Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to comply with the mandated nurse aide (NA) to resident ratios as specified by the regulation effective July 1, 2024. A review of nursing schedules for 21 days across September, October, and December 2024 revealed that the facility did not meet the required staffing levels on multiple occasions. Specifically, the day shift ratio of one NA per ten residents was not met on nine days, and the evening shift ratio of one NA per eleven residents was not met on eight days. These deficiencies were identified through a detailed examination of the nursing time schedules, indicating a consistent shortfall in staffing levels over the reviewed periods.
Plan Of Correction
1 & 2. Education given to the Nurse Scheduler on the Certified Nursing Aides ratio requirements of 1 NA to 10 residents on day shift, 1 NA to 11 residents on evening shift, and 1 NA to 15 residents on night shift. 3. The facility is actively recruiting Certified Nurses Aides; utilizing Nurse Agency to supplement Certified Nursing Aides; recruiting Nursing Aides for classes and training with intent to hire when qualified; and staffing meetings conducted in attempts to maintain State Mandated ratios for Certified Nursing Aides. 4. The DON and/or designee will randomly audit the staffing schedules to ensure the appropriate number of Certified Nursing Aides are scheduled to achieve compliance. The results of the audits will be submitted to the QA Committee to determine if additional action is necessary.