Staffing Deficiency in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the state-required minimum staffing levels for nurse aides across multiple shifts over a three-week period. Specifically, the facility did not provide the required number of nurse aides per resident on nine daylight shifts, four evening shifts, and seven midnight shifts. The deficiency was identified through a review of nursing schedules and staffing documents, which showed that the number of nurse aides on duty was consistently below the required minimums. For example, on the daylight shift of December 24, 2024, the facility needed 7.90 nurse aides for a census of 79 residents but only had 6.25 nurse aides available. The Nursing Home Administrator confirmed these staffing shortfalls during an interview, acknowledging the facility's failure to meet the state-mandated nurse aide-to-resident ratios. The report does not mention any specific residents affected by this deficiency or any immediate consequences resulting from the staffing shortages. The focus is solely on the facility's inability to comply with the staffing requirements as outlined by state regulations.
Plan Of Correction
1. The facility is unable to retroactively correct the staffing ratio for days: 12/22/24, 12/24/24, 12/28/24, 1/10/25, 1/11/25, 1/12/25, 1/13/25, 1/14/25, 1/15/25, 1/16/25, 1/19/25, 1/29/25, and 1/21/25. 2. The facility will schedule CNA's to state ratio. Call outs will be monitored by NHA/DON and/or designee. Facility staff as well as staffing agencies will be utilized to facilitate replacement/procurement of staff. 3. NHA or designee will educate the scheduling coordinator on the requirements of CAN ratios of 1 to for day shifts, 1 to for afternoon shifts and 1 to for midnight shifts. The staffing ratio will be monitored weekly x4 weeks. 4. NHA or designee will randomly audit the staffing ratio weekly x4 weeks. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring or changes needed.