Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides (NAs) on multiple shifts over a seven-day period from February 3, 2025, to February 9, 2025. Specifically, the facility did not provide the mandated one NA per 10 residents during the daylight shift on six out of seven days, one NA per 11 residents during the evening shift on four out of seven days, and one NA per 15 residents during the night shift on three out of seven days. This deficiency was confirmed through a review of staffing documents and an interview with the Assistant Director of Nursing, who acknowledged the shortfall in staffing on the specified shifts.
Plan Of Correction
The facility cannot correct that nurse aide staffing ratios were not met on 2/3/25, 2/4/25, 2/5/25, 2/6/25, 2/7/25, 2/8/25, and 2/9/25. The facility will ensure that nurse aide staffing ratios are met every shift. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5520 and ensuring nurse aide staffing ratios are met each shift. Daily staffing ratios will be reviewed at daily staffing meetings. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure nurse aide staffing ratios are being met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.