Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to comply with the mandated nurse aide (NA) to resident ratios as specified in the regulation effective July 1, 2024. During a review of nursing time schedules from December 2 through 22, 2024, it was found that the facility did not meet the required staffing levels on several occasions. Specifically, the facility did not maintain the minimum ratio of one NA per 10 residents during the day shift on December 8, 9, 14, 15, 20, and 21, 2024. Additionally, the facility failed to meet the minimum ratio of one NA per 15 residents during the night shift on December 8, 9, 10, 14, and 15, 2024. These deficiencies were identified over a period of seven out of the 21 days reviewed.
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. The facility continues to focus on recruitment and retention activities. Valley Manor will hold staffing meetings throughout the week to monitor staffing ratio compliance. The NHA or designee will educate the 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 for 4 weeks, bi-weekly for 2 weeks, and monthly for 1 month. The results will be reviewed at the QAPI meeting.