Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on two specific shifts out of 63 reviewed. On September 4, 2024, during the night shift, the facility had 3.67 nurse aides instead of the required 4.27 for a census of 64 residents. Similarly, on December 29, 2024, during the day shift, the facility had 6.17 nurse aides instead of the required 6.40 for the same census. No additional higher-level staff were available to compensate for these deficiencies, resulting in non-compliance with the staffing regulations effective July 1, 2024, which mandate a minimum of 1 nurse aide per 10 residents during the day, 1 per 11 residents in the evening, and 1 per 15 residents overnight.
Plan Of Correction
The facility cannot retroactively correct past Nursing Aide ratios. The facility will continue to take measures to adequately provide nurse-aide staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff with the required nurse aide to resident ratios. These measures include continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign-on bonuses. The Director of Nursing/designee will continue to educate minimum staffing ratios to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios. The Director of Nursing/designee will audit the daily schedules to ensure that the minimum number of nurse aide staff to resident ratios have been scheduled. The results of the audits will be reviewed at the facility's QAPI meeting for recommendations.