Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required Nurse Aide (NA) staffing ratios during the evening shift on two specific days, February 2 and February 4, 2025. On February 2, with a census of 97 residents, the facility employed 7.96 NAs, falling short of the required 8.82 NAs. Similarly, on February 4, with a census of 95 residents, 8.13 NAs were employed, whereas 8.64 were required. This deficiency was confirmed by the Nursing Home Administrator during a telephone interview on February 6, 2025, acknowledging the failure to meet the minimum NA ratios on the specified days and shifts.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. The facility cannot correct that the nurse aide staffing ratio was not met on 2/2 and 2/4/25. 2. System changes will be put into place to ensure minimum requirements to be put into place will include: 3. Facility currently has multiple nursing assistant staff members in the onboarding process to start employment at the facility. 4. All nursing assistant positions are actively posted in recruitment. 5. Bonuses are offered on an as needed basis to nursing assistants. 6. Staff are mandated as appropriate. 7. Call offs will continue to be monitored, and disciplines will be issued, as appropriate. 8. When call offs occur, all available staff members will be called to ask if they will fill the vacancy to ensure the appropriate staffing levels. 9. On a daily basis, the Director of Nursing and/or Administrator reviews the ability to take admissions based on the staffing numbers; if not meeting staffing numbers, admissions are held for the day. 10. All RN's (Registered Nurse's) and staffing coordinator will be educated on staffing ratios. Education will be done by the Director of Nursing or designee. 11. RN supervisors will be educated that they will need to mandate staff for call off to make sure facility does not fall below staffing ratios per DOH (Department of Health) regulations. 12. Daily meetings will be held, with Director of Nursing, admission coordinator, staffing coordinator, and Administrator to review schedule with ratios. 13. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing ratios, the nursing supervisor/or designee will call off duty facility staff, will notify Director of Nursing, and will utilize pick-up bonuses. DON (Director of Nursing) or designee will monitor staffing ratios/PPD by reviewing the current working schedule and assignment sheets prior to the day and after the day is complete to ensure compliance daily x 10 days then weekly x 6 weeks, then Q (once) monthly x2 to ensure compliance. This will be reviewed at the Quarterly QAPI (Quality Assurance/Performance Improvement) meetings.