Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides on two separate occasions. On the evening shift of April 20, 2025, the facility did not provide the mandated one nurse aide per 11 residents, as evidenced by staffing documents showing 45.69 actual hours against the required 48.75 hours for a census of 65 residents. Similarly, on the night shift of April 19, 2025, the facility did not meet the requirement of one nurse aide per 15 residents, with staffing documents indicating 36.43 actual hours against the required 42.95 hours for a census of 63 residents. This deficiency was confirmed by the Nursing Home Administrator during an interview on April 25, 2025.
Plan Of Correction
No residents were found to be negatively affected by the deficient practice of regulation. The facility will make every effort to meet minimum state regulation as required and calculated by PA DOH Minimum Staffing Ratios. 1. The Administrator and/or designee will have a staffing meeting each business day morning, for four weeks to ensure the proper staff to resident ratios meet shift requirements according to current censuses. Census will be reviewed to ensure staff to resident ratio. 2. The facility will utilize administrative staff that have nursing or certified Nurse Aide certification to maintain the required ratios for the CNA, in the event of unforeseen shortage of CNA. 3. The Administrator and Assistant Administrator will be educated by Regional Support Personnel on staffing ratios, particularly as it pertains to CNAs. 4. The Facility will utilize Open Shift program to make the schedule accessible to staff to see open shifts and pick them up, advertisement of open positions and hiring incentives, and ongoing recruitment efforts. 5. Results of staffing meetings and recruitment efforts will be reviewed weekly by Administrator and DON and monthly by QAPI committee.