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P5520

Staffing Deficiency in Nurse Aide Coverage

Monroeville, Pennsylvania Survey Completed on 04-18-2025

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 (NAs) on multiple shifts over a seven-day period. Specifically, the facility did not provide the mandated one NA per 10 residents during the day shift on six out of seven days, one NA per 11 residents during the evening shift on three out of seven days, and one NA per 15 residents during the night shift on four out of seven days. This deficiency was confirmed through a review of staffing documents and an interview with the Nursing Home Administrator, who acknowledged the shortfall in staffing on the specified dates.

Plan Of Correction

The facility cannot retroactively correct cited deficiencies. The facility will continue to maintain the required ratios and implement a contingency plan if needed by calling in off duty staff, calling sister facilities or utilizing bonuses as needed to ensure sufficient nursing staff. Additionally, the facility will continue to maintain efforts to recruit and retain staff to meet care needs and ensure residents are receiving appropriate care and services. The regional staff educated NHA/DON on ensuring sufficient nursing staff to meet residents' needs and ensure that the facility is holding daily staffing meetings. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 5x weekly for 4 weeks, then monthly for 2 months to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.

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