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P5530

LPN Staffing Deficiency Across Multiple Shifts

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 levels for Licensed Practical Nurses (LPNs) across multiple shifts from December 14 to December 20, 2024. Specifically, on December 14, the day shift had 165 residents with only 4.75 LPNs, falling short of the required 6.60 LPNs. The evening shift on the same day had 5.28 LPNs instead of the required 5.50 for 165 residents, and the night shift had 3.03 LPNs instead of 4.13. Similar deficiencies were noted on December 15, 17, 19, and 20, with the night shifts consistently understaffed. On December 19, the night shift had 166 residents with 4.09 LPNs, not meeting the required 4.15. On December 20, the evening shift had 4.81 LPNs for 164 residents, below the required 4.17, and the night shift had 3.31 LPNs instead of 4.10. 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. LPN ratio noted to be deficient cannot be corrected as this is a past event. 2. LPN 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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