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P5510

Staffing Deficiencies in Nurse Aide Ratios

Tamaqua, Pennsylvania Survey Completed on 01-02-2025

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 nurse aide to resident ratios on several occasions, as evidenced by a review of staffing records and staff interviews. Specifically, the facility did not provide the minimum number of nurse aides required during the day shift on December 21, 24, 25, and 26, 2024, with the number of nurse aides falling short of the required 8.5 for a census of 102 residents. Additionally, on December 24, 2024, the evening shift was understaffed with only 5.09 nurse aides instead of the required 8.42 for a census of 101 residents. Furthermore, the night shift on December 24 and 25, 2024, also failed to meet the minimum staffing requirements, with fewer nurse aides than the required 5.1 and 5.0 for the respective census counts. The Director of Nursing confirmed during an interview that the facility did not meet the required nurse aide to resident ratios on the specified dates. The report indicates that no additional higher-level staff were available to compensate for the staffing deficiencies on these occasions. This lack of adequate staffing could potentially impact the quality of care provided to the residents, although the report does not specify any direct consequences or risks that occurred as a result of the staffing shortfalls.

Plan Of Correction

1. Facility cannot retroactively correct past nursing ratios. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilize agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary ratios. Nursing scheduler was educated on this new process. 4. NHA will audit ratios weekly for 4 weeks and then monthly for 2 months to ensure CNA ratios are met. 5. Audits will be submitted to QAPI for review.

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