Staffing Deficiencies in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required minimum staffing levels for nurse aides (NAs) on several occasions across different shifts. Specifically, during the day shift, the facility did not provide the necessary number of NAs per resident on five out of fourteen days reviewed. For instance, on December 20, 2024, with a resident census of 362, the facility was required to have 36.20 NA full-time equivalents (FTEs) but only provided 35.77. Similar shortfalls were noted on December 21 and 22, 2024, and March 15 and 16, 2025, with the facility consistently failing to meet the required NA FTEs based on the resident census. The evening and night shifts also experienced staffing deficiencies. On four out of fourteen days reviewed for the evening shift, the facility did not meet the required NA FTEs, with notable shortfalls on December 20 and 21, 2024, and March 13 and 14, 2025. Additionally, the night shift was understaffed on two out of seven days reviewed, specifically on March 15 and 16, 2025. These deficiencies were confirmed through an interview with the Nursing Home Administrator, who acknowledged the facility's failure to meet the minimum staffing requirements on the specified dates and shifts.
Plan Of Correction
This provided submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. CNA staffing ratios for dayshift were not met on December 20th, 21st and 22nd, 2024; March 15th and 16th, 2025. CNA staffing ratios for evening shifts were not met on December 20th and 21st, 2024; March 13th and 14th, 2025. CNA staffing ratios were not met on the night shift on March 16th and 17th, 2025. The facility has robust retention and recruitment activities in place. Nursing leadership did all things reasonably possible to meet the required ratios through bonuses, day off on another day, split shifts, extra day pay. All unscheduled staff were contacted and supplemental staffing were contacted to send replacement staff with little avail. Ancillary staff were available and assisted in various tasks such as call bell attendant, delivery and removal of meal trays, delivery of water, bed making and performance of other tasks within their scope of practice. There were no negative outcomes to residents. The facility will continue to ensure schedule reflects the required staffing ratios and address call offs. Staff and supplemental staffing have been reminded of the importance of them reporting to work as assigned. 2. No residents were affected. 3. To prevent this from reoccurring, the NHA/designee completed education with the staffing coordinators on the Pennsylvania Regulation for CNA Staffing Ratios. Nursing supervisors will be educated to make phone calls to replace call offs and no shows. 4. To monitor and maintain ongoing compliance, the NHA/designee will audit 5 schedules weekly x 4 Weeks to ensure CNA ratios are being met every shift. Audit results will be reviewed with QAPI Committee meeting monthly to determine the need for further audits.