Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident staffing ratios as mandated by regulations effective July 1, 2024. The regulation requires a minimum of one NA per 10 residents during the day, one NA per 11 residents during the evening, and one NA per 15 residents overnight. The deficiency was identified through a review of nursing schedules and staffing information, which revealed that the facility did not meet these staffing ratios for several days across different shifts in November and December 2024. Specifically, the facility was found to be understaffed on the day shift for seven out of 21 days, on the evening shift for six out of 21 days, and on the overnight shift for 14 out of 21 days. For instance, on November 17, 2024, the facility had a census of 80 residents, requiring 8.00 NAs during the day shift, but only 7.45 NAs were available. Similar discrepancies were noted on other days, with the number of NAs falling short of the required numbers based on the facility's census data. The deficiency was confirmed through an interview with the Nursing Home Administrator, who acknowledged that the facility did not meet the required staffing ratios on the specified days. No additional higher-level staff were available to compensate for these deficiencies, indicating a systemic issue in maintaining adequate staffing levels to meet regulatory requirements.
Plan Of Correction
1. The facility will continue to take measures to adequately provide staff to ensure the needs of the residents are met. 2. The facility will continue to take measures to adequately provide staff to meet the required Certified Nursing Assistant to resident ratios. When total certified nursing assistant to resident ratios is unable to be met, the facility will reevaluate the scheduling of new admissions. The Nursing Home Administrator or designee will provide education on minimum staffing ratios to the Registered Nurse Supervisor and Scheduler who are responsible to maintain adequate staffing and staffing ratios. 3. The Nursing Home Administrator or designee will audit daily schedules to ensure minimum number of staff are scheduled to meet the needs of the residents weekly times two weeks and monthly times two months. 4. The results will be reviewed at Quality Assurance Performance Improvement meetings until substantial compliance has been met.