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P5520

Facility Fails to Meet Nurse Aide Staffing Ratios

Honesdale, Pennsylvania Survey Completed on 01-10-2025

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 13 out of 63 reviewed shifts. Specifically, the facility did not provide the minimum number of nurse aides needed for the day, evening, and night shifts as per the regulation effective July 1, 2024. The deficiency was identified through a review of the facility's weekly staffing records, which showed that on multiple dates, the number of nurse aides on duty was below the required ratios based on the facility's census. For instance, on October 17, 2024, the night shift had 6.87 nurse aides instead of the required 6.93 for a census of 104 residents. Similarly, on November 23, 2024, the night shift had only 5.80 nurse aides, falling short of the required 6.93 for the same census. The deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the facility did not meet the required staffing ratios on the specified dates. No additional higher-level staff were available to compensate for the staffing shortfall.

Plan Of Correction

5520 1. The facility cannot retroactively correct nurse aide staffing ratios for the past. 2. The facility will review nurse aide ratios daily to provide care according to Pennsylvania regulation on staffing. (1-10; 1-11; 1-15) 3. Regulations for nurse aide ratios have been reviewed by facility management. Facility management will project ratios daily to have staff set according to guidelines. 4. Nursing will track ratios daily and provide a copy of the numbers to the administrator. The numbers will be provided to the QA team to track compliance. 5. February 18, 2025

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