Observations:
Based on review of facility nursing staffing documents and staff interview, it was determined that the facility failed to meet the Nurse Aide (NA) ratios ofr one NA per 10 residents on the day shift for one of 14 days reviewed (8/2/26); failed to meet the NA ratio of one NA per 11 residents on the evening shift for one of 14 days reviewed (8/2/26); and failed to meet the NA ratio of one NA per 15 residents on the overnight shift for one of 14 days reviewed (8/2/26).
Findings include:
Review of facility nursing staffing documents for the time period from 8/1/26, through 8/14/26, revealed the following NA staffing shortage for the day shift where the NA ratios were not met:
8/2/26 census of 161 15.91 NAs worked and 16.10 were required
Review of facility nursing staffing documents for the time period 8/1/26, through 8/14/26, revealed the following NA staffing shortage for the evening shift where the NA ratios were not met:
8/2/26 census of 161 14.59 NAs worked and 14.64 were required
Review of facility nursing staffing documents for the time period 8/1/26, through 8/14/26, revealed the following NA staffing shortage for the overnight shift where the NA ratios were not met:
8/2/26 census of 161 9.40 NAs worked and 10.73 were required
During a telephone interview on 8/20/26, at 3:52 p.m. the Nursing Home Administrator confirmed that the facility did not meet the minimum NA ratios for the above days and shifts.
| | Plan of Correction - To be completed: 10/15/2026
Quality Life Services, New Castle has adopted internal processes as part of our on-going commitment to provide quality care to the residents we serve. The attached information contains Quality Life Services, new Castle's Plan of Correction which we are submitting in response to specific deficiencies identified by the Pennsylvania Department of Health and is required for purposes of our facility's licensure and certification. The information and responses contained in our Plan of Correction are consistent with our own quality improvement efforts and should not be construed as an admission of or agreement with the deficiencies cited in the Department's findings. This Plan of Correction is not an admission of wrongdoing on the part of Quality Life Services New Castle.
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1. The facility was unable to make a corrective action for the nurse aide staffing on the days that have already passed. No residents were adversely affected by the nurse aide staffing on the identified scheduled days.
2. The Director of Nursing and/or designee will re-educate the labor management team on the nurse aide ratio regulation for the state of Pennsylvania including the revised staff ratio effective January 1, 2024.
3. The facility will conduct staffing meetings Monday – Friday to ensure all ratios are met throughout the day, the following day, and weekends. Staff attending will be Nursing Administration, Administrator, Administrative staff member, and Labor manager.
4. Audits of all steps taken to fill any call-offs that could affect the nurse aide staffing ratio will be completed by the Director of Nursing/designee the day following for the previous day's staffing. Audits will be completed 5 days a week with corrective measures implemented as needed. Results of the audits will be reviewed with the Quality Assurance Performance Improvement team with corrections addressed as needed.
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