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P5640

Failure to Meet RN Ratio and Care Hours

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 RN to resident ratio of one RN for 250 residents on January 14 and 15, 2025. Additionally, the facility did not provide the mandated minimum of 3.2 hours of direct care per resident for 19 out of 21 days reviewed between January 4 and January 24, 2025. Specific days where the care hours fell short include January 4, 5, 6, 7, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, and 24, with the lowest being 1.76 care hours per resident on January 20, 2025. This deficiency was identified through a review of nursing time schedules, indicating a consistent failure to meet the required staffing levels and care hours over the specified period.

Plan Of Correction

1. The facility is unable to retroactively ensure minimum PPD hours of Direct Care are met on the cited dates. 2. The facility will maintain minimum PPD hours of direct care. 3. The DON was re-educated on ensuring minimum PPD hours of direct care. There will be a daily staffing meeting to review the current day and future dates PPD hours of direct care. 4. The NHA or designee will complete an audit of PPD hours of direct care 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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