Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to comply with the required nurse aide (NA) to resident ratios over a 21-day period from February 28 through March 20, 2025. Specifically, the facility did not meet the minimum staffing levels on multiple occasions across different shifts. During the day shift, which runs from 7:00 a.m. to 3:00 p.m., the facility did not maintain the required ratio of one NA per ten residents on March 1, 2, 8, 14, 15, 16, 18, and 20, 2025. Similarly, during the evening shift from 3:00 p.m. to 11:00 p.m., the facility failed to meet the ratio of one NA per eleven residents on February 28, 2025, and March 2, 3, 14, 17, and 20, 2025. Additionally, the night shift, which is from 11:00 p.m. to 7:00 a.m., did not meet the required ratio of one NA per fifteen residents on March 3 and 14, 2025. These deficiencies indicate a consistent shortfall in staffing levels necessary to meet regulatory requirements.
Plan Of Correction
All residents received care in accordance with their plan of care and attending physician order. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.