Provider Name: SUMMIT AT BLUE MOUNTAIN NURSING & REHAB CTR, THE
Address: 211 NORTH 12TH STREET, LEHIGHTON, PA 18235
Phone: (610) 377-7206
County: Carbon (190)
Ownership Type: Non profit - Other
Certified Beds: 91
Average Residents Per Day: 39.6 ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: ST LUKE'S HOSPITAL
First Approved Date: January 8, 1970
Affiliated Entity: ()
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 3 ()
Health Inspection Rating: 3 ()
QM Rating: 4 ()
Long Stay QM Rating: 5 ()
Short Stay QM Rating: 3 ()
Staffing Rating: 4 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 1.95656, LPN Staff Hours Per Day: 0.4931, RN Staff Hours Per Day: 1.1460, Licensed Staff Hours Per Day: 1.6391
Total Nurse Staff Hours Per Day, per resident: 3.59568
Weekend Nurse Staff Hours: 2.86222, Weekend RN Staff Hours: 0.9607
PT Staff Hours Per Day, per resident: 0.0365
Nurse Staff Turnover: 41.2, Nurse Turnover Note:
RN Turnover: 55.6, RN Turnover Note:
Admin Left Number: 0, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 2.3695, Case Mix LPN Hours Per Day: 0.6556, Case Mix RN Hours Per Day: 0.2624
Adjusted Nurse Aide Hours Per Day, per resident: 1.68220, Adjusted LPN Hours Per Day: 0.5550, Adjusted RN Hours Per Day: 1.6453
Total Adjusted Nurse Hours Per Day, per resident: 3.44737
Adjusted Weekend Nurse Hours Per Day, per resident: 2.74417
Health Survey Dates and Scores: Cycle 1: 2023-02-09 (Score: 32), Cycle 2: 2022-04-21 (Score: 56), Cycle 3: 2021-05-28 (Score: 12)
Total Weighted Health Score: 46.000
Reported Incidents: 0, Substantiated Complaints: 2
Infection Control Citations: 1
Fines and Penalties: Number of Fines: 1, Total Fines in Dollars: 7442.50, Payment Denials Number: 0, Total Penalties Number: 1
Location and GPS: 211 NORTH 12TH STREET,LEHIGHTON,PA,18235 (40.8325, -75.727)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-04-04
Type: Health, Deficiency: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-04-04
Type: Health, Deficiency: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-04-04
Type: Health, Deficiency: Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-04-04
Type: Health, Deficiency: Ensure each resident’s drug regimen must be free from unnecessary drugs.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-04-04
Type: Health, Deficiency: Provide or obtain dental services for each resident.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-04-04
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-01-04
Type: Health, Deficiency: Ensure each resident receives an accurate assessment.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-22
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-07-18
Type: Health, Deficiency: Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-22
Type: Health, Deficiency: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-22
Type: Health, Deficiency: Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-22
Type: Health, Deficiency: Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-22
Type: Health, Deficiency: Perform COVID19 testing on residents and staff.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-22
Type: Health, Deficiency: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-07-20
Type: Health, Deficiency: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-07-20
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-07-20
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0321, Version: New
Description: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-03-14
Type: Fire Safety, Tag: 0353, Version: New
Description: Inspect, test, and maintain automatic sprinkler systems.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-03-14
Type: Fire Safety, Tag: 0919, Version: New
Description: Meet requirements for the use of electrical equipment.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-03-14
Type: Fire Safety, Tag: 0161, Version: New
Description: Use approved construction type or materials.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2022-06-14
Type: Fire Safety, Tag: 0321, Version: New
Description: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-14
Type: Fire Safety, Tag: 0363, Version: New
Description: Install corridor and hallway doors that block smoke.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-14
Type: Fire Safety, Tag: 0374, Version: New
Description: Install smoke barrier doors that can resist smoke for at least 20 minutes.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-14
Type: Fire Safety, Tag: 0161, Version: New
Description: Use approved construction type or materials.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-06-29
Type: Fire Safety, Tag: 0223, Version: New
Description: Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-06-29
Type: Fire Safety, Tag: 0353, Version: New
Description: Inspect, test, and maintain automatic sprinkler systems.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-06-29
Type: Fire Safety, Tag: 0355, Version: New
Description: Properly select, install, inspect, or maintain portable fire extinguishes.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-06-29
Type: Fire Safety, Tag: 0915, Version: New
Description: Have proper power supply for life support equipment.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-06-29
Type: Fire Safety, Tag: 0920, Version: New
Description: Ensure proper usage of power strips and extension cords.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-06-29