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P5530

Staffing Ratio Deficiencies in Nursing Services

West Reading, Pennsylvania Survey Completed on 12-10-2024

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 nursing assistant (NA) to resident ratio of one NA for 15 residents during the night shift on September 1 and 2, and December 7, 2024. Additionally, the facility did not comply with the minimum licensed practical nurse (LPN) to resident ratios on several occasions. Specifically, the facility did not meet the required ratio of one LPN for 25 residents during the day shift on October 27, 2024. Furthermore, the facility failed to maintain the required ratio of one LPN for 30 residents during the evening shift on December 4 and 7, 2024, and did not meet the ratio of one LPN for 40 residents during the night shift on September 7, 2024. These deficiencies were identified based on a review of nursing time schedules over a period of 21 days, including September 1 through 7, October 25 through 31, and December 3 through 9, 2024. The failure to maintain these staffing ratios indicates a breach in regulatory compliance regarding the provision of adequate nursing services during specified shifts.

Plan Of Correction

1 & 2. Education given to the Nurse Scheduler on the LPN ratio requirements of 1 LPN to 25 residents on day shift, 1 LPN to 30 residents on evening shift, and 1 LPN to 40 residents on night shift. 3. The facility is actively recruiting LPNs; utilizing Nurse Agency to supplement LPNs; and staffing meetings conducted in attempts to maintain State Mandated ratios for LPNs. 4. The DON and/or designee will randomly audit the staffing schedules to ensure the appropriate number of LPNs are scheduled to achieve compliance. The results of the audits will be submitted to the QA Committee to determine if additional action is necessary.

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