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P5530

LPN Staffing Ratio Deficiency

Palmyra, Pennsylvania Survey Completed on 04-04-2025

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 meet the required minimum licensed practical nurse (LPN) to resident ratio on one of the nine days reviewed. Specifically, on March 31, 2025, during the day shift from 7:00 a.m. to 3:00 p.m., the facility did not have the mandated one LPN per 25 residents. This deficiency was identified through a review of nursing schedules covering the period from March 26, 2025, to April 3, 2025.

Plan Of Correction

1) The staffing cannot be corrected retroactively. 2) The Scheduler has been educated on using RN staff to fill the LPN spots in order to maintain the required LPN staffing. Staffing meetings are held daily to review the schedules to ensure compliance. 3) The facility continues to recruit professional nursing staff to meet the required staffing mandates. Staff currently work to maintain compliance. Per diem staff are utilized to fill open positions. The NHA/designee monitor the schedules to ensure compliance. 4) The results of the audits and recruitment efforts will be reviewed at the QAPI meeting for suggestions or comments to maintain continued compliance.

See complete original report
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