Health 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 Page 1 of 2 395682 395682 09/25/2024 Providence Health & Rehab Center 900 Third Ave Beaver Falls, PA 15010

F 0865 9/22/24- census 128 needed 5.12 had 4.00. Day shift. Level of Harm - Minimal harm or potential for actual harm 9/22/24- census- 128 needed 4.27 had 4.00. Evening shift. 9/23/24 - census 128 needed 5.12 had 5.00. Day shift. Residents Affected - Few During an interview on 9/25/24, at 1:59 pm Assistant Director of Nursing confirmed that the facility failed to maintain and implement an effective, quality assurance and performance improvement program by failing to implement a QAPI plan for LPN's. 28 Pa. Code 201.14(a)Responsibility of licensee. 28 Pa. Code 201.18(a)(b)(3)e(1)(3)(4)Management. 395682 Page 2 of 2