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P5520

Staffing Deficiencies in Nurse Aide Ratios

Christiana, Pennsylvania Survey Completed on 04-23-2025

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 staffing levels for nurse aides during specific shifts over a period from April 12 through April 21, 2025. Specifically, the facility did not maintain the minimum staffing ratio of one nurse aide per 10 residents during the day shift on four separate days, one nurse aide per 11 residents during the evening shift on one day, and one nurse aide per 15 residents during the night shift on one day. These deficiencies were identified through a review of the facility's staffing data and were communicated to the Nursing Home Administrator during a telephone interview on April 23, 2025.

Plan Of Correction

NHA/designee reviewed the CNA day shift ratios for 4/12/25, 4/17/25, 4/20/25, and 4/21/25. The CNA evening shift ratio for 4/21/25 and the CNA night shift for 4/21/25. No grievance or residents care were affected due to staffing. To prevent this from happening again, NHA/designee will re-educate staffing coordinators on correct ratios: one nurse aide per 10 residents on day shift, one nurse aide per 11 residents on evening shift, and one nurse aide per 15 residents on the night shift. To monitor and maintain ongoing compliance, NHA/designee will audit nursing schedules weekly x4, then monthly x1, to ensure correct nurse aid ratios. The results of the audit will be forwarded to facility QAPI committee for further review and recommendations as needed.

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