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P5520

Failure to Meet Minimum Nurse Aide Staffing Requirements

Wexford, Pennsylvania Survey Completed on 07-01-2025

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 state-mandated minimum nurse aide staffing levels on specific evening and night shifts, as evidenced by a review of three weeks of nurse staffing schedules. On one evening shift, the number of nurse aides present did not meet the required ratio of one nurse aide per 11 residents, and on one night shift, the number of nurse aides did not meet the required ratio of one nurse aide per 15 residents. The census and required staffing numbers were documented, showing that the facility was understaffed on these particular shifts. Additionally, during interviews, a resident reported that nurse aides were responsible for more residents than the expected ratio, specifically noting that there were more residents per aide than the standard of 10-12 residents per nurse aide. This concern was communicated to the Nursing Home Administrator and the Director of Nursing during the exit interview, confirming the facility's failure to provide the required minimum nurse aide staffing on the identified shifts.

Plan Of Correction

1. NHA or designee to educate staffing coordinator, DON, ADON, Unit Managers, and Nursing Supervisors on the minimum state ratio requirements for CNAs. 2. NHA or designee will conduct daily staffing meetings five times per week for the next two months to ensure the state minimum ratio of CNAs are met. 3. NHA or designee will review staffing sheets once per week for the next two months to ensure adequate CNA coverage is scheduled to meet the minimum ratio of CNAs. 4. Facility recruitment/retention efforts include utilizing job postings on company's career website, Indeed, and LinkedIn. Company offers competitive wages, benefits within 30 days of employment, tuition reimbursement program, etc. Facility administration holds weekly retention events with activities and food and also has a quarterly employee recognition program. 5. Results of findings will be reviewed during Monthly QAPI for recommendations and until compliance is met. --- 1. NHA or designee to educate staffing coordinator, DON, ADON, Unit Managers, and Nursing Supervisors on the minimum state ratio requirements for LPNs. 2. NHA or designee will conduct daily staffing meetings five times per week for the next two months to ensure the state minimum ratio of LPNs are met. 3. NHA or designee will review staffing sheets once per week for the next two months to ensure adequate LPN coverage is scheduled to meet the minimum ratio of LPNs. 4. Facility recruitment/retention efforts include utilizing job postings on company's career website, Indeed, and LinkedIn. Company offers competitive wages, benefits within 30 days of employment, tuition reimbursement program, etc. Facility administration holds weekly retention events with activities and food and also has a quarterly employee recognition program. 5. Results of findings will be reviewed during Monthly QAPI for recommendations and until compliance is met.

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