Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide staffing ratios as per the regulation effective July 1, 2023. Specifically, the facility did not maintain a minimum of one nurse aide per 12 residents during the day and evening shifts, and one nurse aide per 20 residents overnight. During the period from January 11 to January 25, 2025, the facility was found to be non-compliant on January 19, 2025, for the day shift, and on January 22, 2025, for the night shift. The Nursing Home Administrator (NHA) confirmed during an interview on February 4, 2025, that the facility did not meet the minimum required staffing ratios on the identified dates.
Plan Of Correction
1. The facility failed to maintain nurse aide ratios on multiple days and shifts. 2. Facility will need to maintain a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening and 1 nurse aide per 15 residents overnight. Calculation of shift ratios will be completed and reviewed daily for accuracy by the scheduler or designee. 3. The scheduler and nursing supervisors will be educated on these ratios. For staff call offs, every effort will be made to replace the call off using resources available including communicating with staff to replace the vacancy. Staffing patterns are projected at least one week in advance to enable ongoing efforts to fill any vacant shifts. 4. Daily audits will be conducted for 1 month. Audits will be conducted by the scheduler or designee. Results of audits will be reviewed by the QAPI committee. 5. Date Certain is 4-4-25.