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P5530

LPN Staffing Deficiency on Day Shift

State College, 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 meet the regulatory requirement of having a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift. This deficiency was identified during a review of nursing staffing hours for specific dates. On January 18 and 19, 2025, the facility scheduled only 2.00 LPNs for a resident census of 53, which required 2.12 LPNs to meet the mandated staffing levels. This shortfall in staffing was noted during a review of the facility's nursing staff care hours for the periods of September 1-7, 2024, November 24-30, 2024, and January 15-25, 2025. The Director of Nursing was informed of these findings on January 24, 2025.

Plan Of Correction

- Residents were not found to be affected by deficient practice. - The Director of Wellness conducted initial Quality Improvement (QI) monitoring of schedules for the past week to review LPN staffing ratios. - The Director of Wellness and Scheduler will meet daily to review the schedule to ensure ratios and hours meet regulation. The Executive Director will reeducate the wellness team on efforts to improve recruitment and retention of direct care staff and the scheduling process, including critical shift incentives. - The Director of Wellness will conduct Quality Improvement (QI) monitoring of the nursing schedule related to LPN staffing ratios 5 times a week for 2 weeks, then weekly for 2 weeks, and finally monthly for 2 months. Further recommendations will be reported to Quality Assurance Performance Improvement (QAPI).

See complete original report
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