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P5520

Staffing Deficiency in Nurse Aide Coverage

Lower Burrell, Pennsylvania Survey Completed on 02-05-2025

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 nurse aide staffing levels as per the regulation effective July 1, 2024. Specifically, the facility did not provide the minimum of one nurse aide per 10 residents during the day shift for 16 out of 21 days, one nurse aide per 11 residents during the evening shift for two days, and one nurse aide per 15 residents during the night shift for one day. This deficiency was identified through a review of nursing time schedules and staff interviews. The Nursing Home Administrator confirmed the staffing shortages, acknowledging that there were no additional higher-level staff to compensate for the deficiency. The census data and nursing time schedules revealed specific dates where the full-time equivalents (FTE) present were below the required FTE, leading to the staffing shortfall.

Plan Of Correction

Immediate Action: The residents had no negative outcome for not meeting the minimum of one nurse aide per 10 residents on day shift, one nurse aide per 11 residents on evenings, and one nurse aide per 15 on the night shift. The facility has hired additional staff, holds daily staffing meetings to track staffing, and added additional agencies to utilize for staffing needs. Education: DON/designee will provide the Staffing Coordinator/HR with re-education on the Pennsylvania staffing requirements for ratios. Audits: Staffing coordinator/designee will audit the ratios 3 times weekly for 2 weeks and monthly x1 month.

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