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P5520

Staffing Deficiency in Nurse Aide Ratios

Lititz, Pennsylvania Survey Completed on 01-15-2025

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 required staffing levels for nurse aides during specific shifts over a period from December 31, 2024, through January 9, 2025. Specifically, the facility did not maintain a minimum of one nurse aide per 10 residents on the day shift for five days, one nurse aide per 11 residents on the evening shift for two days, and one nurse aide per 15 residents on the night shift for five days. These deficiencies were identified through a review of facility staffing data and were confirmed with the Nursing Home Administrator during a telephone interview on January 15, 2025. The specific dates of non-compliance included December 31, 2024, January 1, 2025, January 2, 2025, January 5, 2025, and January 6, 2025, for the day shift; December 31, 2024, and January 1, 2025, for the evening shift; and December 31, 2024, January 1, 2025, January 4, 2025, and January 7, 2025, for the night shift.

Plan Of Correction

1. Facility can not retroactively correct. 2. All of the residents had the potential to be affected; however, there were no adverse resident outcomes as a result of this deficient practice. 3. Licensed staff have been re-educated on staffing requirements by the DON and/or designee. An ongoing systemic change put in place is the review of staffing in daily meeting. 4. Administrator/Director of Nursing and/or designee will audit the schedule for four weeks and then monthly for two months to ensure appropriate coverage.

See complete original report
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