(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 time schedules and staff interview it was determined that the facility administrative staff failed to provide a minimum of one nurse aide (NA) per 12 residents during the day and/or evening shift, and/or one nurse aid per 20 residents during the night shift for 16 of 21 days (1/4/26, 1/5/26, 1/6/26, 1/7/26, 1/8/26, 1/9/26, 1/10/26, 1/11/26, 1/12/26, 1/13/26, 1/14/26, 1/15/26, 1/16/26, 1/17/26, 1/21/26, and 1/23/26).
Findings include:
Review of the facility census data, nursing time schedules, and deployment sheets revealed the following nurse aide staffing shortages:
On 1/04/26, census 44, night shift required 2.93 NAs, facility provided 2.91.
On 1/05/26, census 45, day shift required 4.50 NAs, facility provided 4.00.
On 1/05/26, census 45, evening shift required 4.09 NAs, facility provided 3.97.
On 1/06/26, census 45, day shift required 4.50 NAs, facility provided 3.97.
On 1/06/26, census 45, evening shift required 4.09 NAs, facility provided 3.97.
On 1/06/26, census 45, night shift required 3.00 NAs, facility provided 2.88.
On 1/07/26, census 44, day shift required 4.40 NAs, facility provided 4.03.
On 1/07/26, census 44, night shift required 2.93 NAs, facility provided 2.72,
On 1/08/26, census 45, day shift required 4.50 NAs, facility provided 4.00.
On 1/08/26, census 45, evening shift required 4.09 NAs, facility provided 3.97.
On 1/09/26, census 44, day shift required 4.40 NAs, facility provided 4.00.
On 1/09/26, census 44, evening shift required 4.00, facility provided 3.94.
On 1/10/26, census 45, day shift required 4.50 NAs, facility provided 4.03.
On 1/10/26, census 45, evening shift required 4.09 NAs, facility provided 3.97.
On 1/11/26, census 45, day shift required 4.50 NAs, facility provided 4.06.
On 1/11/26, census 45, evening shift required 4.09 NAs, facility provided 4.00.
On 1/11/26, census 45, night shift required 3.13 NAs, facility provided 2.56.
On 1/12/26, census 44, day shift required 4.40 NAs, facility provided 4.03.
On 1/13/26, census 44, day shift required 4.40 NAs, facility provided 4.00.
On 1/13/26, census 44, night shift required 2.93 NAs, facility provided 2.88.
On 1/14/26, census 44, day shift required 4.40 NAs, facility provided 4.00.
On 1/15/26, census 44, day shift required 4.40 NAs, facility provided 3.94.
On 1/16/26, census 43, day shift required 4.30 NAs, facility provided 3.81.
On 1/17/26, census 41, day shift required 4.10 NAs, facility provided 4.03.
On 1/21/26, census 41, day shift required 4.10 NAs, facility provided 4.00.
On 1/23/26, census 40, day shift required 4.00 NAs, facility provided 3.97.
During an interview on 2/12/26, at 11:00 a.m. the Nursing Home Administrator confirmed that the facility failed to provide a minimum of one nurse aide per 12 residents during the day and evening shift, and/or one nurse aid per 20 residents during the night shift on 16 of 21 days (1/4/26, 1/5/26, 1/6/26, 1/7/26, 1/8/26, 1/9/26, 1/10/26, 1/11/26, 1/12/26, 1/13/26, 1/14/26, 1/15/26, 1/16/26, 1/17/26, 1/21/26, and 1/23/26).
| | Plan of Correction - To be completed: 03/24/2026
The residents had no negative outcome for not meeting minimum of one CNA per 12 residents during the day and/or evening shift, and/or one nurse aid per 20 residents during the night shift.
The facility is attempting to hire additional staff as well as holding daily staffing meetings to track staffing 5x a week.
DON/designee will provide the Staffing Coordinator/HR with re-education on the Pennsylvania staffing requirements for ratios.
Staffing coordinator/designee will audit the ratios five times weekly for 2 weeks and monthly times two month. Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met
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