Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident staffing ratios on several occasions, as evidenced by a review of nursing schedules, staffing information, and staff interviews. On November 28, 2024, the facility had a census of 75 residents, necessitating 7.50 NAs during the day shift, but only 7.03 NAs were available. On November 29, 2024, the evening shift required 6.82 NAs, but only 5.83 NAs were present. Additionally, the overnight shift on the same day required 5.00 NAs, but only 4.40 NAs were available. Further deficiencies were noted on December 8, 2024, and February 2, 2025, where the overnight shifts were understaffed with 4.60 and 4.90 NAs, respectively, against the required numbers. The Nursing Home Administrator confirmed these staffing deficiencies during an interview on February 6, 2025. The report indicates that no additional higher-level staff were available to compensate for the shortfall in nurse aides, leading to non-compliance with the staffing regulations effective from July 1, 2024. The facility's inability to meet the mandated staffing ratios on these specific days highlights a failure to adhere to the regulatory requirements for adequate resident care.
Plan Of Correction
1. No individual resident was named or harmed. 2. Any resident has potential to be harmed by failure to have adequate staffing. 3. Facility has contracted with temporary agencies to fill upcoming vacancies. In the case of call-offs, there is not often adequate time to find another coverage. Two upcoming nurse aide training classes will yield newly trained aides to fill vacancies on a permanent basis. Facility continues to advertise openings and opportunities. 4. Review of the daily schedule with nursing administration and Administrator continue. Weekly audits to ensure compliance of staffing ratios will be done x 4 weeks, then monthly x 2. Reviews submitted to the Quality Assurance team for review. Administrator to monitor for compliance.