(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.
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Observations:
Based on review of the facility nursing staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one Nurse Aide (NA) per 10 residents for the day shift for seven of 21 days reviewed (2/14/26, 2/15/26, 2/19/26, 2/20/26, 2/22/26, 2/28/26 and 3/01/26); failed to ensure a minimum of one NA per 11 residents for the evening shift for 18 of 21 days reviewed (2/10/26, 2/12/26, 2/13/26, 2/15/26, 2/16/26, 2/17/26, 2/18/26, 2/19/26, 2/20/26, 2/22/26, 2/23/26, 2/24/26, 2/25/26, 2/26/26, 2/27/26, 2/28/26, 3/01/26 and 3/02/26); and failed to ensure a minimum of one NA per 15 residents for the overnight shift for 20 of 21 days reviewed (2/11/26, 2/12/26, 2/13/26, 2/14/26, 2/15/26, 2/16/26, 2/17/26, 2/18/26, 2/19/26, 2/20/26, 2/21/26, 2/22/26, 2/23/26, 2/24/26, 2/25/26, 2/26/26, 2/27/26, 2/28/26, 3/01/26, and 3/02/26).
Findings include:
Review of facility nursing staffing documents for the time period of 2/10/26, through 3/02/26, revealed the following NA staffing shortages for the day shift where the NA ratios were not met:
2/14/26 census of 97 residents 6.06 NA worked and 9.70 were required
2/15/26 census of 97 residents 8.15 NA worked and 9.70 were required
2/19/26 census of 97 residents 8.36 NA worked and 9.70 were required
2/20/26 census of 96 residents 9.44 NA worked and 9.60 were required
2/22/26 census of 98 residents 9.57 NA worked and 9.80 were required
2/28/26 census of 92 residents 6.83 NA worked and 9.20 were required
3/01/26 census of 91 residents 5.21 NA worked and 9.10 were required
Review of facility nursing staffing documents for the time period of 2/10/26, through 3/02/26, revealed the following NA staffing shortages for the evening shift where the NA ratios were not met:
2/10/26 census of 93 residents 7.85 NA worked and 8.45 were required
2/12/26 census of 96 residents 7.45 NA worked and 8.73 were required
2/13/26 census of 96 residents 5.33 NA worked and 8.73 were required
2/15/26 census of 97 residents 7.99 NA worked and 8.82 were required
2/16/26 census of 96 residents 6.75 NA worked and 8.73 were required
2/17/26 census of 96 residents 8.21 NA worked and 8.73 were required
2/18/26 census of 97 residents 8.07 NA worked and 8.82 were required
2/19/26 census of 97 residents 7.91 NA worked and 8.82 were required
2/20/26 census of 96 residents 7.09 NA worked and 8.73 were required
2/22/26 census of 98 residents 8.38 NA worked and 8.91 were required
2/23/26 census of 98 residents 7.28 NA worked and 8.91 were required
2/24/26 census of 96 residents 7.49 NA worked and 8.73 were required
2/25/26 census of 96 residents 6.58 NA worked and 8.73 were required
2/26/26 census of 95 residents 8.62 NA worked and 8.64 were required
2/27/26 census of 93 residents 6.37 NA worked and 8.45 were required
2/28/26 census of 92 residents 5.70 NA worked and 8.36 were required
3/01/26 census of 91 residents 7.01 NA worked and 8.27 were required
3/02/26 census of 91 residents 6.14 NA worked and 8.27 were required
Review of facility nursing staffing documents for the time period of 2/10/26, through 3/02/26, revealed the following NA staffing shortages for the overnight shift where the NA ratios were not met:
2/11/26 census of 92 residents 5.06 NA worked and 6.13 were required
2/12/26 census of 96 residents 4.24 NA worked and 6.40 were required
2/13/26 census of 96 residents 4.06 NA worked and 6.40 were required
2/14/26 census of 97 residents 4.04 NA worked and 6.47 were required
2/15/26 census of 97 residents 4.69 NA worked and 6.47 were required
2/16/26 census of 96 residents 4.88 NA worked and 6.40 were required
2/17/26 census of 96 residents 5.23 NA worked and 6.40 were required
2/18/26 census of 97 residents 5.27 NA worked and 6.47 were required
2/19/26 census of 97 residents 4.52 NA worked and 6.47 were required
2/20/26 census of 96 residents 4.79 NA worked and 6.40 were required
2/21/26 census of 97 residents 4.47 NA worked and 6.47 were required
2/22/26 census of 98 residents 4.21 NA worked and 6.53 were required
2/23/26 census of 98 residents 4.63 NA worked and 6.53 were required
2/24/26 census of 96 residents 4.72 NA worked and 6.40 were required
2/25/26 census of 96 residents 3.79 NA worked and 6.40 were required
2/26/26 census of 95 residents 5.53 NA worked and 6.33 were required
2/27/26 census of 93 residents 5.16 NA worked and 6.20 were required
2/28/26 census of 92 residents 4.09 NA worked and 6.13 were required
3/01/26 census of 91 residents 5.14 NA worked and 6.07 were required
3/02/26 census of 91 residents 5.14 NA worked and 6.07 were required
During a telephone interview on 3/05/26, at 11:10 a.m. the Nursing Home Administrator confirmed the NA ratios were not met for the above days and shifts.
| | Plan of Correction - To be completed: 04/09/2026
- No residents were found to be negatively affected by the deficient practice of regulation.
- The facility will make every effort to meet minimum state regulation as required and calculated by PA Department of Health Minimum Staffing Ratios.
1. The Administrator and/or designee will have a staffing meeting each business day morning, for four weeks to ensure the proper staff to resident ratios meet shift requirements according to current censuses. Census will be reviewed to ensure staff to resident ratio. The meetings will be audited M-F and weekends will be reviewed at Friday's meetings, for 4 weeks and monthly thereafter.
2. The facility will utilize administrative staff that have nursing licenses (registered nurse or licensed practical nurse or certified Nurse Aide certification) to maintain the required ratios for the Certified Nurse Aides, in the event of unforeseen shortage of Certified Nurse Aides.
3. The Director of Nursing and Assistant Director Of Nursing will be educated by Nursing Home Administrator or designee on staffing ratios, particularly as it pertains to CNAs.
4. The Facility will utilize On Shift program to make the schedule accessible to staff to see open shifts and pick them up, advertisement of open positions and hiring incentives, and ongoing recruitment efforts.
5. Results of staffing meetings and recruitment efforts will be reviewed weekly by Administrator and Director of Nursing and monthly by QAPI committee.
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