Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on multiple occasions, as evidenced by a review of staffing records. Specifically, on the day shift, the facility did not provide the minimum required number of nurse aides on December 4, 7, 8, and 10, 2024. The staffing levels were below the required ratios for the census on these dates, with the facility having fewer nurse aides than needed to meet the 1:10 ratio. Similarly, on the evening shift, the facility did not meet the 1:11 ratio on December 4, 7, and 9, 2024, with staffing levels again falling short of the required number of nurse aides for the census. Additionally, the night shift staffing was inadequate on December 7 and 10, 2024, where the facility failed to meet the 1:15 ratio. On these dates, the number of nurse aides was insufficient for the census, and no additional higher-level staff were available to compensate for this deficiency. An interview with the Director of Nursing confirmed that the facility did not meet the required nurse aide to resident ratios on the specified dates.
Plan Of Correction
P5520 CNA Staffing Ratios 1. The facility is unable to correct CNA staffing ratios for December 4, 2024, December 7, 2024, December 8, 2024, December 9, 2024 and December 10, 2024. 2. No other dates were identified during the survey. 3. To prevent this from reoccurring, the DON/designee completed education with the nursing supervisors and scheduler to ensure the CNA staffing ratios are adequate for the census. Staffing will be based on current census and supervisors or scheduler will contact other staff to cover call offs. Recruitment of nursing staff will continue via facility website, indeed, social media websites, job fairs and off-site recruiters. Agency will be utilized for open shifts as needed and available. 4. To monitor or maintain ongoing compliance, the DON/designee will audit the schedule weekly x 4 weeks and biweekly x 4 to ensure the CNA staffing ratio has been met. Results will be reviewed at the QAPI meeting. 5. 1/16/2025