Non-Compliance with Overnight NA Staffing Ratios
Penalty
Summary
The facility failed to meet the regulatory requirement of maintaining a minimum of one nurse aide (NA) per 15 residents during the overnight shift for five out of the 21 days reviewed. Specifically, on February 9, 2025, with a census of 18 residents, only 1.00 NA was scheduled, whereas 1.20 NAs were required. On February 11, 2025, with a census of 20 residents, 1.00 NA was scheduled, but 1.33 NAs were needed. Similarly, on April 11, 12, and 13, 2025, with a census of 17 residents each night, only 1.00 NA was scheduled, while 1.13 NAs were required. This deficiency was confirmed through an interview with the Nursing Home Administrator and Director of Nursing on April 16, 2025.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. At the time of the finding, the ratios and total nursing hours for the current working schedule were reviewed and staffing was sufficient to meet the needs of the residents or there was sufficient time to coordinate sufficient staffing. 2. The RNs and LPNs will be re-educated on the nursing assistant ratio requirements, and the importance of monitoring staffing as the day and/or shift progress. Education will be completed by the Director of Nursing and/or designee. 3. The Director of Nursing and/or designee will audit the current working schedule, and the deployment sheets prior to the day and after the day is complete to ensure nursing assistant ratios have been met. 4. Audits will be completed 3 times per week for 1 month, and weekly for 1 month thereafter or until substantial compliance is achieved. Results will be reviewed at the QAPI meeting.