Inspection·September 25, 2024

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on review of facility documentation and interviews with staff it was determined that the facility failed to maintain and implement an effective, quality assurance and performance improvement program that focuses on outcome as required by failing to implement a QAPI for staffing for LPN's. Residents Affected - Few Finding include: Review of Plan of Correction for PA State tag 5530 indicated: Facility Administration will ensure a minimum of one license practical nurse per 25 residents during day shift and 30 residents during the evening shift. The facility staffing schedule was reviewed to ensure that it provided the necessary coverage of License practical nurses per regulation. To prevent this from happening again the facility Administrator, Director of Nursing and Scheduler will conduct a staffing meeting to review staffing ratios weekly times four weeks then monthly times two month. Regional Director of Clinical Services will educate the facility Administrator, Director of Nursing and scheduler on the LPN staffing ratios implemented on 07/01/2023. The Nursing Home Administrator or designee will educate the licensed staff on the facility call off policy. To monitor and maintain ongoing compliance the Director of Nursing/designee will audit staffing weekly times four weeks then monthly times two months. Results will be taken to the QAPI for review and revision as needed. Review of the Plan of correction dated 9/12/24, and accepted by the state survey agency on 9/20/24, indicated that the facility would monitor and maintain ongoing compliance the Director of Nursing/designee will audit staffing weekly times four weeks then monthly time two months. Results will be taken to the QAPI for review and revision as needed. Review of staffing sheets from 9/21/24, indicated the following: 9/21/24 - census 127 needed 5.08 had 3.00. Day shift. 09/21/24 - census 128 needed 4.27 had 4.00. Evening shift (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395682 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395682 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Health & Rehab Center 900 Third Ave Beaver Falls, PA 15010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)