Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required staffing ratios for nurse aides across all shifts over a seven-day period. Specifically, the facility did not maintain the mandated minimum of one nurse aide per 10 residents during the day, one per 11 residents during the evening, and one per 15 residents overnight. This deficiency was identified through a review of nursing staff schedules, punch reports, and staff interviews. On each day from November 28 to December 4, 2024, the facility's staffing levels fell short of the required hours of nurse aide care based on the facility census data. For instance, on November 28, 2024, the facility had a census of 207 residents, necessitating 141.14 hours of nurse aide care during the evening shift, but only 128.00 hours were provided. Similarly, on December 1, 2024, with a census of 210 residents, the facility required 157.50 hours of nurse aide care during the day shift, yet only 80.00 hours were provided. These discrepancies were consistent throughout the week, with significant shortfalls in nurse aide hours across various shifts, indicating a systemic issue in maintaining adequate staffing levels.
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.