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P5520

Failure to Meet Minimum Nurse Aide Staffing Requirements on Day Shift

Washington, 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 the required minimum nurse aide (NA) staffing levels on the daylight shift for six out of eight days during the period reviewed. Specifically, staffing documents showed that on multiple days, the actual NA hours provided were significantly below the hours required based on the resident census. For example, on days when the census ranged from 66 to 69 residents, the facility provided between 22.5 and 45 NA hours, while the required hours ranged from 49.5 to 51.75. This deficiency was confirmed by the Nursing Home Administrator during an interview, who acknowledged that the facility did not provide the mandated number of NAs on the specified shifts.

Plan Of Correction

1. The facility cannot correct the ratio of 1 NA to 10 residents on the daylight shift on six of eight days (6/23/25 through 6/25/25 and 6/28/25 through 6/30/25) as required. 2. The facility will ensure that nurse aide staffing ratios are met every shift. 3. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5520 and the correct ratios. 4. In order to help to retain/attain sufficient staff for the facility, NHA will continue to focus on hiring qualified candidates as well as utilizing retention strategies. Facility will continue to utilize Indeed postings are being utilized and facility department heads are assisting with recruiting as needed per department. 5. The Nursing Home Administrator/designee will audit staffing daily for four weeks to ensure nurse aide staffing ratios are being met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.

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