Failure to Meet Nurse Aide to Resident Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios on three occasions over a 14-day period. Specifically, the facility did not maintain the minimum ratio of one NA per ten residents during the day shift on December 25, 2024, and January 1, 2025. Additionally, the facility did not meet the required ratio of one NA per eleven residents during the evening shift on December 31, 2024. These deficiencies were identified through a review of nursing schedules and were confirmed by the Administrator during an interview on January 13, 2025.
Plan Of Correction
Administrator, Assistant Administrator, and Nursing Administration including Nursing Supervisors will review staffing ratios and PPD requirements. The DON or designee will re-educate the Nursing Supervisors and nursing schedulers on the ratio and PPD requirements. A daily audit of nursing hours/ratios will be completed by the DON or designee for 7 days, then weekly for three weeks, and then every other week for 4 weeks. Results of the audits will be reported to the QAPI committee.