Staffing Deficiency in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides during the period from January 26 through February 4, 2025. Specifically, the facility did not maintain the minimum staffing ratio of one nurse aide per 10 residents during the day shift for ten days, one nurse aide per 11 residents during the evening shift for eight days, and one nurse aide per 15 residents during the night shift for two days. This deficiency was identified through a review of the facility's staffing data and was confirmed by the Nursing Home Administrator during a telephone interview on February 6, 2025.
Plan Of Correction
1. A comprehensive facility audit will be undertaken to ensure that the minimum staffing ratios for Certified Nursing Assistants (CNAs) are consistently met on a daily basis. The Recruitment Team is proactively enhancing recruitment efforts to attract additional CNAs while also assessing and adjusting wages to remain competitive with those offered by nearby healthcare facilities. 2. To support the staffing requirements, agency staff is currently being utilized to fill gaps and maintain compliance with the established minimum staffing ratios. We are actively engaging with local nursing schools to build relationships and identify potential candidates from their graduating CNA classes. This networking initiative aims to create a robust pipeline of qualified applicants. 3. In addition, the Nursing Scheduler/Designee will undergo a thorough re-education process to reinforce the importance of adhering to the minimum staffing ratios for CNAs. This training will focus on strategies and protocols to maximize staffing efficiency and ensure adequate coverage at all times. 4. To monitor compliance, the Administrator or an appointed designee will conduct regular audits aimed at confirming adherence to staffing ratios. These audits will take place daily, weekly, and then monthly for a period of three months. The findings from these audits will be meticulously compiled and submitted to the Quality Assurance and Performance Improvement (QAPI) Committee for thorough review and analysis. This ongoing evaluation will help determine the necessity for continued monitoring and any potential adjustments to our staffing strategies moving forward.