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P5520

Failure to Meet Minimum Nurse Aide and LPN Staffing Ratios

Lower Burrell, Pennsylvania Survey Completed on 07-31-2025

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

Facility administrative staff failed to meet required nurse aide (NA) staffing ratios on multiple occasions. Specifically, the facility did not provide the minimum of one NA per 10 residents during the day shift for 17 out of 21 days, one NA per 11 residents during the evening shift for 9 days, and one NA per 15 residents during the night shift for 5 days within the reviewed periods. Review of census data and nursing time schedules showed that the number of NA full-time equivalents (FTEs) present was consistently below the required levels for the respective shifts and census counts. The Director of Nursing confirmed these staffing shortages and acknowledged that there were no additional higher-level staff present to compensate for the deficiency. Additionally, the facility failed to provide the required minimum of one Licensed Practical Nurse (LPN) per 30 residents during the evening shift on one occasion. On that day, the number of LPN FTEs present was below the required amount based on the facility census. The Director of Nursing confirmed this LPN staffing shortage and also noted that there were no excess higher-level staff to offset the deficiency.

Plan Of Correction

The residents had no negative outcome for not meeting the minimum of one nurse aide per 10 residents on day shift, one nurse aide per 11 residents on evening shift, and one nurse aide per 15 residents on night shift. The facility has hired additional staff, holds daily staffing meetings to track staffing, and added additional agencies to utilize for staffing needs. Education: DON or designee will provide the staffing coordinator and HR with education on the Pennsylvania staffing requirements for ratios. Audits: Staffing coordinator or designee will audit the staffing ratios 3 times weekly for 2 weeks and monthly times 1 month. --- The residents had no negative outcome for not meeting the minimum of one LPN per 30 residents on evening shift. The facility has hired additional staff, holds daily staffing meetings to track staffing, and added additional agencies to utilize for staffing needs. Education: DON or designee will provide the staffing coordinator and HR with education on the Pennsylvania staffing requirements for ratios. Audits: Staffing coordinator or designee will audit the staffing ratios 3 times weekly for 2 weeks and monthly times 1 month.

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