Stay Ahead of Compliance with Monthly Citation Updates


In your State Survey window and need a snapshot of your risks?

Survey Preparedness Report

One Time Fee
$79
  • Last 12 months of citation data in one tailored report
  • Pinpoint the tags driving penalties in facilities like yours
  • Jump to regulations and pathways used by surveyors
  • Access to your report within 2 hours of purchase
  • Easily share it with your team - no registration needed
Get Your Report Now →

Monthly citation updates straight to your inbox for ongoing preparation?

Monthly Citation Reports

$18.90 per month
  • Latest citation updates delivered monthly to your email
  • Citations organized by compliance areas
  • Shared automatically with your team, by area
  • Customizable for your state(s) of interest
  • Direct links to CMS documentation relevant parts
Learn more →

Save Hours of Work with AI-Powered Plan of Correction Writer


One-Time Fee

$49 per Plan of Correction
Volume discounts available – save up to 20%
  • Quickly search for approved POC from other facilities
  • Instant access
  • Intuitive interface
  • No recurring fees
  • Save hours of work
P5530

Failure to Meet LPN Staffing Ratios

Shenandoah, Pennsylvania Survey Completed on 01-22-2025

Penalty

No penalty information released
tooltip icon
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 on three separate night shifts out of 21 reviewed. Specifically, on January 15, 19, and 21, 2025, the facility did not provide the minimum LPN staffing levels required by regulation. On January 15, the facility had 2.20 LPNs instead of the required 2.28 for a census of 91 residents. On January 19, there were 1.33 LPNs instead of the required 2.20 for a census of 88 residents. On January 21, the facility had 2.03 LPNs instead of the required 2.25 for a census of 90 residents. No additional higher-level staff were available to compensate for this deficiency. An interview with the Nursing Home Administrator confirmed the facility's failure to meet the required LPN to resident ratios on these dates.

Plan Of Correction

1. Facility cannot retroactively correct the failure to meet the ratio requirements of the LPN's as identified in the outlined PA-2567. 2. Education given to the Nurse Scheduler and Director of Nursing on the LPN's ratio requirements. 3. Facility is actively recruiting LPN's through outside marketing sources; utilizing outside Nurse Agency to supplement LPN's; and daily staffing meetings being conducted in attempts to maintain State Mandated ratios for LPN's. 4. The Administrator will audit the staffing schedules to ensure the appropriate number of LPN's are scheduled to achieve compliance. Audits will occur three times per week for one week; weekly for four weeks and monthly for four weeks. The results of the audits will be submitted to the QA Committee.

An unhandled error has occurred. Reload 🗙