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P5520

Failure to Meet Minimum Nurse Aide Staffing Ratios

Lower Burrell, Pennsylvania Survey Completed on 12-17-2025

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 ratios as mandated by regulation. Specifically, for 14 out of 21 days reviewed, the facility did not provide at least one NA per 10 residents during the day shift. Additionally, on two days, the evening shift did not meet the minimum requirement of one NA per 11 residents. This was determined through a review of facility census data and nursing time schedules, which showed that the number of NA full-time equivalents (FTEs) present was consistently below the required levels for the census on those days. During an interview, the Nursing Home Administrator confirmed that the facility did not meet the minimum NA staffing requirements for the day and evening shifts as specified. There was no indication that additional higher-level staff were present to compensate for these staffing shortages. The deficiency was identified based on direct review of staffing records and census data, with no mention of specific residents or their conditions in the report.

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 has agency contracts to utilize for staffing needs. The Director of Nursing or designee will provide the staffing coordinator and HR with education on the Pennsylvania staffing requirements for ratios. The Staffing coordinator or designee will audit the staffing ratios 3 times weekly for 2 weeks and monthly times 1 month.

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