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P5530

Failure to Meet Minimum LPN Staffing Requirements Across All Shifts

Bethel Park, Pennsylvania Survey Completed on 07-28-2025

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

Facility administrative staff failed to provide the minimum required number of LPNs per state regulations for all shifts over a 21-day period. Review of nursing schedules and census information revealed that on multiple occasions, the number of LPN hours provided during day, evening, and night shifts did not meet the required staffing ratios. Specific shortfalls included shifts where no LPN hours were provided at all, as well as shifts where the hours provided were consistently below the required minimums based on the resident census. This deficiency was confirmed through both documentation review and staff interviews, including confirmation from the Nursing Home Administrator. The report details each day and shift where the required LPN coverage was not met, with deficiencies occurring on every day reviewed. No information about specific residents or their medical conditions was provided in the report.

Plan Of Correction

The residents had no negative outcome for not meeting the minimum of one LPN per 25 residents on day shift, one LPN per 30 residents on the evening shift, and one LPN to 40 residents on the night shift. The facility is attempting to hire additional staff, hold daily staffing meetings to track staffing, and has added additional agencies to utilize for staffing needs. The DON/designee will provide the Staffing Coordinator/HR with re-education on the Pennsylvania staffing requirements for ratios. Staffing coordinator/designee will audit the ratios five times weekly for two weeks and monthly times two months. Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met.

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