(e) The facility shall designate a charge nurse who is responsible for overseeing total nursing activities within the facility on each tour of duty each day of the week.
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Observations:
Based on review of the nursing schedules and interviews with staff, it was determined that the facility administrative staff failed to provide the minimum of one nursing assistant per 10 residents during the day shift on two of seven days reviewed (March 23, 2025 through March 29, 2025) and failed to provide the minimum of one nursing assistant per 11 residents during the evening shift on two of seven days reviewed (March 23, 2025 through March 29, 2025).
Findings include:
A review of the nursing staff schedule for the week of March 23, 2025 through March 29, 2025, revealed that for the day tour on March 23, 2025, the facility failed to employ an adequate amount of nursing assistants (NA) to give care and services to the residents. The census for the shift was 115 residents, requiring a minimum of 11.5 NAs to meet the 1:10 ratio. There were 10.49 NAs on duty.
A review of the nursing staff schedule for the week of March 23, 2025 through March 29. 2025, revealed that for the day tour on March 24, 2025, the facility failed to employ an adequate amount of nursing assistants (NA) to give care and services to the residents. The census for the shift was 117 residents, requiring a minimum of 11.7 NAs to meet the 1:10 ratio. There were 11.6 NAs on duty.
A review of the nursing staff schedule for the week of March 23, 2025 through March 29, 2025, revealed that for the evening tour on March 25, 2025, the facility failed to employ an adequate amount of nursing assistants (NA) to give care and services to the residents. The census for the shift was 118 residents, requiring a minimum of 10.73 NAs to meet the 1:11 ratio. There were 10.3 NAs on duty.
A review of the nursing staff schedule for the week of March 23, 2025 through March 29, 2025, revealed that on the evening tour on March 28, 2025, the facility failed to employ an adequate amount of nursing assistants (NA) to give care and services to the residents. The census for the shift was 118 residents, requiring a minimum 10.73 NAs to meet the 1:11 ratio. There were 9.77 NAs on duty.
Interview with the nursing home administrator, Employee E1, at 1:00 p.m. on April 18, 2025 confirmed that the facility failed to provide the minimum number of nursing assistants to provide care for the residents on March 23, 24, 25, and 28.
| | Plan of Correction - To be completed: 05/27/2025
The facility can not retroactively correct the deficient practice.
The Director of Nursing, or designee, will re-inservice the Staffing Coordinator regarding the Pennsylvania Department of Health Staffing Regulations for nurse aide staff to ensure that the facility is providing one nurse aide for per 10 residents on day shift, one nurse aide per 11 residents for evening shift and one nurse aide per 15 residents for night shift.
The Director of Nursing, or designee, will audit the Nurse Aide staffing to ensure the facility is providing one nurse aide for one nurse aide for per 10 residents on day shift, one nurse aide per 11 residents for evening shift and one nurse aide per 15 residents for night shift. Audits will be completed weekly x 4 weeks and monthly for 90 days thereafter.
The results of the audits will be forwarded to the QAPI Committee for additional review and recommendations.
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