(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 ensure a minimum of one Nurse Aide (NA) per 10 residents on the day shift for 13 of 21 days reviewed (10/17/25, 10/19/25, 10/21/25, 10/22/25, 10/24/25, through 10/28/25, 10/30/25, through 11/02/25); failed to ensure one NA per 11 residents on the evening shift for 16 of 21 days (10/15/26, 10/16/25, 10/19/25, through 10/21/25, 10/24/25, through 10/27/25, 10/29/25, through 11/04/25); and failed to ensure a minimum of one NA per 15 residents on the overnight shift for five of 21 days (10/15/25, through 10/17/25, 10/20/25, through 10/21/25) reviewed for staffing.
Findings include:
Review of facility nursing staffing documents for the time periods of 10/15/25, through 10/21/25, 10/22/25, through 10/28/25, and 10/29/25, through 11/04/25, revealed following NA shortages for the day shift:
10/17/25facility census of 109 residents9.45 NAs worked and 10.90 were required.
10/19/25facility census of 108 residents 8.99 NAs worked and 10.80 were required.
10/21/25facility census of 108 residents9.87 NAs worked and 10.80 were required.
10/22/25facility census of 110 residents9.66 NAs worked and 11.00 were required.
10/24/25facility census of 111 residents10.37 NAs worked and 11.10 were required.
10/25/25facility census of 111 residents10.52 NAs worked and 11.10 were required.
10/26/25facility census of 110 residents10.06 NAs worked and 11.00 were required.
10/27/25facility census of 109 residents10.73 NAs worked and 10.90 were required.
10/28/25facility census of 108 residents10.66 NAs worked and 10.80 were required.
10/30/25facility census of 110 residents9.45 NAs worked and 11.00 were required.
10/31/25facility census of 107 residents10.25 NAs worked and 10.70 were required.
11/01/25facility census of 108 residents9.78 NAs worked and 10.80 were required.
11/02/25 facility census of 107 residents10.55 NAs worked and 10.70 were required.
Review of facility nursing staffing documents for the time periods of 10/15/25, through 10/21/25, 10/22/25, through 10/28/25, and 10/29/25, through 11/04/25, revealed following NA shortages for the evening shift:
10/15/25facility census of 109 residents8.73 NAs worked and 9.91 were required.
10/16/25 facility census of 111 residents8.84 NAs worked and 10.09 were required.
10/19/25 facility census of 108 residents9.59 NAs worked and 9.82 were required.
10/20/25facility census of 109 residents8.05 NAs worked and 9.91 were required.
10/21/25 facility census of 108 residents6.29 NAs worked and 9.82 were required.
10/24/25 facility census of 111 residents9.23 NAs worked and 10.09 were required.
10/25/25 facility census of 111 residents6.98 NAs worked and 10.09 were required.
10/26/25 facility census of 110 residents 6.28 NAs worked and10.00 were required.
10/27/25facility census of 109 residents7.96 NAs worked and 9.91 were required.
10/29/25facility census of 112 residents9.22 NAs worked and 10.18 were required.
10/30/25 facility census of 110 residents 7.57 NAs worked and10.00 were required.
10/31/25facility census of 107 residents7.67 NAs worked and 9.73 were required.
11/01/25 facility census of 108 residents8.73 NAs worked and 9.82 were required.
11/02/25facility census of 107 residents9.23 NAs worked and 9.73 were required.
11/03/25facility census of 106 residents7.52 NAs worked and 9.64 were required.
11/04/25facility census of 107 residents6.72 NAs worked and 9.73 were required.
Review of facility nursing staffing documents for the time periods of 10/15/25, through 10/21/25, 10/22/25, through 10/28/25, and 10/29/25, through 11/04/25, revealed following NA shortages for the evening shift:
10/15/25 facility census of 109 residents5.73 NAs worked and 7.27 were required.
10/16/25 facility census of 111 residents5.02 NAs worked and 7.40 were required.
10/17/25 facility census of 109 residents6.50 NAs worked and 7.27 were required.
10/20/25 facility census of 109 residents4.42 NAs worked and 7.27 were required.
10/21/25 facility census of 108 residents4.91 NAs worked and 7.20 were required.
During an interview on 11/06/25, at 12:45 p.m. the Nursing Home Administrator confirmed that the facility failed to meet the minimum NA ratio requirements on the above shifts and dates.
| | Plan of Correction - To be completed: 12/30/2025
All residents received the appropriate care and services to meet their needs on the identified days and there was no direct correlation to an individual resident.
Residents of Warren Manor will be protected from future staff ratios below the 1:10 nurse aide for days, 1:11 nurse aide for evenings and 1:15 nurse aide for nights by a proactive preview of daily staff assignments and schedules to ensure adequate staff coverage by Director of nursing/Designee. The nursing scheduler/designee will review projected staffing levels with the Director of nursing/designee daily to ensure that any foreseeable staffing levels below nurse aide ratios are adequately covered. Charge Nurses will be educated by Director of nursing/designee 12/1/25 to immediately contact Director of nursing for any day that ratios unexpectedly drop below the nurse aide ratio minimum for immediate resolution.
Warren Manor will continue to aggressively advertise externally for the recruitment of nursing/nurse aide applicants to enhance current staffing levels. Facility will also review potential admissions and reconsider admissions if the facility is unable to meet minimum staffing levels. Warren Manor is an approved provider of the Pennsylvania Nurse Aide Training and Competency Evaluation Program and has ongoing class trainings throughout the year. Administrative nurses are assigned to an on-call schedule and are available to cover shifts when foreseeable staffing levels are below the ratio levels. Facility offers extra incentives to current staff to cover extra shifts. A weekly recruiting meeting is held to address open positions. Open walk-in interview sessions will be held weekly. Nursing Assistants are using a self scheduling system. Facility is currently offering referral bonus's for any employee who refers another employee. Warren Manor increased the shift differential for all nursing staff. Facility is using a corporate talent acquisition specialist to help with recruitment of new staff.
Nurse aide ratios will be reviewed by Director of nursing/nursing designee 3x's a week for a month, then weekly x3 weeks then monthly x2 months. Results will be reported at monthly Quality Assurance Performance Improvement committee meeting.
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