Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios as mandated by regulations effective July 1, 2024. Specifically, the facility did not maintain a minimum of one NA per 10 residents during the day shift for 21 consecutive days, from December 31, 2024, to January 20, 2025. Additionally, the facility did not meet the required ratio of one NA per 11 residents during the evening shift on 10 out of 21 days within the same period. Furthermore, the overnight shift consistently fell short of the required one NA per 15 residents for all 21 days reviewed. The review of nursing staffing documents revealed specific instances of NA shortages across all shifts. For example, on January 13, 2025, with a census of 44 residents, only 3.88 NAs worked during the day shift when 4.40 were required. Similarly, on January 12, 2025, during the overnight shift, only 2.25 NAs worked when 2.93 were required for a census of 44 residents. These staffing deficiencies were confirmed by the Nursing Home Administrator during an interview on January 22, 2025.
Plan Of Correction
1. The facility was unable to make corrective action for the (nurse aide ratio) for identified days that have already passed. All residents received care in accordance with their care plans and physician orders. 2. Director of nursing or designee will re-educate the labor manager and the Registered nurse supervisors on the 7/1/2024 requirements for Nurse Aide ratios. 3. Facility continues to offer incentives, competitive wages, and several other benefits in an effort to hire for all open positions. 4. Nursing home administrator, DON, and Labor manager will conduct daily staffing meetings Monday - Friday to review (nurse aide ratios) throughout the day, the following day, and the weekend. In the event of vacancies, the Labor Manager or designee will follow staffing policies including offering open shifts to internal staff, contracted agency staff, and offering current staff to stay extra or start earlier. 5. Director of Nursing or designee will audit daily staffing ratios and along with all steps taken to fill vacancies 5 days a week and ongoing. 6. Results of the audits will be reviewed and recorded in the monthly Quality Assurance Performance Improvement meeting.