Nurse Aide Staffing Deficiency
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) to resident ratio during the day shift for six out of 21 days reviewed. Specifically, on the dates of 12/22/24, 12/23/24, 12/24/24, 12/25/24, 12/28/24, and 12/29/24, the facility did not have enough NAs working to meet the regulatory requirement of one NA per 10 residents. For instance, on 12/22/24, with a census of 67 residents, only 5.90 NAs worked when 6.70 were required. Similarly, on 12/24/24, with a census of 69 residents, only 5.09 NAs worked when 6.90 were required. These shortages were confirmed by the Nursing Home Administrator and Director of Nursing during an interview on 12/30/24.
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 12/22, 12/23, 12/24, 12/25, 12/28 and 12/29. 2. Weekend nursing supervisors and scheduler will be re-educated regarding the state ratios by the Director of Nursing/ designee. 3. Schedule with ratios are reviewed at our stand-up meeting. 4. 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, notify Director of Nursing and will utilize pick-up bonuses. 5. All nursing positions are actively posted in recruitment and are sponsored ads. 6. Facility will hold a recruitment/retention committee. 7. Facility will hold open interviews. 8. Call offs will continue to be monitored and disciplines will be issued, as appropriate. 9. Director of Nursing/designee will audit staffing daily for three weeks and monthly for three months to ensure staffing ratios are being met. 10. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations. 11. Accepting new admissions will depend on staffing levels.