P5540

Failure to Provide Required RN Coverage on Night Shifts

Dallas, Pennsylvania Survey Completed on 04-14-2026

Penalty

No penalty information released

Summary

The facility failed to meet the regulatory requirement, effective July 1, 2023, to provide a minimum of one RN per 250 residents on all shifts, as evidenced by staffing records and staff interview. A review of the weekly staffing records showed that on four separate night shifts, when the facility census ranged from 27 to 28 residents, there were no RNs scheduled or present, despite the requirement for at least one RN on duty. Specifically, on four identified nights, the RN count was zero against the required minimum of one RN for the existing census.

During an interview on April 14, 2026, at 2:00 PM, the Nursing Home Administrator confirmed that the facility did not meet the required RN-to-resident ratio on those dates and shifts. No additional resident-specific clinical details, medical histories, or conditions at the time of the deficiency were documented in the report.

Plan Of Correction

1.) There were no ill effects suffered by the residents due to the facility's failure to meet the ratio for residents to RNS for 4 shifts.

2.A facility wide audit was completed to ensure ratios were met. RN on bonuses and wages are competitive with surrounding areas. The facility uses bonuses for employees to pick up shifts.

3.DON and Corporate HR were re-educated on staffing ratios and ensure the facility is actively recruiting to fill any open positions. The DON will review census and staffing ratios to ensure ratios are being met.

4.The DON or designee will conduct an audit of nursing care ratios weekly x 4 weeks then monthly x2 months to ensure ratios are being met. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.