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

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LEBANON SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

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LEBANON SKILLED NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated survey in response to a complaint completed on February 14, 2024, at Lebanon Skilled Nursing and Rehabilitation Center, it was determined that there were no federal deficiences identified under the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care; however, the facility was not in compliance with the 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 a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for 10 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from January 24, 2024, through February 13, 2024, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for 12 residents on day (7:00 a.m. to 3:00 p.m.) shift on January 28, 2024, and February 6, 7, 9, 12, and 13, 2024..

The facility failed to meet the minimum NA to resident ratio of one NA for 12 residents on evening (3:00 p.m. to 11:00 p.m.) shift on February 3, 4, 7, 10, 11, 12, and 13, 2024.

The facility failed to meet the minimum NA to resident ratio of one NA for 20 residents on night (11:00 p.m. to 7:00 a.m.) shift on February 13, 2024.


 Plan of Correction - To be completed: 03/12/2024

The statements made on this plan of correction are not admission to, and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations the center has taken or will take actions set forth in the following plan of corrections. The following plan of corrections constitutes the center's allegation of compliance.

1. Identified practice is unable to be retroactively corrected.

2. NA to resident ratio of one NA to twelve residents will be scheduled for day and evening shifts and one NA to twenty residents for night shift.

3. Nursing Scheduler will receive re-education on the NA to resident ratio.

4. NHA/designee will conduct random audits of five shifts per week for four weeks. Results of audits will be presented to the QAPI Committee for review and recommendations as 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 a review of nursing time schedules, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for 1 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from January 24, 2024, through February 13, 2024, revealed the following:

The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on night (11:00 p.m. to 7:00 a.m.) shift on January 28, 2024, and February 11, 2024.


 Plan of Correction - To be completed: 03/12/2024

1. Identified practice is unable to be retroactively corrected.

2. LPN to resident ratio of one LPN to forty residents will be scheduled on night shift.

3. Nursing Scheduler will receive re-education on the LPN to resident ratio.

4. NHA/designee will conduct random audits of five night shifts per week for four weeks. Results of audits will be presented to the QAPI Committee for review and recommendations as needed.


§ 211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(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 a review of nursing time schedules, it was determined that the facility failed to provide a minimum of 2.87 hours of direct care for each resident for 7 of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from January 24, 2024, through February 13, 2024, revealed the following total nursing care hours below minimum requirements:

January 28, 2024: 2.82 care hours per resident.
February 3, 2024: 2.81 care hours per resident.
February 4, 2024: 2.69 care hours per resident.
February 10, 2024: 2.68 care hours per resident.
February 11, 2024: 2.79 care hours per resident.
February 12, 2024: 2.47 care hours per resident.
February 13, 2024: 2.59 care hours per resident.


 Plan of Correction - To be completed: 03/12/2024

1. Identified practice is unable to be retroactively corrected.

2. A minimum of 2.87 hours of direct resident care for each resident will be scheduled for a twenty four time period.

3. Nursing Scheduler will receive re-education on the 2.87 hours of direct resident care per resident in a twenty four time period.

4. NHA/designee will conduct random audits of five days of the nursing schedule for four weeks. Results of the audits will be presented to the QAPI Committee for review and recommendations as needed.



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