Failure to Provide Required RN Coverage on Night Shifts
Summary
The facility failed to meet the regulatory requirement, effective July 1, 2023, to provide a minimum of one RN per 250 residents on all shifts, as evidenced by staffing records and staff interview. A review of the weekly staffing records showed that on four separate night shifts, when the facility census ranged from 27 to 28 residents, there were no RNs scheduled or present, despite the requirement for at least one RN on duty. Specifically, on four identified nights, the RN count was zero against the required minimum of one RN for the existing census. During an interview on April 14, 2026, at 2:00 PM, the Nursing Home Administrator confirmed that the facility did not meet the required RN-to-resident ratio on those dates and shifts. No additional resident-specific clinical details, medical histories, or conditions at the time of the deficiency were documented in the report.
Plan Of Correction
1.) There were no ill effects suffered by the residents due to the facility's failure to meet the ratio for residents to RNS for 4 shifts. 2.A facility wide audit was completed to ensure ratios were met. RN on bonuses and wages are competitive with surrounding areas. The facility uses bonuses for employees to pick up shifts. 3.DON and Corporate HR were re-educated on staffing ratios and ensure the facility is actively recruiting to fill any open positions. The DON will review census and staffing ratios to ensure ratios are being met. 4.The DON or designee will conduct an audit of nursing care ratios weekly x 4 weeks then monthly x2 months to ensure ratios are being met. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.
Penalty
The facility did not provide the required RN coverage on two separate shifts, resulting in no RN hours being recorded when a minimum of 8.0 hours was required for each shift.
The facility did not meet the required RN staffing ratios during overnight shifts for five consecutive nights. The facility provided significantly fewer RN service hours than the required 8 hours per shift, with a resident census ranging from 48 to 50. This deficiency was confirmed by the Administrator and DON.
The facility did not meet the required RN-to-resident ratio on the overnight shift for eight out of 21 days reviewed. On several occasions, the facility had fewer RNs than required, with some nights having no RN present. This deficiency was confirmed by the Nursing Home Administrator and the DON.
The facility did not meet the required RN staffing ratio of 1 RN per 250 residents during overnight shifts on two days. With 109 residents, the RN ratios were 0.88 and 0.81, falling short of the mandated levels. This was confirmed by staffing documents and the DON.
The facility did not meet the required RN to resident ratio of 1:250 during the night shift for seven consecutive nights, with no RNs on duty despite a census of 32 to 34 residents. This staffing deficiency was confirmed by facility records and an interview with the Nursing Home Administrator.
The facility did not meet the required RN staffing ratio during an evening shift, with only 0.49 RNs available for 107 residents, instead of the required 1.00 RN. This deficiency was confirmed by the Nursing Home Administrator.
Failure to Meet Minimum RN Staffing Requirements
Penalty
Summary
The facility failed to comply with Pennsylvania state regulations requiring a minimum of one registered nurse (RN) per 250 residents on all shifts. A review of the facility's nursing staff ratio for the week of July 29, 2025, through August 5, 2025, showed that on two separate shifts, the required RN coverage was not met. Specifically, there was no RN coverage for the entire night shift on July 31, 2025, and no RN coverage for the entire evening shift on August 2, 2025, despite a minimum of 8.0 hours being required for each shift. These findings were discussed with the facility's administrator.
Plan Of Correction
No negative outcomes occurred due to this deficient practice. DON/designee will review and approve all schedules to ensure one RN is scheduled for each shift. DON/designee will audit staffing daily for 4 weeks, then weekly for 2 months, reporting results to the QA Committee. Noncompliance will be corrected immediately.
Failure to Meet RN Staffing Ratios on Overnight Shifts
Penalty
Summary
The facility failed to meet the minimum nursing staff to resident ratios of one Registered Nurse (RN) per 250 residents during the overnight shift for five consecutive nights from March 6, 2025, to March 10, 2025. A review of the nursing schedules revealed that on these dates, the facility provided significantly fewer RN service hours than the required 8 hours per shift, despite having a resident census ranging from 48 to 50. Specifically, the facility provided only 1.59 hours on March 6, 0.83 hours on March 7, 0.75 hours on March 8, 1.13 hours on March 9, and 0.90 hours on March 10. This deficiency was confirmed in an interview with the Administrator and Director of Nursing on March 19, 2025.
Plan Of Correction
1. The facility reviewed the RN ratios from March 6, 2025 through March 10, 2025. No grievance or residents care were affected on those dates due to staffing ratios. 2. Other days were reviewed to see if ratios were met and if care levels were affected. 3. Scheduling coordinator will be educated on RN ratios for day shift, evening shift, and night shift. Facility will attempt with every reasonable resource to add an LPN in place of the RN due to the waiver related to our building size to ensure ratios are met. 4. DON/designee will conduct daily audits to verify nursing ratios for all shifts weekly x 4 weeks. Results will be presented to QAPI.
Failure to Meet RN Staffing Requirements on Overnight Shifts
Penalty
Summary
The facility failed to comply with the regulation requiring a minimum of one registered nurse (RN) per 250 residents during all shifts. This deficiency was identified during a review of nursing staffing hours and staff interviews, which revealed that the facility did not meet the required RN-to-resident ratio on the overnight shift for eight out of the 21 days reviewed. Specifically, on several dates between November 2024 and February 2025, the facility had fewer RNs than required, with some nights having no RN present at all. The Nursing Home Administrator and the Director of Nursing confirmed the facility's failure to meet the regulatory RN-to-resident ratios during an interview on February 6, 2025.
Plan Of Correction
1. Facility can not retroactively correct. 2. Facility can not retroactively correct. Facility will continue to recruit and retain RN staff through a variety of services. 3. NHA/Designee will educate the scheduler and DON on state regulation. DON or designee will conduct review of staffing deployment assignments daily to ensure the staffing ratio is being met for a period of 4 weeks and a weekly review x 2 months. Results of the audit will be presented for review and recommendations at the monthly QAPI meeting.
Failure to Meet RN Staffing Requirements
Penalty
Summary
The facility failed to meet the required minimum staffing ratio of one Registered Nurse (RN) per 250 residents during all shifts on two specific days. On January 24 and 25, 2025, during the overnight shifts, the facility had 109 residents but did not have the required RN staffing levels, with ratios of 0.88 and 0.81 RNs, respectively. This deficiency was confirmed through a review of staffing documents and an interview with the Director of Nursing, who acknowledged the shortfall in meeting the mandated RN staffing ratio on those dates.
Plan Of Correction
1. Facility cannot retroactively correct staffing deficiencies. 2. All residents are at risk for staffing levels that fail to meet minimum ratio requirements. 3. Facility continues to use recruiting services to fulfill staffing needs. Re-education will be provided to licensed nursing staff regarding staffing requirements and ratios, as well as education to ensure they do not leave the building before their relief has arrived. Facility continues to offer bonuses, use of agency, and mandate as needed to meet requirements. 4. NHA/DON will monitor daily staffing needs to ensure adequate licensed staffing is met. Audits will be reviewed at QAPI for ongoing compliance and quality assurance.
Failure to Meet RN Staffing Requirements
Penalty
Summary
The facility failed to meet the required Registered Nurse (RN) to resident ratio of 1 RN per 250 residents during the night shift for seven consecutive nights. Specifically, from January 20 to January 26, 2025, the facility did not have any RNs on duty during the night shift, despite having a census ranging from 32 to 34 residents, which necessitated at least one RN per shift. The absence of RNs on these nights was confirmed by a review of the facility's weekly staffing records and an interview with the Nursing Home Administrator. No additional higher-level staff were available to compensate for this deficiency, leading to non-compliance with the staffing regulation effective July 1, 2023.
Plan Of Correction
Step 1. The facility cannot retroactively provide the minimum number of Registered Nurses hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated Registered Nurse ratio hours. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum staffing of Registered Nurses for the facility. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum Nurse Aide hours needed for the facility. Audits will be completed 3x/week weekly x 4 and then monthly x 2. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
RN Staffing Shortage During Evening Shift
Penalty
Summary
The facility failed to meet the regulatory requirement of having a minimum of one Registered Nurse (RN) per 250 residents during the evening shift on one of the days reviewed. Specifically, on January 18, 2025, the facility had a census of 107 residents but only 0.49 RNs were on duty, whereas 1.00 RN was required. This staffing shortage was confirmed by the Nursing Home Administrator during a telephone interview on January 27, 2025.
Plan Of Correction
Plan of Correction: P 5540 Nursing Services 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Nursing Home Administrator/NHA or designee to in-service staffing coordinator, staff educator, DON/director of nursing and assistant director of nursing and charge nurses on the state required minimum staffing ratios for registered nurses. 2. How the care community will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. NHA/designee to conduct staffing meetings 3 times/week to ensure the state required minimum staffing ratios for registered nurses are met throughout the week, weekends and holidays. 3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. NHA/designee to review staffing sheets 3x weekly to ensure the state required minimum staffing ratios for registered nurses are met for the day/ shifts prior. Staffing meeting includes discussion of open shifts, vacation coverage, review of current nursing staff schedule and coverage needed to meet state required registered nurse ratio and PPD, the interviews scheduled, new hires and orientation date. NHA/ designee to utilize corporate recruitment platform and Indeed for job applicants, attend job fairs, corporate talent acquisition specialist, newspaper ads, employee referral bonus program and tuition reimbursement for recruitment efforts. Registered Nurses are offered call-in bonus pay and incentive programs for picking up additional shifts. NHA or designee will host open interview hours to increase recruitment efforts. The admission team will review potential admissions based on the ability to meet the care needs of the residents and meet minimum staffing needs. 4. How will the corrective action(s) be monitored to ensure that deficient practice will not recur, i.e., what quality assurance program will be put into place; and NHA/designee to meet 3x weekly with DON/designee and staffing coordinator to review registered nurse's ratios. Staffing meetings will continue to ensure sustained compliance. All audits will be reviewed through the quality performance and improvement process. 5. Dates when corrective action will be completed. March 3, 2025
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