Staffing Deficiencies in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on nine out of twenty-one reviewed shifts. Specifically, the facility did not provide the minimum number of nurse aides needed for the day, evening, and night shifts according to the census on several dates in January 2025. For instance, on January 23, 2025, the evening shift had 9.1 nurse aides instead of the required 10.27 for a census of 113. Similarly, on January 24, 2025, the day shift had 10.73 nurse aides instead of the required 11.40 for a census of 114. These staffing deficiencies were confirmed during an interview with the Nursing Home Administrator on January 30, 2025, who acknowledged the facility's failure to meet the required nurse aide to resident ratios on the specified dates. No additional higher-level staff were available to compensate for these deficiencies.
Plan Of Correction
1. Facility cannot retroactively correct nurse aide staffing ratio. 2. Director of Nursing/Designee will conduct an initial audit of the next two weeks' schedule to determine if nurse aide ratio is in compliance. 3. Director of Nursing or Designee will re-educate the scheduler on the proper nurse aide staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made. Incentives will be put in place for staff to pick up shifts, not call out, and assist with recruiting efforts. 4. Director of Nursing/Designee will conduct random audits of nurse aide staffing weekly for four weeks, then monthly for two months thereafter to verify proper nurse aide ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee, and changes will be made as necessary.