Failure to Maintain Required Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to maintain the required staffing ratios for nurse aides on seven out of fourteen days reviewed. Specifically, the facility did not meet the mandated ratios of one nurse aide per 10 residents during the day shift, one nurse aide per 11 residents during the evening shift, and one nurse aide per 15 residents during the overnight shift. This deficiency was identified through a review of nursing staff schedules, punch reports, and interviews with staff. The facility's census data and staffing records revealed discrepancies in the number of nurse aide hours provided compared to the required hours based on the resident census. On several specific dates, the facility's staffing fell short of the required hours. For instance, on December 29, 2024, the facility provided only 72.00 hours of nurse aide care during the day shift when 131.20 hours were required. Similar shortfalls were noted on other dates, such as January 25, 2025, where the facility provided 83.59 hours of care during the day shift against a requirement of 130.40 hours. These findings were confirmed with the Director of Nursing, who acknowledged the failure to meet the staffing ratios on the specified dates.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The facility cannot go back retroactively to correct this issue. The NHA, DON, and staffing coordinator were educated by the regional nurse on the CNA staffing ratios for dayshift, evening shift, and nightshift. The NHA/designee will audit staffing ratios daily as well as projected ratios for the upcoming shifts using the PA DOH staffing grid to ensure the required CNA ratios are met. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.