Failure to Meet RN to Resident Ratios
Penalty
Summary
The facility failed to meet the minimum licensed registered nurse (RN) to resident ratios as required by regulation effective July 1, 2023. Specifically, the review of nursing schedules for a 21-day period from January 4 through 24, 2025, revealed that the facility did not have at least one RN per 250 residents during all shifts on two of those days. This deficiency was identified based on the examination of nursing time schedules.
Plan Of Correction
5540 1. The facility is unable to retroactively ensure RN to resident ratios are met on the cited dates. 2. The facility will maintain RN to resident ratios. 3. The DON was re-educated on ensuring RN to resident ratios are met. There will be a daily staffing meeting to review the current day and future dates RN ratios. 4. The NHA or designee will complete an audit of RN 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.