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P5520

Non-compliance with Nurse Aide Staffing Ratios

Willow Grove, Pennsylvania Survey Completed on 01-24-2025

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 nurse aide (NA) to resident ratios on two separate occasions within a 21-day review period. On January 19, 2025, during the day shift from 7:00 a.m. to 3:00 p.m., the facility did not maintain the minimum ratio of one NA per ten residents. Additionally, on January 17, 2025, during the night shift from 11:00 p.m. to 7:00 a.m., the facility did not meet the required ratio of one NA per 15 residents. These deficiencies were identified through a review of the nursing schedules for the specified period.

Plan Of Correction

1. The facility is unable to retroactively correct the CNA hours for the dates mentioned. 2. The facility will schedule CNA's to meet the ratio of 1 CNA to 10 residents for 7a - 3p shifts, and 1 CNA to 15 residents on 11pm - 7am. Call outs will be monitored by NHA/DON and/or designee. 3. NHA or designee will educate the scheduling coordinator on the state ratio requirements. The ratios will be monitored weekly x4 weeks. 4. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring or changes needed. 5. Date of compliance: 2/20/25

See complete original report
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