Staffing Deficiencies in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides (NAs) on multiple occasions over a 14-day period. Specifically, on the day shift of March 15, 2025, the facility did not provide the required number of NA hours for a census of 97 residents, falling short by 2.5 hours. On the evening shift of March 16, 2025, with a census of 99 residents, the facility was short by 2.5 hours. Additionally, on the night shifts of March 6, 13, and 16, 2025, the facility failed to meet the required NA hours for a census of 97 and 99 residents, with deficits ranging from 3.5 to 9.5 hours. These deficiencies were confirmed by the Nursing Home Administrator during an interview on March 18, 2025.
Plan Of Correction
The facility cannot retroactively correct past staffing issues. To prevent this from reoccurring, the Scheduler will be reeducated on staffing Nurses Aides to include expectations of HPPD and ratios by the DON/ designee. The facility will hold staffing meetings 5 days per week, consisting of the Nursing Home Administrator, Director of Nursing, Human Resources, and Scheduler, to review ratio and PPD compliance for upcoming schedules. DON/ designee will monitor PPD hours 5 days a week and ongoing to ensure compliance. Ad hoc education will be provided as needed. The results of the meeting will be forwarded to the facility QAPI committee for further review and recommendations.