Failure to Meet 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, 2024. Specifically, the facility did not provide the minimum staffing levels 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 for 8 out of 21 shifts reviewed. This deficiency was identified through a review of the facility's weekly staffing records. On several dates in January 2025, the facility's staffing levels fell short of the required ratios. For instance, on January 24, 2025, the night shift had only 5.17 nurse aides instead of the required 5.93 for a census of 89 residents. Similarly, on January 26, 2025, the day shift had 7.93 nurse aides instead of the required 8.90, and the evening shift had 7.17 nurse aides instead of the required 8.09. No additional higher-level staff were available to compensate for these deficiencies, indicating a consistent failure to meet staffing requirements across multiple shifts.
Plan Of Correction
Facility cannot retroactively correct this deficiency. Recruitment of nursing staff will continue via facility websites, Indeed, social media websites, job fairs, off site recruiters, and instant interviews from walk-in candidates. Agency staff may be utilized for open shifts if available. The Valentine Open Hiring Event was conducted with interest expressed. Retention efforts will be made in earnest. Referral bonuses are offered to current employees. The facility is currently offering a significant sign-on bonus for all new nursing staff. The Director of Nursing/designee will review the ratio daily for compliance. All efforts will be made to meet certified aide staffing ratios. If a call off occurs, all efforts will be made to fill that position. The Director of Nursing/designee will audit the certified aide ratio 1x/week for 4 weeks, then monthly for 2 months. Results of the audits will be presented to the QA committee for review and recommendation.