Pennsylvania Department of Health
DALLASTOWN NURSING CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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DALLASTOWN NURSING CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a follow-up survey completed on January 3, 2025, it was determined that Dallastown Nursing Center failed to correct the deficiency cited during the survey of November 6, 2024, under the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

Plan of Correction:

§ 211.12(f.1)(5) LICENSURE Nursing services. :

(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.

Observations:

Based on staffing document review and staff interview, it was determined that the facility failed to ensure a required minimum of one Registered Nurse during night shifts for 11 of 14 days reviewed (December 13, 2024 - December 26, 2024).

Findings Include:

A review of facility-provided staffing ratio information for December 14, 2024, on the night shift, revealed a census of 17 residents. Further review revealed a Registered Nurse (RN) ratio of 0 hours worked on night shift; therefore, the facility did not meet the required minimum RN ratio for the facility census on that shift.

A review of facility-provided staffing ratio information for December 16-18, 2024, on the night shift, revealed a census of 17 residents. Further review revealed a RN ratio of 0 hours worked on night shift; therefore, the facility did not meet the required minimum RN ratio for the facility census on those shifts.

A review of facility-provided staffing ratio information for December 20-26, 2024, on the night shift, revealed a census of 18 residents. Further review revealed a RN ratio of 0 hours worked on night shift; therefore, the facility did not meet the required minimum RN ratio for the facility census on those shifts.

During an interview with the Director of Nursing on January 3, 2024, at 2:33 PM, he confirmed that the facility did not meet the RN ratio on the aformentioned dates.

Plan of Correction - To be completed: 02/21/2025

1. Cannot retroactively correct for dates where requirements were misunderstood.

2. Immediately implement a 2-nurse staffing on overnight shift while simultaneously seeking a waiver for this requirement.

3. Educate NHA and DON on current staffing requirements in accordance with regulations.

4. Audit staffing patterns dailky X 5 days a week to ensure compliance with current regulations for 4 weeks, then weekly for 8 weeks.

5. Report audit findings to QAPI for continued monitoring and effectiveness evaluation.

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