Non-compliance with NA to Resident Ratio
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratio on one of the seven days reviewed. Specifically, on January 11, 2025, during the day shift from 7:00 a.m. to 3:00 p.m., the facility did not maintain the minimum ratio of one NA per ten residents. This deficiency was identified through a review of nursing schedules covering the period from January 10 through January 16, 2025. The Director of Nursing confirmed during an interview on January 17, 2025, that the facility did not meet the required staffing ratios on the specified day.
Plan Of Correction
The facility staffs the facility to at least meet the required staffing ratios of NAs, including the use of agency staff if necessary. When there are staff call outs, the facility attempts to call other staff in and notify agency staff as well. Facility continues to focus on recruitment and retention activities. Valley Manor will hold staffing meetings throughout the week to monitor staffing ratio compliance. NHA or designee will educate DON/ADON/ and Nursing Supervisors on state ratio staffing regulation. To monitor the corrective action and ensure that it does not recur, the DON will audit nursing staff to resident ratios weekly X4; bi-weekly X 2 and monthly X 1. The results will be reviewed at the QAPI meeting.