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P5530

LPN Staffing Deficiency on Day Shift

Chambersburg, Pennsylvania Survey Completed on 04-03-2025

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 staffing levels for Licensed Practical Nurses (LPNs) during the day shift on October 5, 2024. The regulation mandates a minimum of one LPN per 25 residents, but the facility only had an LPN ratio of 2.13 for a resident census of 63, falling short of the required 2.52 LPNs. This deficiency was identified through a review of staffing documents and confirmed during an interview with the Nursing Home Administrator, who acknowledged the shortfall was due to a call-off that could not be filled.

Plan Of Correction

1. Facility identified no adverse outcome from days identified. 2. Education will be provided by the Administrator to the Nursing Administration, scheduler, and charge nurses on calculation of the ratios and replacement of staff if indicated. 3. Daily staffing meeting will be implemented with NHA, DON staff coord or designees to review staffing and appropriate ratios. If a call off occurs the Charge Nurse will contact Part Time and PRN staff, and contract agency staffing to meet staffing ratios. 4. A ratio audit will be completed by NHA or designee daily for 5 days then weekly x3. Audits will be taken to QAPI for review and further interventions if warranted.

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