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P5640

Failure to Meet Minimum Nursing Care Hours

Shenandoah, Pennsylvania Survey Completed on 01-22-2025

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 consistently meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident per day. A review of the facility's staffing levels revealed that on January 19, 2025, the facility provided only 2.92 hours of direct care nursing per resident, which is below the mandated minimum. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 22, 2025, who acknowledged the facility's failure to meet the required nursing care hours consistently.

Plan Of Correction

1. Facility cannot retroactively correct the failure to meet the overall PPD requirements of the nursing staff as identified in the outlined PA-2567. 2. Education given to the Nurse Scheduler and Director of Nursing on the overall PPD requirements for nursing staff. 3. Facility is actively recruiting Certified Nurses Aides and Licensed Practical Nurses through outside marketing sources; utilizing outside Nurse Agency to supplement Certified Nursing Aides and Licensed Practical Nurses; and daily staffing meetings being conducted in attempts to maintain State Mandated PPD requirements. 4. The Administrator will audit the staffing schedules to ensure the facility is staffed appropriately to reach the mandated State PPD. Audits will occur three times per week for four weeks and weekly for four weeks. The results of the audits will be submitted to the QA Committee.

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