/1/24, the census was 100, which required 5.00 NAs during the night shift. Review of the nursing time schedules revealed 3.91 NAs provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 2/2/24, the census was 103, which required 8.58 NAs during the day shift. Review of the nursing time schedules revealed 6.94 NAs provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

On 2/3/24, the census was 100, which required 5.00 NAs during the night shift. Review of the nursing time schedules revealed 4.09 NAs provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 2/4/24 the census was 98, which required 8.17 NAs during the day shift. Review of the nursing time schedules revealed 8.00 NA's provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

On 2/5/24, the census was 99, which required 8.25 NAs during the day shift. Review of the nursing time schedules revealed 7.09 NAs provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

On 2/6/24, the census was 98, which required 4.90 NAs during the night shift. Review of the nursing time schedules revealed 4.00 NA's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 2/13/24, the census was 98, which required 8.17 NAs during the day shift. Review of the nursing time schedules revealed 6.97 NAs provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

On 2/15/24, the census was 100, which required 8.33 NAs during the day shift and evening shift. Review of the nursing time schedules revealed 6.80 NAs provided care on the day shift and 6.84 NAs provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

On 2/16/24, the census was 101, which required 8.42 NAs during the evening shift. Review of the nursing time schedules revealed 6.97 NAs provided care on the evening shift. No additional excess higher-level staff were available to compensate this deficiency.

On 2/18/24, the census was 102, which required 8.50 NAs during the day shift. Review of the nursing time schedules revealed 7.88 NAs provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

During an interview on 2/23/24, at 11:42 a.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a minimum of one nurse aide per twelve residents during the day and evening shift, and/or one nurse aid per 20 residents during the night shift on 10 of 21 days.



 Plan of Correction - To be completed: 03/11/2024

- The facility is unable to retroactively correct the staffing ratio for days: 2/1/24, 2/2/24, 2/3/24, 2/4/24, 2/5/24, 2/6/24, 2/13/24, 2/15/24, 2/16/24, 2/18/24.
- The facility will schedule CNA's, LPN's and RNs to State Ratio. Call outs will be monitored by NHA/DON and/or designee. Facility staff as well as staffing agencies will be utilized to facilitate replacement/procurement of staff.
- The staffing ratio will be monitored daily for 5 days, weekly for 2 weeks, and monthly for 2 months.
- Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring or changes needed.

§ 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 staff interview it was determined that the facility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per forty residents during the night shift for 2 of 21 days (1/30/24 and 2/3/24).

Findings include:

Review of the facility census data, nursing time schedules, and deployment sheets from 1/30/24 through 2/19/24, revealed the following nurse LPN staffing shortages:

On 1/30/24 the census was 95, which required 2.52 LPN's during the night shift. Review of the nursing time schedules revealed 2.19 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 2/3/24, the census was 100, which required 2.66 LPN's during the night shift. Review of the nursing time schedules revealed 2.42 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

During an interview on 2/21/24, at 2:30 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a minimum of one LPN per forty residents during the night shift on 2 of 21 days.




 Plan of Correction - To be completed: 03/11/2024

- The facility is unable to retroactively correct the staffing ratio for days: 2/1/24, 2/2/24, 2/3/24, 2/4/24, 2/5/24, 2/6/24, 2/13/24, 2/15/24, 2/16/24, 2/18/24.
- The facility will schedule CNA's, LPN's and RNs to State Ratio. Call outs will be monitored by NHA/DON and/or designee. Facility staff as well as staffing agencies will be utilized to facilitate replacement/procurement of staff.
- The staffing ratio will be monitored daily for 5 days, weekly for 2 weeks, and monthly for 2 months.
- Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring or changes needed.


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