Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to comply with the mandated nurse aide (NA) to resident ratios as specified in the regulation effective July 1, 2024. During a review of nursing schedules over a 21-day period from February 13, 2025, to March 5, 2025, it was found that the facility did not meet the required staffing levels on three occasions. Specifically, on February 16 and February 23, 2025, the day shift (7:00 a.m. to 3:00 p.m.) did not have the minimum one NA per ten residents. Additionally, on March 3, 2025, the evening shift (3:00 p.m. to 11:00 p.m.) failed to maintain the required one NA per eleven residents. These deficiencies indicate a failure to adhere to the staffing regulations set forth for ensuring adequate care for residents.
Plan Of Correction
1. The facility staffs the facility to at least meet the required staffing ratios of NAs, including the use of agency staff if necessary. When there are staff callouts, the facility attempts to call other staff in and notify agency staff as well. Facility continues to focus on recruitment and retention activities. 2. Valley Manor will hold staffing meetings throughout the week to monitor staffing ratio compliance. 3. NHA or designee will educate DON/ADON/ and Nursing Supervisors on state ratio staffing regulation. 4. To monitor the corrective action and ensure that it does not recur, the DON will audit nursing staff to resident ratios weekly X4; bi-weekly X 2 and monthly X 1. The results will be reviewed at the QAPI meeting.