Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide-to-resident ratios as mandated by the regulation effective July 1, 2024. The regulation stipulates a minimum of one nurse aide per 10 residents during the day, one per 11 residents in the evening, and one per 15 residents overnight. However, during the specified periods of August 9, 2024, to August 14, 2024, December 21, 2024, to December 27, 2024, and January 24, 2025, to January 30, 2025, the facility consistently fell short of these staffing requirements. For instance, on August 9, 2024, the evening shift required a minimum of 149.32 hours, but only 144.0 hours were worked, and the night shift required 109.5 hours, but only 96.0 hours were worked. The deficiency was further evidenced by similar shortfalls on other days within the specified periods. On December 22, 2024, the day shift required 151.50 hours, but only 96.0 hours were worked. On January 24, 2025, the day shift required 166.40 hours, but only 120.0 hours were worked, and the night shift required 110.93 hours, but only 80.0 hours were worked. These findings were discussed with the facility's administration on January 31, 2025, indicating a pattern of non-compliance with the staffing regulations over multiple weeks.
Plan Of Correction
Step 1 The facility is currently staffed at or above state minimum requirements. Step 2 The facility will partner with agencies to ensure that nurse aid requirements are met and to better manage last-minute callouts and unexpected events related to staffing. Step 3 The staff coordinator and other administrative staff involved in coordinating staffing educated on federal and state CNA staffing requirements. Step 4 The NHA or designee will audit staffing levels weekly x4 and monthly x2. Results will be reviewed during the monthly QAPI meeting.