Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios on multiple occasions during the review period from December 18, 2024, to December 31, 2024. Specifically, the facility did not have enough NAs on the day shift for four days, the evening shift for four days, and the overnight shift for one day. The required ratio of one NA per 10 residents during the day, one NA per 11 residents during the evening, and one NA per 15 residents overnight was not met. For instance, on December 19, 2024, with a census of 96 residents, only 9.43 NAs worked when 9.60 were required for the day shift. The deficiency was confirmed during a telephone interview with the Nursing Home Administrator on January 3, 2025, who acknowledged that the facility did not meet the minimum NA ratios on the specified days and shifts. The report provides detailed staffing numbers for each day where the facility fell short of the required NA ratios, highlighting the specific shortages in staffing that led to the deficiency.
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 12/19, 12/22, 12/24, 12/25, 12/26, 12/28, and 12/29/24. 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 staff members in the onboarding process to start employment at the facility. 4. All nursing positions are actively posted in recruitment. 5. Holding open interview day. 6. Bonuses are offered on an as needed basis. 7. Staff are mandated as appropriate. 8. Call offs will continue to be monitored, and disciplines will be issued, as appropriate. 9. 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. 10. On a daily basis, the facility reviews the ability to take admissions based on the staffing numbers. 11. All RN's and staffing coordinator will be educated on staffing ratios. 12. 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 regulations. 13. Daily meetings will be held to review schedule with ratios. 14. 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 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 monthly x2 to ensure compliance. The DON (Director of Nursing), NHA (Nursing Home Administrator), and staffing coordinator will be in the daily meetings to monitor staffing ratios. This will be reviewed at the Quarterly QAPI meetings.