Pennsylvania Department of Health
ASBURY HEALTH CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ASBURY HEALTH CENTER
Inspection Results For:

There are 196 surveys for this facility. Please select a date to view the survey results.

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ASBURY HEALTH CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an Abbreviated Survey in response to three complaints, completed on April 2, 2025, at Asbury Health Center, it was determined that there were no federal deficiencies identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care; however, the facility was not in compliance with 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 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 10 residents during the day shift for 2 of 21 days (3/16/25 and 3/19/25), and one NA per 15 residents during the night shift for 2 of 21 days (3/13/25 and 3/22/25).

Findings include:

Review of the facility census data, nursing time schedules, and deployment sheets from 3/13/25 through 4/2/25, revealed the following nurse aide staffing shortages:

On 3/16/25 the census was 128, which required 12.80 NAs during the day shift. Review of the nursing time schedules revealed 12.40 NAs provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

On 3/19/25 the census was 132, which required 13.20 NAs during the day shift. Review of the nursing time schedules revealed 12.53 NAs provided care on the day shift. No additional excess higher-level staff were available to compensate this deficiency.

On 3/13/25 the census was 123, which required 8.20 NAs during the night shift. Review of the nursing time schedules revealed 7.47 NAs provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 3/22/25 the census was 131, which required 8/73 NAs during the night shift. Review of the nursing time schedules revealed 7.20 NAs provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

During an interview on 3/2/25, at 3:00 p.m. the Director of Nursing (DON) confirmed that the facility failed to provide a minimum of one nurse aide per 10 residents during the day shift for 2 of 21 days and one NA per 15 residents during the night shift for 2 of 21 days.

Plan of Correction - To be completed: 05/19/2025

Current master schedule was reviewed to ensure all days are scheduled to meet ratios. NHA and DON will have daily staffing meetings to review daily staffing needs. Facility is actively advertising referral bonuses and job openings for CNAs and LPNS. A monthly town hall meeting is held to help support employee retention. NHA or designee will educate the scheduler on the current CNA ratios of 1:10 on daylight, 1:11 on evening, and 1:15 on overnight. NHA or designee will audit schedule for ratio compliance daily times four weeks, and monthly times two months. Results will be reviewed at QAPI and revised as needed.

§ 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 review of nursing time schedules and staff interview it was determined that the facility administrative staff failed to provide a minimum of one LPN per 40 residents on the night shift for two of 21 days (3/23/25 and 3/25/25).

Findings include:

Review of the facility census data, nursing time schedules, and deployment sheets from 3/13/25 through 4/2/25, revealed the following nurse LPN staffing shortages:

On 3/23/25 the census was 130, which required 3.25 LPN's during the night shift. Review of the nursing time schedules revealed 3.00 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

On 3/25/25 the census was 129, which required 3.23 LPN's during the night shift. Review of the nursing time schedules revealed 2.75 LPN's provided care on the night shift. No additional excess higher-level staff were available to compensate this deficiency.

During an interview on 4/2/25, at 3:00 p.m. the Director of Nursing (DON) confirmed that the facility failed to provide a minimum of one LPN per 40 residents during the night shift on two of 21 days.

Plan of Correction - To be completed: 05/19/2025

Current master schedule was reviewed to ensure all days are scheduled to meet ratios. NHA and DON will have daily staffing meetings to review daily staffing needs. Facility is actively advertising referral bonuses and job openings for CNAs and LPNS. A monthly town hall meeting is held to help support employee retention. NHA or designee will educate the scheduler on the current LPN ratios of 1:25 on daylight, 1:30 on evening, and 1:40 on overnight. NHA or designee will audit schedule for ratio compliance daily times four weeks, and monthly times two months. Results will be reviewed at QAPI and revised as needed.

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