(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 nursing schedules, nursing staffing documents and staff interview, it was determined that the facility failed to provide the State required minimum of one Nurse Aide (NA) per ten residents during the day on five of 21 days (3/24/25, 4/1/25, 4/5/25, 4/11/25, and 4/13/25), failed to provide the State required minimum of one NA per 11 residents during the evening on 14 of 21 days (3/24/25, 3/25/25, 3/27/25, 3/28/25, 3/29/25, 3/30/25, 4/1/25, 4/4/25, 4/7/25, 4/8/25, 4/9/25, 4/10/25, 4/11/25, and 4/12/25), and failed to provide the State required minimum of one NA per 15 residents overnight on three of 21 days (3/25/25, 4/12/25, and 4/13/25).
Findings include:
Review of the facility's 3-week nurse staffing schedules (3/24/25 - 4/13/25) did not include the State required minimum of Nurse Aides (NA) on:
-Daylight Shift:
-3/24/25, Census 114 Needed 11.4, only had 11.28.
-4/1/25, Census 110 Needed 11, only had 10.16.
-4/5/25, Census 112 Needed 11.2, only had 10.97.
-4/11/25, Census 110 Needed 11, only had 9.94.
-4/13/25, Census 109 Needed 10.9, only had 9.5.
-Evening Shift:
-3/24/25, Census 116 Needed 10.55, only had 7.66.
-3/25/25, Census 114 Needed 10.36, only had 6.72.
-3/27/25, Census 112 Needed 10.18, only had 9.56.
-3/28/25, Census 112 Needed 10.18, only had 9.69.
-3/29/25, Census 110 Needed 10, only had 9.75.
-3/30/25, Census 109 Needed 9.91, only had 9.63.
-4/1/25, Census 110 Needed 10, only had 9.66.
-4/4/25, Census 112 Needed 10.18, only had 8.56.
-4/7/25, Census 109 Needed 9.91, only had 9.66.
-4/8/25, Census 110 Needed 10, only had 9.06.
-4/9/25, Census 108 Needed 9.82, only had 9.31.
-4/10/25, Census 110 Needed 10, only had 8.88.
-4/11/25, Census 110 Needed 10, only had 8.5.
-4/12/25, Census 110 Needed 10, only had 9.28.
-Overnight Shift:
-3/25/25, Census 114 Needed 7.60, only had 7.56.
-4/12/25, Census 109 Needed 7.27, only had 6.63.
-4/13/25, Census 109 Needed 7.27, only had 6.94.
Telephonic interview on 4/16/25, at 10:00 a.m. the Nursing Home Administrator confirmed the facility failed to provide the State required minimum of one Nurse Aide (NA) per ten residents during the day on five of 21 days (3/24/25, 4/1/25, 4/5/25, 4/11/25, and 4/13/25), failed to provide the State required minimum of one NA per 11 residents during the evening on 14 of 21 days (3/24/25, 3/25/25, 3/27/25, 3/28/25, 3/29/25, 3/30/25, 4/1/25, 4/4/25, 4/7/25, 4/8/25, 4/9/25, 4/10/25, 4/11/25, and 4/12/25), and failed to provide the State required minimum of one NA per 15 residents overnight on three of 21 days (3/25/25, 4/12/25, and 4/13/25).
| | Plan of Correction - To be completed: 05/04/2025
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.
1. DON/designee will re-educate the staffing coordinator on the Pennsylvania staffing ratio regulation and specifically for nursing assistants.
2. NHA, DON, and Staffing Coordinator will meet daily on weekdays to ensure staffing ratios are being met per regulation.
3. Efforts to recruit are to continue to post employment ads on Indeed with occasional sign on bonus, interviews immediately and to use contracted staff for open shifts or call offs. CAN and RN wages were increased to encourage recruitment as well.
4. Efforts to maintain staff, include continuing to develop and post a monthly event calendar for staff, monthly IMPACT awards to recognize a staff member that goes above and beyond, referral bonuses for current staff that refer new nurses or care staff that are hired and bonuses for nursing staff that pick up open shifts.
5. DON/designee will audit nursing schedules weekly for 4 weeks and then monthly for 2 months to ensure compliance with nursing assistant ratios.
6. Results of the audits will be reviewed by the QAPI committee x 3 months and then as directed by the committee.
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