Pennsylvania Department of Health
MOUNTAIN LAUREL HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

MOUNTAIN LAUREL HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

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MOUNTAIN LAUREL HEALTHCARE AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Findings of a complaint survey completed on March 26, 2024, at Mountain Laurel Healthcare 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. :

(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 schedules, staffing information provided by the facility, and staff interviews, it was determined that the facility failed to meet the required nurse aide-to-resident staffing ratio on the afternoon shift for two of 21 days (24-hour periods) reviewed.

Finding include:

Nursing time schedules provided by the facility for the days of February 17, 2024, through March 8, 2024, revealed that the facility provided one nurse aide per 14 residents on February 17 and 19, 2024, and provided one nurse aide per 16 residents on February 18 and March 7, 2024, during the afternoon shift.

Interview with the Nursing Home Administrator on March 26, 2024, at 11:30 a.m. confirmed that the facility did not meet the required nurse aide-to-resident staffing ratios for the days listed above.

Plan of Correction - To be completed: 05/09/2024

1. The administrator and/or designee will conduct a review of the last 30-days of nursing schedules to determine compliance with proper nurse aide to resident ratios.
2. The administrator and/or designee will conduct reviews at least 5-days per week for two weeks then 3-days per week for one month to ensure compliance. In the event of extensive call offs, we ask for volunteers with bonuses, then we will mandate, and should it become necessary we will utilize administrative nursing staff, as well as stopping admissions. We also utilize staffing agencies. We continue to meet regularly to determine We continue to recruit all levels of staff, RN's, LPN's, CNA's,
Housekeeping, Laundry, and Dietary. We also have staffing meetings each day to discuss staffing and census. We continue a bonus structure for: Open Shift Bonus 4hrs 8hrs RNs, LPN's, CNA's, paid out over 1-yr RNs, LPN's, CNA's. Referral Bonus RNs, LPN's, CNA's.
3. The results of the audits, along with a Root Cause Analysis of any identified issues, will be brought to the Quality Assurance and Performance Improvement Committee for further analysis and corrective action.

§ 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 a review of nursing schedules and staff interviews, it was determined that the facility failed to provide 2.87 hours of direct resident care for each resident for one of 21 days (24-hour periods) reviewed.

Findings include:

Nursing time schedules provided by the facility for the days of February 17, 2024, through March 8, 2024, revealed that the facility provided only 2.75 hours of direct care for each resident on February 17, 2024; 2.65 hours of direct care for each resident on February 18, 2024; 2.86 hours of direct care for each resident on February 20, 2024; 2.70 hours of direct care for residents on February 24, 2024; and 2.86 hours of direct care for each resident on February 25, 2024.

Interview with the Nursing Home Administrator on March 26, 2024, at 11:30 a.m. confirmed that the staffing was below the required minimum number of nursing care hours for the day listed above.

Plan of Correction - To be completed: 05/09/2024

1. The administrator and/or designee will conduct a review of the last 30-days of nursing schedules to ensure that we maintain 2.87 hours of direct resident care for each resident in a 24-hour period.
2. The administrator and/or designee will conduct reviews at least 5-days per week for two weeks then 3-days per week for one month to ensure compliance. In the event of extensive call offs, we ask for volunteers with bonuses, then we will mandate, and should it become necessary we will utilize administrative nursing staff, as well as stopping admissions. We also utilize staffing agencies. We continue to meet regularly to determine We continue to recruit all levels of staff, RN's, LPN's, CNA's. We also have staffing meetings each day to discuss staffing and census. We continue a bonus structure for: Open Shift Bonus 4hrs 8hrs RNs, LPN's, CNA's, paid out over 1-yr RNs, LPN's, CNA's. Referral Bonus RNs, LPN's, CNA's.
3. The results of the audits, along with a Root Cause Analysis of any identified issues, will be brought to the Quality Assurance and Performance Improvement Committee for further analysis and corrective action.

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