Facility Fails to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the minimum nursing staff to resident ratios as required by regulations effective July 1, 2023. Specifically, the facility did not have the required number of nurse aides per residents during various shifts from March 6, 2025, to March 10, 2025. On the day shift, the facility was short of the required nurse aide hours on March 7, March 8, and March 9, 2025. Similarly, the evening shift was understaffed on March 7 and March 9, 2025. The overnight shift also did not meet the required staffing levels on March 6 and March 8, 2025. The deficiency was confirmed through a review of nursing schedules and an interview with the Administrator and Director of Nursing on March 19, 2025. The facility's failure to meet the staffing requirements was evident in the shortfall of nurse aide service hours compared to the minimum required hours for the resident census on the specified dates. This lack of adequate staffing was acknowledged by the facility's administration during the interview.
Plan Of Correction
1. The facility reviewed the CNA ratios from March 6, 2025 through March 10, 2025. No grievance or residents care were affected on those dates due to staffing ratios. 2. Other days were reviewed to see if ratios were met and if care levels were affected. 3. Scheduling coordinator will be educated on CNA ratios for day shift, evening shift, and night shift. Facility will attempt with every reasonable resource to ensure ratios are met. 4. DON/designee will conduct daily audits to verify CNA ratios for all shifts weekly x 4 weeks. Results will be presented to QAPI.