Staffing Deficiency on Daylight Shift
Summary
The facility failed to meet the required staffing levels for nurse aides during the daylight shift on November 29, 2024. Specifically, the facility did not provide the mandated one nurse aide per 12 residents, as evidenced by staffing documents and confirmed by the Nursing Home Administrator. On this date, the facility had a census of 47 residents but only provided 32.03 hours of nurse aide coverage, falling short of the required 37.60 hours. This deficiency was identified during a review of staffing documents covering the period from November 29, 2024, to December 3, 2024, and was confirmed in an interview with the Nursing Home Administrator on December 4, 2024.
Plan Of Correction
The facility failed to meet the CNA required ratios on one daylight shift, 11/29/2024, during the five-day period of 11/29/24 through 12/3/24. The state ratio regulation will be reviewed with the nurse scheduler and RNS. Ratios are reviewed daily by the DON when posting staffing sheets. Ratios are met at the time of scheduling. If there is a call off or no show, and the staffing ratios would not be met, the DON/designee will attempt to replace the call off or no show as follows: 1. Seek CNAs to volunteer from all qualified staff who are working. 2. Contact qualified employees who have made themselves available for overtime. 3. Attempt to contact employees on the next shift to come in early. 4. Use Per Diem Staff. 5. Use Temporary Staffing Agencies. In addition, the facility uses bonus incentives for internal staff, and we contract with 5 different nursing temporary agencies. The nurse scheduler will complete the DOH staffing ratio spreadsheet and turn it into NHA for review on a weekly basis. Information will be presented to the QAPI committee for review and recommendations.
Penalty
The facility did not meet the required NA-to-resident staffing ratios on certain days. On one occasion, the evening shift had 129 residents requiring 11.73 NAs, but only 11.07 were available. Another day, the day shift had 128 residents needing 12.80 NAs, but only 10.73 were present, and the evening shift required 11.64 NAs, but only 9.47 were available. No additional staff were available to cover these deficiencies.
The facility did not meet the required nurse aide to resident ratios during several shifts, as evidenced by a review of nursing schedules and confirmed by the Administrator and DON. The shortfall in nurse aide service hours occurred on multiple days and shifts, failing to provide the minimum required care for the resident census.
The facility failed to meet the required NA to resident ratios for 21 consecutive days across all shifts. During the day shift, the facility consistently scheduled fewer NA hours than required, with discrepancies ranging from 4.8 to 17.6 hours short. The evening and overnight shifts also experienced significant staffing deficiencies, with shortfalls ranging from 2.18 to 13.09 hours in the evening and 3.2 to 9.53 hours overnight. These consistent staffing inadequacies were confirmed by the facility's administrator.
The facility did not meet the required nurse aide to resident ratios on 12 out of 21 shifts reviewed, as per the 28 PA Code regulations effective July 1, 2023. The deficiency was confirmed by the Nursing Home Administrator, who acknowledged the shortfall in staffing levels, with no additional higher-level staff available to compensate.
The facility failed to meet required nurse aide staffing ratios on two consecutive days, with significant shortfalls in care hours during the day and evening shifts. Despite a census of 93-94 residents, the facility did not provide the necessary hours of care, and no higher-level staff were available to compensate for the deficiency.
The facility did not meet the required nurse aide staffing ratios, failing to provide the minimum number of nurse aides per residents during specific day and night shifts. The NHA confirmed the non-compliance during an interview.
Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident staffing ratios as mandated by regulations effective July 1, 2023. Specifically, the facility did not provide the necessary number of NAs during the day and evening shifts on certain days. On April 4, 2025, the facility had a census of 129 residents during the evening shift, necessitating 11.73 NAs, but only 11.07 NAs were available. Similarly, on April 6, 2025, with a census of 128 residents, the day shift required 12.80 NAs, yet only 10.73 NAs were present, and the evening shift required 11.64 NAs, but only 9.47 NAs were available. There were no additional higher-level staff to compensate for these staffing deficiencies. The Nursing Home Administrator confirmed the shortfall in meeting the required staffing ratios.
Plan Of Correction
1. The ratios noted in the survey findings cannot be corrected as this is a past event. 2. Calculation of shift ratios will be completed and reviewed daily for accuracy by the scheduler or designee. 3. The facility has developed internal incentives to retain and attract staff and meet shift ratio requirements. Administrator will re-educate Director of Nursing and Scheduler regarding staffing ratios regulations. Facility scheduler, Director of Nursing, Human Resources, and Administrator have a daily staffing meeting (5 days per week) to review schedules including compliance with ratios. For staff call offs, every effort will be made to replace the call off using resources available including communicating with staff to replace the vacancy. Staffing patterns are projected at least one week in advance to enable ongoing efforts to fill any vacant shifts. The facility will take admissions when staffing is appropriate. 4. Ratios will be monitored daily by Scheduler and/or Director of Nursing or designee. Audits of ratios will be completed by Director of Nursing or designee daily for 4 weeks then 3 days per week x 2 months or until substantial compliance is achieved. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee.
Facility Fails to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the minimum nursing staff to resident ratios as required by regulations effective July 1, 2023. Specifically, the facility did not have the required number of nurse aides per residents during various shifts from March 6, 2025, to March 10, 2025. On the day shift, the facility was short of the required nurse aide hours on March 7, March 8, and March 9, 2025. Similarly, the evening shift was understaffed on March 7 and March 9, 2025. The overnight shift also did not meet the required staffing levels on March 6 and March 8, 2025. The deficiency was confirmed through a review of nursing schedules and an interview with the Administrator and Director of Nursing on March 19, 2025. The facility's failure to meet the staffing requirements was evident in the shortfall of nurse aide service hours compared to the minimum required hours for the resident census on the specified dates. This lack of adequate staffing was acknowledged by the facility's administration during the interview.
Plan Of Correction
1. The facility reviewed the CNA ratios from March 6, 2025 through March 10, 2025. No grievance or residents care were affected on those dates due to staffing ratios. 2. Other days were reviewed to see if ratios were met and if care levels were affected. 3. Scheduling coordinator will be educated on CNA ratios for day shift, evening shift, and night shift. Facility will attempt with every reasonable resource to ensure ratios are met. 4. DON/designee will conduct daily audits to verify CNA ratios for all shifts weekly x 4 weeks. Results will be presented to QAPI.
Consistent Staffing Deficiencies Across All Shifts
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios across all shifts for 21 consecutive days. During the day shift, the facility consistently scheduled fewer NA hours than required, with discrepancies ranging from 4.8 to 17.6 hours short of the necessary staffing levels based on the resident census. For instance, on February 20, 2025, with a census of 45 residents, only 24 NA hours were scheduled when 36 hours were required. Similar shortfalls were observed on other days, indicating a pattern of understaffing during the day shift. The evening and overnight shifts also experienced significant staffing deficiencies. The evening shift required one NA per 11 residents, yet the facility consistently scheduled fewer hours than needed, with shortfalls ranging from 2.18 to 13.09 hours. On February 23, 2025, for example, 32 NA hours were scheduled for a census of 62 residents, while 45.09 hours were required. The overnight shift, which required one NA per 15 residents, also fell short, with discrepancies ranging from 3.2 to 9.53 hours. These consistent staffing inadequacies were confirmed by the facility's administrator, indicating a systemic issue in meeting the mandated staffing ratios.
Plan Of Correction
Nursing schedules were reviewed to ensure the proper Nurse's Aide ratio on the morning, evening, and overnight shifts. NHA/designee will reeducate the scheduler and Director of Nursing on the correct Nurse's Aide ratio. NHA/designee will audit the nursing schedules in advance daily x4 weeks to ensure Nurse Aids are being staffed at the proper ratio. Results will be shared at QA.
Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios as mandated by the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, §211.12 Nursing Services, effective July 1, 2023. Specifically, the regulation requires a minimum of 1 nurse aide per 12 residents during the day and evening shifts, and 1 nurse aide per 20 residents overnight. A review of the facility's staffing records revealed that on 12 out of 21 shifts reviewed, the facility did not provide the minimum required number of nurse aides. For instance, on February 4, 2025, the day shift had 6.75 nurse aides instead of the required 8.25 for a census of 99 residents, and the evening shift had 7.53 nurse aides instead of the required 8.42 for a census of 101 residents. The deficiency was confirmed during an interview with the Nursing Home Administrator on February 12, 2025, who acknowledged that the facility did not meet the required nurse aide to resident ratios on the specified dates. Additionally, there were no excess higher-level staff available to compensate for the staffing shortfall. This failure to comply with staffing regulations was documented across multiple shifts, indicating a pattern of non-compliance with the mandated staffing levels.
Plan Of Correction
1. Facility cannot retroactively correct past nursing ratios. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilize agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary ratios. Nursing scheduler was educated on this new process. 4. NHA will audit ratios weekly for 4 weeks and then monthly for 2 months to ensure CNA ratios are met. 5. Audits will be submitted to QAPI for review.
Staffing Ratio Deficiency
Penalty
Summary
The facility failed to maintain the required staffing ratios for nurse aides during the day, evening, and overnight shifts on June 29 and 30, 2024. On June 29, the facility had a census of 94 residents, necessitating 58.75 hours of nurse aide care during the evening shift. However, only 43.00 hours of care were provided, with no additional higher-level staff available to compensate for the shortfall. Similarly, on June 30, the facility had a census of 93 residents, requiring 58.13 hours of nurse aide care during both the day and evening shifts. The facility only provided 37.50 hours of care for each of these shifts, again without any higher-level staff to make up for the deficiency. The deficiency was confirmed during a review of staffing calculations, nursing staff schedules, and punch reports with the Nursing Home Administrator on February 11, 2024. The administrator acknowledged that the required staffing ratios were not met on the specified dates. The report does not mention any corrective actions or follow-up measures taken to address the staffing shortfall.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly x4 weeks then monthly for two months. 5. Results will be taken to the QAPI for review and revision as needed.
Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide staffing ratios as per the regulation effective July 1, 2023. Specifically, the facility did not maintain a minimum of one nurse aide per 12 residents during the day and evening shifts, and one nurse aide per 20 residents overnight. During the period from January 11 to January 25, 2025, the facility was found to be non-compliant on January 19, 2025, for the day shift, and on January 22, 2025, for the night shift. The Nursing Home Administrator (NHA) confirmed during an interview on February 4, 2025, that the facility did not meet the minimum required staffing ratios on the identified dates.
Plan Of Correction
1. The facility failed to maintain nurse aide ratios on multiple days and shifts. 2. Facility will need to maintain a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening and 1 nurse aide per 15 residents overnight. Calculation of shift ratios will be completed and reviewed daily for accuracy by the scheduler or designee. 3. The scheduler and nursing supervisors will be educated on these ratios. For staff call offs, every effort will be made to replace the call off using resources available including communicating with staff to replace the vacancy. Staffing patterns are projected at least one week in advance to enable ongoing efforts to fill any vacant shifts. 4. Daily audits will be conducted for 1 month. Audits will be conducted by the scheduler or designee. Results of audits will be reviewed by the QAPI committee. 5. Date Certain is 4-4-25.
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