Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide-to-resident staffing ratios on multiple occasions. On March 31, 2025, the facility had a census of 57 residents, necessitating 5.70 nurse aides during the day shift, 5.18 during the evening shift, and 3.80 during the night shift. However, the facility only provided 5.27, 4.40, and 3.17 nurse aides, respectively, for these shifts. Similarly, on April 2, 2025, with a census of 58 residents, the facility required 5.70 nurse aides during the day shift, 5.27 during the evening shift, and 3.87 during the night shift, but only provided 4.97, 4.17, and 3.37 nurse aides, respectively. On April 3, 2025, the facility's census increased to 62 residents, requiring 5.80 nurse aides during the day shift and 5.64 during the evening shift. However, the facility only provided 4.00 and 4.20 nurse aides, respectively. The Nursing Home Administrator confirmed that the facility did not meet the required staffing ratios for the days reviewed. No additional higher-level staff were available to compensate for these deficiencies, leading to a failure in meeting the regulatory staffing requirements.
Plan Of Correction
Unable to retroactively correct staffing ratios for Certified Nurse Aides (CNAs) on dates noted. Residents who receive nursing care services have the potential to be affected. Recruitment and retention activities: 1. Generous Sign on Bonus 2. Flexible Scheduling 3. Benefits Package for full-time employees 4. Wage analysis completed 5. "Kudos" recognition program 6. Referral bonus 7. Agency Contracts 8. Administrative Coverage 9. Attend Job Fair Monitoring will be captured through auditing staff schedules. Audit will be conducted daily for 12 weeks. The audits will be conducted by the Staffing Coordinator or designee. Results of the audits will be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.