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P5520

Staffing Deficiency in Nurse Aide Coverage

Canonsburg, Pennsylvania Survey Completed on 02-10-2025

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

The facility failed to meet the required staffing levels for nurse aides on six out of twenty-one days between January 14, 2025, and February 3, 2025. Specifically, the facility did not provide the minimum number of nurse aides per residents during various shifts. On January 19, 2025, the evening shift required 51.82 hours of nurse aide care, but only 36.25 hours were provided, and the night shift required 38.00 hours, but only 32.00 hours were provided. On January 20, 2025, the day shift required 57.00 hours, but only 48.00 hours were provided, and the night shift required 38.00 hours, but only 28.50 hours were provided. On January 25, 2025, the evening shift was slightly under by 0.05 hours. On January 27, 2025, the day shift required 59.25 hours, but only 46.50 hours were provided. On February 1, 2025, the night shift required 38.00 hours, but only 26.75 hours were provided. On February 2, 2025, the day shift required 57.00 hours, but only 47.75 hours were provided; the evening shift required 51.82 hours, but only 39.50 hours were provided; and the night shift required 38.00 hours, but only 24.00 hours were provided. The Nursing Home Administrator confirmed these deficiencies during an interview on February 6, 2025.

Plan Of Correction

1. The facility cannot correct that the nurse aide staffing ratio was not met on 1/19/25, 1/20/25, 1/25/25, 1/27/25, 2/1/25 and 2/2/25. There were no adverse effects to the residents on the identified dates. 2. The facility will ensure that staffing ratios are met every shift. 3. Nursing administration and the nursing scheduler will be re-educated by the Nursing Home Administrator/designee on ensuring staffing ratios are met each shift. A Daily staffing meeting will be held by administration to monitor staffing ratios. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing ratios, the scheduler/or designee will call off duty facility staff and will utilize external staffing support resources. 4. The Nursing Home Administrator/designee will audit staffing daily for three weeks and monthly for three months to ensure staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.

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