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P5520

Failure to Meet Minimum Nurse Aide Staffing Ratios

Carlisle, Pennsylvania Survey Completed on 06-27-2025

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 nurse aide (NA) staffing ratios on multiple shifts between June 20 and June 23, 2025. Specifically, on the evening and night shifts of June 21, 2025, and the day and night shifts of June 22, 2025, the number of NAs scheduled did not meet the mandated ratios based on a resident census of 107. Staffing documents showed that the evening shift had 9.13 NAs instead of the required 9.73, and the night shift had 6.52 and 5.54 NAs on consecutive nights, both below the required 7.13. The day shift on June 22 had 10.62 NAs, which was also below the required 10.70. An interview with the Nursing Home Administrator confirmed that the facility was unable to fulfill the required staffing levels due to numerous call offs.

Plan Of Correction

1. Facility is unable to retroactively correct the nurse aide ratios for June 21 & 22, 2025. 2. Nursing Home Administrator/designee will have a daily staffing meeting with the Director of Nursing and facility Nursing Scheduler to review daily staffing schedules to ensure compliance with staffing regulations, discuss potential barriers to meeting required staffing ratios, and identify strategies to meet staffing ratios including but not limited to recruitment efforts, bonus structure, use of agency, and overtime hours. 3. Nursing Home Administrator/designee will educate Director of Nursing and facility Nursing Scheduler on P5520 and the importance of ensuring compliance with nurse aide ratios as mandated by state laws regarding mandated minimum staffing requirements. 4. Nursing Home Administrator/designee will audit daily nursing staffing ratios to ensure nurse aide ratios are in compliance with mandated state laws regarding minimum staffing ratios. These audits will be conducted weekly for 4 weeks and monthly for 2 months. Results of these audits will be reviewed by the Quality Assurance Performance Improvement committee.

See complete original report
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