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P5520

Staffing Deficiency in Nurse Aide Coverage

Lancaster, Pennsylvania Survey Completed on 01-10-2025

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 minimum staffing requirements for nurse aides on four out of seven days reviewed, from January 3 to January 6, 2025. Specifically, on January 3, the evening shift had a census of 374 residents, requiring 255.00 hours, but only 246.36 hours were worked. On January 4, the day shift had a census of 372 residents, requiring 279.0 hours, but only 261.71 hours were worked. On January 5, the night shift had a census of 374 residents, requiring 187.0 hours, but only 186.66 hours were worked. On January 6, the day shift required 280.50 hours with a census of 374, but only 256.54 hours were worked, and the evening shift required 255.0 hours, but only 238.38 hours were worked. These deficiencies were confirmed during a telephone conversation with the Nursing Home Administrator on January 10, 2025.

Plan Of Correction

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. P 5520 Effective July 1, 2024 a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening and 1 nurse aide per 15 residents overnight. 1. Findings of Nurse aide care ratios cannot be retroactively corrected. 2. The facility will provide a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening and 1 nurse aide per 15 residents overnight. 3. The scheduling coordinators will be educated on the requirements of a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening and 1 nurse aide per 15 residents overnight. 4. NHA or designee will conduct random audits to verify that the requirements are met for nurse aides. Nurse aide ratios of a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening and 1 nurse aide per 15 residents overnight. Audits will be conducted daily x 7 days then weekly for 3 weeks and then monthly for 2 months. Audit results will be presented at QAPI meeting for review and recommendations.

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