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P5530

LPN Staffing Deficiency in November and December 2024

Lititz, Pennsylvania Survey Completed on 12-19-2024

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 staffing ratios for Licensed Practical Nurses (LPNs) during specific shifts in November and December 2024. Specifically, the facility did not maintain the minimum staffing of one LPN per 25 residents during the day shift on November 23, December 6, and December 12, 2024. Additionally, the evening shift staffing requirement of one LPN per 30 residents was not met on November 19, November 22, December 4, December 5, December 9, and December 13, 2024. This deficiency was confirmed through a review of facility staffing data and an interview with the Nursing Home Administrator on December 18, 2024, who acknowledged the failure to meet the staffing ratios on the specified dates.

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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