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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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:

Based on a revisit survey completed on March 18, 2025, it was determined that Southwestern Nursing and Rehabilitation Center corrected the deficiencies cited during the survey of January 24, 2025, under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities, however, has continued deficiencies under the requirements of the 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 a review of staffing documents provided by the facility and staff interview it was determined that the facility failed to provide one nurse assistant (NA) per 10 residents on the day shift on five of 13 days (3/9/25, 3/11/25, 3/12/25, 3/13/25 and 3/15/25) one NA per 11 residents on the second shift on seven of 13 days (3/7/25, 3/10/25 through 3/13/25, 3/15/25 and 3/16/25 ) and one NA per 15 residents on the night shift on seven of 13 days (3/7/25, 3/9/25 through 3/13/25 and 3/15/25) as required.

Findings include:

A review of facility staffing documents provided by the facility from 3/4/25 through 3/16/25, revealed the facility failed to provide NA on the following shifts as required:

Day shift:

DateCensusActual hoursHours required
3/9/256742.7350.25
3/11/256948.0651.75
3/12/256947.9251.75
3/13/257147.9353.25
3/15/257049.2452.50

Evening shift:

DateCensusActual hoursHours required

3/7/256942.7947.05
3/10/256639.9545.00
3/11/256944.1147.05
3/12/256946.0147.05
3/13/257147.5748.41
3/15/257046.6447.73
3/16/257347.3549.77

Night shift:

DateCensusActual hoursHours required

3/7/256931.7634.50
3/9/256731.9533.50
3/10/256632.6233.00
3/11/256931.1634.50
3/12/256932.3734.50
3/13/257128.5735.50
3/15/257030.5835.00

During an interview on 3/18/25 at 4:14 p.m., the Nursing Home Administrator confirmed that the facility failed to provide NA's in the facility on the above shifts as required.

Plan of Correction - To be completed: 05/08/2025

1. The facility is unable to retroactively correct the staffing ratios for the days and shifts listed in the deficiency statement.
2. The facility will schedule CNA's 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.
3. NHA or designee will educate the new scheduling coordinator on the requirements of CNA ratios of 1 to 10 for day shifts, 1 to 11 for afternoon shifts and 1 to 15 for midnight shifts.
4. NHA or designee will randomly audit the staffing ratio 3 days per week, for 4 weeks. 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. :

(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 30 residents on the evening shift on one of 13 days (3/14/25).

Findings include:

Review of facility census data and nursing time schedules from 3/4/25 through 3/16/25 revealed the following LPN staffing shortage:

Evening shift:

3/14/25census 7122.06 actual hours22.72 hours required.

During an interview on 3/18/25, at 4:14 p.m. the Nursing Home Administrator confirmed the facility failed to provide the minimum of LPN's on the above day as required.

Plan of Correction - To be completed: 05/08/2025

1. The facility is unable to retroactively correct the staffing ratios for the days and shifts listed in the deficiency statement.
2. The facility will schedule LPNs to state ratio of 1 to 30 on evening shift. 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.
3. NHA or designee will educate the scheduling coordinator on the requirements of LPN ratios of 1 to 30 for evening shifts.
4. NHA or designee will randomly audit the staffing ratios 3 days per week for 4 weeks. 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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