Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios for 20 out of 21 days reviewed in January 2025. Specifically, the facility did not maintain the minimum staffing levels of one NA per 10 residents during the day shift, one NA per 11 residents during the evening shift, and one NA per 15 residents during the night shift. This deficiency was observed across multiple dates and shifts, indicating a consistent shortfall in staffing. The Nursing Home Administrator confirmed the failure to meet these staffing requirements during an interview conducted on February 2, 2025.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. P5520 Nurse Aide Ratio 1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the center follows staffing procedures including exhausting all possible replacements from internal staffing pool and contracted agency staff. The center continues to offer incentives, coordinate staffing schedules, and replace call offs per protocol while actively continuing to hire for all open positions and additional pool staff. 3. All registered nurses and the scheduler have been educated on the 7/01/2024 nurse aide ratio and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON/designee will audit staffing weekly x4 weeks then monthly for 2 months. Results will be reviewed by the QAPI Committee for recommendations as needed.