Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide staffing ratios on three out of 21 shifts reviewed. Specifically, on March 27, 29, and 30, 2025, the night shift staffing levels were below the mandated minimum of 1 nurse aide per 15 residents. On March 27, there were 5.63 nurse aides instead of the required 6.47 for a census of 97 residents. On March 29, there were 5.00 nurse aides instead of the required 6.20 for a census of 93 residents. On March 30, there were 3.63 nurse aides instead of the required 6.13 for a census of 92 residents. No additional higher-level staff were available to compensate for this deficiency. An interview with the Nursing Home Administrator on April 2, 2025, confirmed the facility's failure to consistently provide the minimum nurse aide staffing hours required for each resident during the specified shifts.
Plan Of Correction
1. The facility cannot retroactively correct nurse aide staffing ratio. 2. NHA/designee will conduct an initial audit of the past two weeks' schedule to determine if nurse aide ratio is in compliance. 3. NHA/designee will re-educate the scheduler on the proper nurse aide staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made. 4. NHA/designee will conduct random audits of nurse aide staffing weekly for four weeks, then monthly for two months thereafter to verify proper nurse aide ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.