Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident staffing ratios as mandated by regulations effective July 1, 2024. The deficiency was identified through a review of nursing schedules, staffing information, and staff interviews. Specifically, the facility did not provide the required number of NAs per residents during the day, evening, and night shifts for several days between January 19 and February 11, 2025. This failure was observed on 12 out of 21 days for the day shift, 11 out of 21 days for the evening shift, and 14 out of 21 days for the night shift. The review of facility census data revealed specific instances where the number of NAs scheduled was below the required ratio. For example, on January 19, 2025, with a census of 56 residents, the facility required 5.60 NAs during the day shift but only provided 5.30 NAs. Similar discrepancies were noted on other days, such as January 20, 2025, where 4.57 NAs were provided against a requirement of 5.40 NAs. These staffing shortages were consistent across multiple days and shifts, indicating a systemic issue in meeting the staffing requirements. Interviews with the Nursing Home Administrator confirmed the facility's failure to meet the required staffing ratios. The report does not mention any additional higher-level staff available to compensate for these deficiencies, further highlighting the staffing shortfall. The lack of adequate staffing could potentially impact the quality of care provided to residents, although the report does not explicitly state any direct consequences or risks resulting from the deficiency.
Plan Of Correction
Unable to retroactively correct staffing ratios for Certified Nurse Aides (CNAs) on dates noted. Residents who receive nursing care services have the potential to be affected. Recruitment and retention activities: 1.) Generous Sign on Bonus 2.) Flexible Scheduling 3.) Benefits Package for full-time employees 4.) Wage analysis completed 5.) "Kudos" recognition program 6.) Referral bonus 7.) Agency Contracts 8.) Administrative Coverage Monitoring will be captured through auditing staff schedules. Audit will be conducted daily for 12 weeks. The audits will be conducted by the Staffing Coordinator or designee. Results of the audits will be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.