Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on five out of twenty-one reviewed shifts. Specifically, on March 27, 2025, the day shift had 8.2 nurse aides instead of the required 8.5 for a census of 85 residents. On March 28, 2025, the night shift had 5.5 nurse aides instead of the required 5.6 for a census of 84 residents. On March 30, 2025, the night shift had 4.75 nurse aides instead of the required 5.67 for a census of 85 residents. On March 31, 2025, the day shift had 7.7 nurse aides instead of the required 8.6 for a census of 86 residents, and the evening shift had 7.36 nurse aides instead of the required 7.82 for a census of 86 residents. No additional higher-level staff were available to compensate for these deficiencies. The Nursing Home Administrator confirmed the facility's failure to meet the required staffing ratios during an interview on April 1, 2025.
Plan Of Correction
The facility will provide a staffing ratio based on July 1, 2024, regulations of one nurse aide per 10 residents on the day shift, one nurse aide per 11 residents during the evening shift, and one nurse aide per 15 residents during the night shift. All facility residents have the potential to be affected by this practice. The facility has implemented staff incentives for current and new staff as well as reinforcing the facility call off policy to deter unnecessary call offs. We are also hiring PRN CNAs to assist in covering shifts with call offs or openings in the schedule. We will be using Indeed for advertisements of open positions, participating in career fairs as they are available, and giving sign on bonuses and/or referral bonuses to new hires and our staff. NHA or designee will educate staff on incentives and call off policy. Administrator/designee during weekday daily review of nursing schedules will audit to ensure Certified Nurse Aide ratios are maintained. The results of these audits will be discussed at the facility QAPI meeting monthly for further review and recommendations.