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P5640

Failure to Meet Minimum Nursing Care Hours

Malvern, Pennsylvania Survey Completed on 03-04-2025

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 nursing care per resident per day. A review of the facility's staffing levels revealed that on multiple dates in February 2025, the facility's nursing hours fell below the required minimum. Specifically, on February 8, 9, 10, 11, 13, 14, 15, 16, 17, and 19, the direct care nursing hours per resident ranged from 2.80 to 3.19, all below the mandated 3.2 hours. This deficiency was confirmed by the Director of Nursing via email on March 8, 2025.

Plan Of Correction

1. Review staffing needs, workload, and determining units with the current gaps. 2. Distribution of Assignments: Review staff assignments and the rotation schedule involved with each. 3. Weekend Staffing Log: Assure all weekend shifts are covered and all steps needed for call offs. 4. Identify recruitment strategies. Continue to develop effective recruitment strategies to attract qualified candidates. This includes flyers, sign on/referral bonus, advertising job openings, utilizing on-line job portals, and word of mouth. 5. Streamline onboarding and "processing" process for the facility. This includes looking at any inefficiencies to ensure process is candidate friendly and focuses on selecting the best-suited individuals for the positions. 6. Retention Events: Access the factors that contribute to turnover and taking steps to improve employee retention. Performance review and evaluation: Assuring timely performance reviews are completed and staff are evaluated properly. 7. Training and Development of Staff utilizing facility training portal and in-services. Also partnering with leadership to set up workshops for employee development. 8. Communication: Continue to work on communication channels within the organization. Encourage staff members to provide feedback, share concerns and suggest improvements related to staffing to help identify potential issues early on and facilitate collaborative problem solving.

See complete original report
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