Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides (NAs) on multiple occasions between December 16, 2024, and January 1, 2025. Specifically, the facility did not provide the mandated number of NAs per resident during the daylight, evening, and night shifts on several days. For the daylight shift, the facility was short on seven days, with actual hours worked falling below the required hours. Similarly, the evening shift was understaffed on seven days, and the night shift on eight days, with actual hours consistently below the required staffing levels. This deficiency was confirmed by the Nursing Home Administrator during an interview on January 3, 2025.
Plan Of Correction
1. The facility will ensure state-required nurse aide ratios are met for all shifts. The facility cannot correct that nurse aide staffing ratios were not met on the following dates: Daylight shift on (12/25/24 through 12/30/24 and 1/1/25), evening shift on (12/22/24 and 12/26/24 through 12/31/24), and night shift on (12/16/24, 12/18/24, 12/21/24, 12/22/24, and 12/26/24 through 12/29/24). 2. The facility will ensure that nurse aide staffing ratios of 1:10 on day shift, 1:11 on the evening shift and 1:15 on night shift are met. Open positions will continue to be posted on platforms to attract new hires. We will continue with a weekly retention and recruitment meeting. 3. The Nursing Home Administrator will re-educate the Director of Nursing, HR Director/Scheduler and RN Supervisors on regulation P5510 and ensuring nurse aide staffing ratios are met each shift. Staffing ratios will be reviewed at our daily staffing meeting to ensure ratios are scheduled to be met. The RN Nursing Supervisors will continue to review shift staffing ratios on evenings and weekends. If the facilities projections to meet ratios fall below required ratios due to call offs, No Call No Shows etc, the RN Supervisors will be responsible to ask currently working staff to pick up a shift, call off duty personnel and/or call extra support staff via staffing agencies to assist as necessary. 4. The Nursing Home Administrator/designee will audit staffing sheets daily for three months to ensure nurse aide staffing ratios are being met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits. 5. Date of compliance: 1/20/2025.