Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to comply with the mandated nurse aide (NA) to resident ratios over a 21-day period from January 4 through 24, 2025. Specifically, the facility did not meet the required ratio of one NA per ten residents during the day shift on 15 days, one NA per 11 residents during the evening shift on 18 days, and one NA per 15 residents during the night shift on four days. This deficiency was identified through a review of nursing schedules, indicating a consistent shortfall in staffing levels across multiple shifts and days, thereby failing to meet the regulatory requirements effective from July 1, 2024.
Plan Of Correction
1. The facility is unable to retroactively ensure NA to resident ratios are met on the cited dates. 2. The facility will maintain NA to resident ratios. 3. The DON was re-educated on ensuring NA to resident ratios are met. There will be a daily staffing meeting to review the current day and future dates NA ratios. 4. The NHA or designee will complete an audit of NA to resident ratios daily x 7 days then weekly x 4 weeks to ensure ratios are met. Results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.