(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 staffing document review and staff interview, it was determined that the facility failed to ensure a required minimum of one Nurse Aide (NA) per 10 residents on day shift for four of seven days reviewed (May 4, 5, 7, and 8, 2025), one NA per 11 residents on evening shift for four of seven days reviewed (May 4, 6, 7, and 8, 2025), and one NA per 15 residents on night shift for three of seven days reviewed (May 6, 7, and 8, 2025) as calculated by full time equivalent (FTE - number of staff required calculated by determining the required number of hours of full time shifts worked to meet the minimum staff to resident ratio).
Findings include:
Review of staffing information for the day shift of May 4, 2025, revealed a resident census of 183, which resulted in a minimum NA FTE of 18.30; submitted information revealed the facility provided 17.93.
Review of staffing information for the day shift of May 5, 2025, revealed a resident census of 183, which resulted in a minimum NA FTE of 18.30; submitted information revealed the facility provided 17.83.
Review of staffing information for the day shift of May 7, 2025, revealed a resident census of 182, which resulted in a minimum NA FTE of 18.20; submitted information revealed the facility provided 16.27.
Review of staffing information for the day shift of May 8, 2025, revealed a resident census of 183, which resulted in a minimum NA FTE of 18.30; submitted information revealed the facility provided 16.47.
Review of staffing information for the evening shift of May 4, 2025, revealed a resident census of 183, which resulted in a minimum NA FTE of 16.64; submitted information revealed the facility provided 15.90.
Review of staffing information for the evening shift of May 6, 2025, revealed a resident census of 180, which resulted in a minimum NA FTE of 16.36; submitted information revealed the facility provided 15.23.
Review of staffing information for the evening shift of May 7, 2025, revealed a resident census of 182, which resulted in a minimum NA FTE of 16.55; submitted information revealed the facility provided 15.37.
Review of staffing information for the evening shift of May 8, 2025, revealed a resident census of 183, which resulted in a minimum NA FTE of 16.64; submitted information revealed the facility provided 11.93.
Review of staffing information for the night shift of May 6, 2025, revealed a resident census of 180, which resulted in a minimum NA FTE of 12.00; submitted information revealed the facility provided 11.47.
Review of staffing information for the night shift of May 7, 2025, revealed a resident census of 182, which resulted in a minimum NA FTE of 12.13; submitted information revealed the facility provided 9.00.
Review of staffing information for the night shift of May 8, 2025, revealed a resident census of 183, which resulted in a minimum NA FTE of 12.20; submitted information revealed the facility provided 10.23.
During a staff interview on May 28, 2025, at approximately 1:30 PM, Nursing Home Administrator confirmed that the facility did not meet the minimum staffing for NA identified on the submitted documentation.
| | Plan of Correction - To be completed: 06/24/2025
1. An immediate correction cannot be performed; no residents were affected by the alleged non-compliance.
2. Calculation of shift CNA Ratios will be completed and reviewed daily for accuracy and compliance by scheduler and DON/designee.
3. The facility has agency contracts in place in efforts to meet daily CNA Ratio requirements. The facility has also incorporated sign-on bonuses in an effort to attract and retain new staff. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate CNA Ratios as needed. The facility will monitor census each shift and make all attempts to adjust staffing to ensure CNA Ratio requirements are met.
4. DON/Designee will re-educate nursing scheduler on the PA DOH CNA Ratio requirements.
5. CNA Ratios will be audited by DON/designee daily for 4 weeks, then 3 days per week x2 months or until substantial compliance is achieved. Results to QAPI.
6. Date of compliance 6.24.25
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