Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to comply with the required nurse aide (NA) to resident ratios as mandated by the regulation effective July 1, 2024. A review of nursing schedules for the period from March 26, 2025, to April 4, 2025, revealed multiple instances of non-compliance. Specifically, the facility did not meet the minimum ratio of one NA per ten residents during the day shift on March 29, 30, and April 3, 2025. Additionally, the evening shift ratio of one NA per eleven residents was not met on March 28, 30, and April 2, 2025. Furthermore, the night shift ratio of one NA per fifteen residents was not adhered to from March 26 through 29, and 31, 2025, and April 1 through 3, 2025. These findings indicate a consistent failure to maintain adequate staffing levels across all shifts during the reviewed period.
Plan Of Correction
1) The facility cannot retroactively correct the staffing for the days in question. 2) The staffing ratios are reviewed on an ongoing basis. The NHA and DON continue to hire and recruit staff to fill the open positions. The scheduler has been educated on the numbers necessary to maintain compliance based on the facility census. 3) The NHA/designee monitors the schedule daily to ensure compliance. Additional staff are being hired for the shifts that have impacted our compliance. Per diem staff are also being hired to utilize for staff call offs and staff schedules. 4) Results of the reviews will be reviewed with the Quality Assurance committee for input and suggestions.