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P5530

Non-Compliance with LPN Staffing Ratios

Palmyra, Pennsylvania Survey Completed on 01-25-2025

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 licensed practical nurse (LPN) to resident ratios as mandated by the regulation effective July 1, 2023. A review of nursing schedules for the period from January 4 through 24, 2025, revealed multiple instances of non-compliance. Specifically, the facility did not maintain the minimum ratio of one LPN per 25 residents during the day shift on January 17, 2025. Additionally, the evening shift ratio of one LPN per 30 residents was not met on January 11, 12, 14, 15, 16, 17, 18, and 19, 2025. Furthermore, the night shift ratio of one LPN per 40 residents was not adhered to on January 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, and 24, 2025. These findings indicate a consistent failure to comply with staffing requirements over the reviewed period.

Plan Of Correction

1. The facility is unable to retroactively ensure LPN to resident ratios are met on the cited dates. 2. The facility will maintain LPN to resident ratios. 3. The DON was re-educated on ensuring LPN to resident ratios are met. There will be a daily staffing meeting to review the current day and future dates LPN ratios. 4. The NHA or designee will complete an audit of LPN to resident ratios daily x 7 days then weekly x 4 weeks to ensure ratios are met. Results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.

See complete original report
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