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P5530

Facility Fails to Meet LPN 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 licensed practical nurse (LPN) to resident ratios on 13 out of 63 shifts reviewed. Specifically, the facility did not provide the minimum number of LPNs needed for the day, evening, and night shifts on several dates between October 2024 and January 2025. For instance, on October 17, 2024, the facility had 4.00 LPNs on the day shift, whereas 4.16 were required for a census of 104 residents. Similar deficiencies were noted on other dates, with the facility consistently falling short of the required LPN staffing levels. The report indicates that no additional higher-level staff were available to compensate for the deficiency in LPN staffing on the mentioned dates. An interview with the Nursing Home Administrator on January 9, 2025, confirmed the facility's failure to meet the required LPN to resident ratios. This deficiency was identified through a review of the facility's weekly staffing records and staff interviews, highlighting a pattern of inadequate staffing levels that persisted over several months.

Plan Of Correction

1. The facility cannot retroactively correct LPN staffing ratios for the past. 2. The facility will review LPN ratios daily to provide care according to Pennsylvania regulation on staffing. (1-25; 1-25; 1-40) 3. Regulations for LPN ratios have been reviewed by facility management. Facility management will project ratios daily to have staff set according to guidelines. 4. Nursing will track LPN 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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