Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident staffing ratios as mandated by regulations effective July 1, 2023. Specifically, the facility did not provide the necessary number of NAs during the day and evening shifts on certain days. On April 4, 2025, the facility had a census of 129 residents during the evening shift, necessitating 11.73 NAs, but only 11.07 NAs were available. Similarly, on April 6, 2025, with a census of 128 residents, the day shift required 12.80 NAs, yet only 10.73 NAs were present, and the evening shift required 11.64 NAs, but only 9.47 NAs were available. There were no additional higher-level staff to compensate for these staffing deficiencies. The Nursing Home Administrator confirmed the shortfall in meeting the required staffing ratios.
Plan Of Correction
1. The ratios noted in the survey findings cannot be corrected as this is a past event. 2. Calculation of shift ratios will be completed and reviewed daily for accuracy by the scheduler or designee. 3. The facility has developed internal incentives to retain and attract staff and meet shift ratio requirements. Administrator will re-educate Director of Nursing and Scheduler regarding staffing ratios regulations. Facility scheduler, Director of Nursing, Human Resources, and Administrator have a daily staffing meeting (5 days per week) to review schedules including compliance with ratios. For staff call offs, every effort will be made to replace the call off using resources available including communicating with staff to replace the vacancy. Staffing patterns are projected at least one week in advance to enable ongoing efforts to fill any vacant shifts. The facility will take admissions when staffing is appropriate. 4. Ratios will be monitored daily by Scheduler and/or Director of Nursing or designee. Audits of ratios will be completed by Director of Nursing or designee daily for 4 weeks then 3 days per week x 2 months or until substantial compliance is achieved. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee.