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P5640

Deficiency in Meeting Minimum Nursing Care Hours

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 state regulation requiring a minimum of 3.2 hours of direct resident care per patient per day over a 7-day period from January 1, 2025, to January 7, 2025. Specifically, on January 4 and January 6, 2025, the facility provided only 3.12 hours of general nursing care per patient per day, falling short of the mandated requirement. This deficiency was identified through a review of the facility's staffing data and was confirmed 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 5640 Effective July 1, 2024 the total number of hours of general nursing care provided in each 24-hr period shall, when totaled for the entire facility, be a minimum of 3.20 hours of direct resident care for each resident. 1. Findings of PPD cannot be retroactively corrected. 2. The facility will have daily staffing meetings to review staffing levels and make the necessary adjustments as possible to meet the state minimum requirements of 3.2. 3. NHA or designee will provide re-education to facility nursing administration and scheduling that staffing levels must be a 3.2 or above and have the appropriate staff to perform care in the facility. 4. Facility leadership will complete random audits weekly x 4 and then monthly x 2 months to ensure the facility had a PPD of 3.2 or above. The audits will be reviewed by the QAPI committee and the QAPI committee will determine the need for further audits.

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