Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on 15 out of 21 shifts reviewed. The regulation mandates a minimum of 1 nurse aide per 10 residents during the day, 1 per 11 residents in the evening, and 1 per 15 residents overnight. However, the facility's staffing records showed consistent understaffing across multiple shifts. For instance, on February 4, 2025, the day shift had 7.13 nurse aides instead of the required 7.50 for a census of 75, and the evening shift had 5.23 nurse aides instead of the required 6.91 for a census of 76. Similar deficiencies were noted on subsequent days, with the facility failing to provide the necessary number of nurse aides based on the resident census. The deficiency was confirmed during an interview with the Nursing Home Administrator on February 11, 2025, who acknowledged that the facility did not meet the required nurse aide to resident ratios on the specified dates. Additionally, there were no higher-level staff available to compensate for the shortage of nurse aides during these shifts. This lack of adequate staffing was observed across various shifts, including day, evening, and night, indicating a systemic issue in maintaining the mandated staffing levels.
Plan Of Correction
Facility cannot retroactively correct past CNA to resident ratios. Facility is focusing on retention of existing nursing assistants and recruitment of new nursing assistants, through efforts of the Human Resources Manager and Nursing Administration. A corporate team has been identified to assist with recruiting efforts for nursing positions. Union SEIU has extended a free tuition for nurse aides as hired in ancillary positions. The scheduler has been educated regarding the CNA ratio regulatory requirements. Calculation of the daily CNA ratios will be completed and reviewed for accuracy by the scheduler/designee. Facility acquired OnShift platform for scheduling. Application alerts scheduler, DON, and Administrator when nursing ratios are not scheduled to be met so corrections, additions etc. can be made to meet minimum requirements. Daily ratios will be audited weekly X 4 weeks then monthly X 2 months. Audits will be reviewed at QAPI for compliance.