(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 facility nursing staffing documents and staff interview, it was determined that the facility failed to meet the Nurse Aide (NA) ratios for one NA per 10 residents on day shift for 17 of 21 days reviewed (11/13/25, 11/14/25, 11/15/25, 11/16/25, 11/17/25, 11/18/25, 11/19/25, 11/20/25, 11/22/25, 11/23/25, 11/24/25, 11/25/25, 11/26/25, 11/27/25, 11/28/25, 11/29/25, and 12/02/25); failed to meet the NA ratio for one NA per 11 residents on the evening shift for 17 of 21 days reviewed (11/12/25, 11/13/25, 11/14/25, 11/15/25, 11/16/25, 11/17/25, 11/18/25, 11/19/25, 11/21/25, 11/22/25, 11/23/25, 11/25/25, 11/26/25, 11/27/25, 11/29/25, 11/30/25 and 12/02/25; and failed to meet the NA ratio for one NA per 15 residents on the overnight shift for 18 of 21 days reviewed (11/12/25, 11/13/25, 11/14/25, 11/15/25, 11/16/25, 11/17/25, 11/18/25, 11/19/25, 11/20/25, 11/22/25, 11/23/25, 11/24/25, 11/25/25, 11/26/25, 11/27/25, 11/29/25, 12/01/25, and 12/02/25).
Findings include:
Review of facility nursing staffing documents for the time period from 11/12/25 through 12/02/25, revealed the following NA staffing shortages for the day shift where the NA ratios were not met:
11/13/25 census of 57 residents 5.57 NAs worked and 5.70 were required
11/14/25 census of 57 residents 5.23 NAs worked and 5.70 were required
11/15/25 census of 57 residents 5.00 NAs worked and 5.70 were required
11/16/25 census of 57 residents 5.00 NAs worked and 5.70 were required
11/17/25 census of 57 residents 5.40 NAs worked and 5.70 were required
11/18/25 census of 58 residents 5.00 NAs worked and 5.80 were required
11/19/25 census of 58 residents 5.47 NAs worked and 5.80 were required
11/20/25 census of 58 residents 5.00 NAs worked and 5.80 were required
11/22/25 census of 59 residents 5.33 NAs worked and 5.90 were required
11/23/25 census of 59 residents 5.80 NAs worked and 5.90 were required
11/24/25 census of 59 residents 5.27 NAs worked and 5.90 were required
11/25/25 census of 59 residents 4.93 NAs worked and 5.90 were required
11/26/25 census of 57 residents 4.93 NAs worked and 5.70 were required
11/27/25 census of 57 residents 5.00 NAs worked and 5.70 were required
11/28/25 census of 60 residents 5.93 NAs worked and 6.00 were required
11/29/25 census of 60 residents 5.73 NAs worked and 6.00 were required
12/02/25 census of 59 residents 5.40 NAs worked and 5.90 were required
Review of facility nursing staffing documents for the time period from 11/12/25 through 12/02/25, revealed the following NA staffing shortages for the evening shift where the NA ratios were not met:
11/12/25 census of 58 residents 4.93 NAs worked and 5.27 were required
11/13/25 census of 57 residents 4.93 NAs worked and 5.18 were required
11/14/25 census of 57 residents 5.00 NAs worked and 5.18 were required
11/15/25 census of 57 residents 5.03 NAs worked and 5.18 were required
11/16/25 census of 57 residents 5.00 NAs worked and 5.18 were required
11/17/25 census of 57 residents 5.00 NAs worked and 5.18 were required
11/18/25 census of 58 residents 5.00 NAs worked and 5.27 were required
11/19/25 census of 58 residents 5.00 NAs worked and 5.27 were required
11/21/25 census of 58 residents 3.73 NAs worked and 5.27 were required
11/22/25 census of 59 residents 5.00 NAs worked and 5.36 were required
11/23/25 census of 59 residents 5.00 NAs worked and 5.36 were required
11/25/25 census of 59 residents 4.93 NAs worked and 5.36 were required
11/26/25 census of 57 residents 5.00 NAs worked and 5.18 were required
11/27/25 census of 57 residents 5.00 NAs worked and 5.18 were required
11/29/25 census of 60 residents 5.00 NAs worked and 5.45 were required
11/30/25 census of 60 residents 5.00 NAs worked and 5.45 were required
12/02/25 census of 59 residents 5.00 NAs worked and 5.36 were required
Review of facility nursing staffing documents for the time period from 11/12/25 through 12/02/25, revealed the following NA staffing shortages for the overnight shift where the NA ratios were not met:
11/12/25 census of 58 residents 3.00 NAs worked and 3.87 were required
11/13/25 census of 57 residents 3.00 NAs worked and 3.80 were required
11/14/25 census of 57 residents 3.00 NAs worked and 3.80 were required
11/15/25 census of 57 residents 3.00 NAs worked and 3.80 were required
11/16/25 census of 57 residents 3.00 NAs worked and 3.80 were required
11/17/25 census of 57 residents 3.00 NAs worked and 3.80 were required
11/18/25 census of 58 residents 3.53 NAs worked and 3.87 were required
11/19/25 census of 58 residents 3.00 NAs worked and 3.87 were required
11/20/25 census of 58 residents 2.00 NAs worked and 3.87 were required
11/22/25 census of 59 residents 3.53 NAs worked and 3.93 were required
11/23/25 census of 59 residents 2.90 NAs worked and 3.93 were required
11/24/25 census of 59 residents 3.00 NAs worked and 3.93 were required
11/25/25 census of 59 residents 3.53 NAs worked and 3.93 were required
11/26/25 census of 57 residents 3.00 NAs worked and 3.80 were required
11/27/25 census of 57 residents 3.00 NAs worked and 3.80 were required
11/29/25 census of 60 residents 3.80 NAs worked and 4.00 were required
12/01/25 census of 60 residents 3.53 NAs worked and 4.00 were required
12/02/25 census of 59 residents 3.00 NAs worked and 3.93 were required
During a telephone interview on 12/08/25, at 4:05 p.m. the Nursing Home Administrator confirmed that the facility did not meet the minimum NA ratios for the above day and shift.
| | Plan of Correction - To be completed: 01/28/2026
No residents experienced negative effects as a result of not meeting the required ratio on those shifts indicated in the observations.
The Nursing Home Administrator and Director of Nursing have reviewed and understand 28 PA code 211.12
System changes include The Director of Nursing or designee will review the nurse aide schedule four weeks in advance to identify areas to deploy additional staffing to maintain compliance with nurse aide staffing hours and staff-to-resident ratios.
The Director of Human Resources or the Staffing Coordinator will print out the rolling four week schedule which will be initialed by the Director of Nursing or designee and kept in a binder.
The Director of Nursing, Nursing Home Administrator or their designee, will complete a staffing tracker daily to identify areas to deploy additional staffing.
An ongoing roster of Per-diem nurse aides and full-time and part-time nurse aides who wish to be included in a "call out" list will be maintained by the Scheduling Coordinator and distributed to afternoon, evening, and weekend supervisors responsible for taking and filling call offs on their shifts.
A bonus payment of one hundred dollars will be offered to nurse aides on the "call out" roster if they pick up a shift
Education will be provided by the Director of Nursing or designee to the facility Nursing Supervisors, Scheduling Coordinator and Assistant Director of Nursing on the requirements of 28 Pa code 211.12 and on facility staffing policy including the process for filling call offs.
An audit of the staffing process will be conducted by the Nursing Home Administrator to ensure that all steps were utilized to ensure compliant nurse aid ratios. The audits will be conducted daily for one week and weekly ongoing until compliance is achieved.
Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee in the form of a Process Improvement Project at each monthly meeting until such time as the facility is in compliance and the committee resolves to retire the project.
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