Overnight Staffing Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide-to-resident staffing ratios during the overnight shift on February 28, 2025. The regulation mandates a minimum of one nurse aide per 15 residents overnight, but the facility provided only 5.43 nurse aides for a census of 86 residents, which required 5.73 nurse aides. This deficiency was confirmed through a review of nursing schedules, staffing information, and an interview with the Nursing Home Administrator. No additional higher-level staff were available to compensate for the shortfall in nurse aide staffing.
Plan Of Correction
1. The facility cannot retroactively correct nursing staffing hours and ratios. 2. The facility is focusing on the retention of existing nursing staff and recruiting new staff through the efforts of the staffing committee and human resource department. 3. The Executive Director (ED) re-educated the scheduler and nursing supervisors on the staffing ratios and hours per patient day (HPPD). Staffing meetings to review the calculations for nursing staff ratios and HPPD for accuracy. 4. The ED or Designees to conduct Quality Improvement (QI) monitoring of daily schedules to ensure the ratio of care/minimum PPD will be met. QI monitoring conducted via OnShift Daily Schedules reviewed 5X per week X 4 weeks, then weekly X 4 weeks. Findings reported to the Quality Improvement Performance Improvement (QAPI) committee and updated as indicated. QI monitoring schedule modified based on findings.