Staffing Deficiency in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios on several occasions, as evidenced by a review of nursing staffing documents and staff interviews. Specifically, on three out of six days reviewed, the facility did not have the minimum of one NA per 10 residents during the day shift. On January 29, 2025, with a census of 69 residents, only 6.07 NAs worked when 6.90 were required. On February 2, 2025, with 68 residents, 6.07 NAs worked when 6.80 were required. On February 3, 2025, with 69 residents, only 4.89 NAs worked when 6.90 were required. Additionally, on February 3, 2025, during the evening shift, the facility had a census of 68 residents but only 4.63 NAs worked when 6.18 were required. The Nursing Home Administrator confirmed these staffing shortages during an interview on February 4, 2025.
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 1/29/25, 2/2/25 and 2/3/25. There were no adverse effects to residents on the identified dates. 2. The scheduler will be re-educated regarding the state ratios by the Nursing Home Administrator/designee. 3. The Director of Nursing and RN Supervisors will be re-educated on staffing ratios by the Nursing Home Administrator/designee. 4. Twice a day staffing meetings will be held Monday through Friday to review the schedule with ratios. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing ratios, the scheduler/or designee will call off duty facility staff and will utilize pick up bonuses. 5. The facility has developed a monthly recruitment and retention committee meeting. 6. Nurse Aide positions are actively posted in recruitment. 7. Nursing Home Administrator/designee will audit staffing daily for three weeks and monthly for three months to ensure staffing ratios are being met. 8. Admission intake will be reviewed in relationship to staffing. 9. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.