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P5520

Facility Fails to Meet Nurse Aide Staffing Ratios

Millersburg, Pennsylvania Survey Completed on 12-24-2024

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 staffing ratios for nurse aides (NAs) across multiple shifts from December 14 to December 20, 2024. Specifically, the facility did not provide the mandated number of NAs per resident during the day, evening, and night shifts. On December 14, the evening shift had 165 residents but only 13.67 NAs, falling short of the required 15.0 NAs. Similar deficiencies were noted on December 15, with both day and evening shifts understaffed, and on December 16, where the evening shift again did not meet the required staffing ratio. The issue persisted throughout the week, with the evening and night shifts on December 17, the evening shift on December 18, and the evening shift on December 19 all failing to meet the required NA-to-resident ratios. On December 20, all three shifts were understaffed, with the day shift having 13.33 NAs for 164 residents, the evening shift having 6.33 NAs, and the night shift having 6.57 NAs, all below the required ratios. The Nursing Home Administrator confirmed the facility's failure to meet staffing requirements during an electronic communication on December 24, 2024.

Plan Of Correction

1. CNA ratio noted to be deficient cannot be corrected as this is a past event. 2. CNA schedules will be monitored daily to ensure scheduled staff meet projected ratio requirement by the Scheduler and DON/Designee. 3. Re-education to Scheduler and Nursing Administrative Staff regarding the required ratio to be completed. Facility is increasing its presence with advertising on social media in regard to promoting/advertising open positions and vetting applicants; Agency rate has been increased and shift bonus being offered. HR attends job fairs as they are available. Tuition reimbursement and referral bonus are all in place as incentive for recruiting and committal purposes. 4. Ratio will be audited by DON/designee daily x4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results provided to QAPI. Date of compliance 02/04/2025.

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