Inadequate Nurse Aide Staffing Levels
Penalty
Summary
The facility failed to comply with the required nurse aide (NA) to resident ratios over a 21-day period from March 14 to April 3, 2025. Specifically, the facility did not meet the minimum staffing requirements on multiple occasions across different shifts. During the day shift, the facility was short of the required one NA per ten residents on seven days. The evening shift was understaffed on eleven days, failing to maintain the required one NA per eleven residents. Additionally, the night shift did not meet the minimum requirement of one NA per fifteen residents on two days. These deficiencies were identified through a review of the nursing schedules, indicating a consistent pattern of inadequate staffing levels.
Plan Of Correction
1. C.N.A. ratios for the dates noted in the survey cannot be corrected as this is a past event. 2. Calculation of shift C.N.A. ratios will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. The facility continues to attend job fairs and nursing schools to recruit direct care staff, in addition to other ongoing recruiting initiatives. Nurse Aide classes will resume at the facility on 4/28/25. Facility continues with an employee referral program to recruit staff also. Agency staff are being utilized in an effort to reach daily shift ratios. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate C.N.A. ratios as needed. 4. C.N.A. ratios will be audited by scheduler and DON daily for 4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results will be reported to QAPI committee. 5. Date of correction is 06/11/2025.