(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.
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Observations:
Based on a review of the facility's nurse staffing documents and staff interviews, it was determined that the facility failed to provide one Nurse Assistant (NA) per 12 residents on the daylight shift on 10 of 21 days (1/22/24, 1/23/24, 2/18/24, 2/19/24, 2/24/24, 2/26/24, 2/28/24, 2/29/24, 3/1/24, and 3/3/24), one NA per 12 residents on the evening shift on six of 21 days (1/27/24, 2/23/24, 2/24/24, 2/26/24, 3/1/24, and 3/3/24) and one NA per 20 residents on the night shift on two of 21 days (3/1/24, and 3/2/24) as required.
Findings include:
During a review of the facility nurse staffing documents for the weeks of 1/21/24 through 1/27/24, 2/8/24 through 2/24/24, and 2/26/24, through 3/3/24, revealed the following
Date Census Required staff Provided Staff
Daylight shift
1/22/24715.923.08
1/23/24715.924.61
2/18/24715.924.96
2/19/24715.924.48
2/24/24726.004.65
2/26/24736.084.40
2/28/24736.084.66
2/29/24726.05.59
3/1/24715.923.11
3/3/24726.04.97
Evening shift
1/27/24726.05.73
2/23/24726.03.75
2/24/24726.05.71
2/26/24736.085.19
3/1/24715.923.70
3/3/24726.05.25
Night Shift
3/1/24713.553.18
3/2/24723.603.20
During an interview on 3/6/24 at 12:30 pm the Nursing Home Administrator confirmed that the facility failed to provide the one NA per 12 residents on the daylight shift for 10 of 21 days, one NA per 12 residents on the evening shift for six of 21 days and one NA per 20 residents on the night shift for two of 21 days for the review period of 1/21/24 through 1/27/24, 2/8/24 through 2/24/24, and 2/26/24, through 3/3/24.
| | Plan of Correction - To be completed: 04/24/2024
WeCare at Penn acknowledges receipt of the Statement of Deficiencies and proposes this Plan of Correction to the extent that the summary of findings is factually correct and to maintain compliance with applicable rules and provisions of quality of care of residents.
The Plan of Correction is submitted as a written allegation of compliance. WeCare at Penn's response to this Statement of Deficiencies does not denote agreement with the Statement of Deficiencies nor does it constitute an admission that any deficiency is accurate. Further, WeCare at Penn reserves the right to refute any of the deficiencies on this Statement of Deficiencies through Informal Dispute Resolution, formal appeal procedure and/or any other administrative or legal proceeding.
No residents were affected.
The Director of Nursing and scheduling coordinator were provided re-education regarding the minimum certified nurse aide's (CNA) hour requirement.
The facility has previously increased hourly wages (as recent as 3/3/24), we offer sign on bonuses and extra shift pick up bonuses to qualified staff, flexible schedules and have placed advertisements on media settings for recruitment.
The facility has an ongoing weekly staffing meeting which consists of the Director of Nursing or designee and the Staffing Coordinator, in which a review and "look ahead" for the week occurs.
The Director of Nursing or designee will monitor the nursing hours/nurse aide ratios daily and report any noted under hour days to the Nursing Home Administrator as appropriate.
Results of the monitoring will be reported through the facility Quality Assurance Meetings.
Date Certain: 4/24/24
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