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P5520

Facility Fails to Meet Minimum Nurse Aide Staffing Ratios

Hanover, Pennsylvania Survey Completed on 01-14-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet the required minimum nurse aide (NA) staffing ratios across multiple shifts from January 6 to January 12, 2025. Specifically, the facility did not provide the mandated number of NAs per resident during the day, evening, and night shifts on several days. For instance, on January 6, 2025, the day shift had 102 residents but only 9.10 NAs, falling short of the required 10.20 NAs. Similar deficiencies were noted on other days and shifts, with the facility consistently understaffed compared to the state-mandated ratios. The deficiency was identified through a review of staffing documents and staff interviews, which confirmed the facility's failure to comply with the staffing requirements. The Nursing Home Administrator acknowledged the expectation for the facility to be appropriately staffed according to state regulations during an email correspondence on January 14, 2025. This consistent understaffing across various shifts indicates a systemic issue in maintaining adequate staffing levels to meet regulatory requirements.

Plan Of Correction

1. Facility cannot retroactively correct this concern. 2. Current residents are at risk of being affected by staffing levels. Will review resident council meeting minutes for staffing related concerns. 3. Will continue to offer bonuses when PPD is below minimum and attempt to mandate staff when call outs and absences occur. Agency rates for aides were recently increased to assist with staffing challenges. 4. NHA/designee will monitor staffing ratios and PPD daily to ensure appropriate levels are being met. Audits will be reviewed at QAPI to ensure compliance and quality care.

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