Staffing Deficiencies in Nursing Services
Penalty
Summary
The facility failed to meet the required minimum staffing levels for nurse aides (NAs) across various shifts over a 21-day review period. Specifically, the day shift was understaffed on four days, the evening shift on seven days, and the night shift on eleven days. For instance, on February 13, 2025, the day shift had 10.8 NAs for 114 residents, falling short of the required 11.4 NAs. Similarly, on February 9, 2025, the evening shift had 8.47 NAs for 109 residents, while 10 NAs were needed. The night shift on February 9, 2025, had 4.27 NAs for 110 residents, whereas 7.33 NAs were required. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the staffing deficiencies. These staffing shortfalls indicate that the facility did not comply with the regulation requiring a minimum number of NAs per resident during each shift. The report highlights specific dates and staffing numbers, demonstrating a consistent pattern of inadequate staffing levels that did not meet the regulatory requirements.
Plan Of Correction
A - N/A B - Staffing Coordinator will staff the daily nursing staff to meet the required CNA to resident ratio of 1:10 on 7-3, 1:11 on 3-11, and 1:15 on 11-7. C - NHA, DON, and Staffing Coordinator educated on minimum staff to resident ratio. D - Weekly x4 then monthly x2 random audits by DON or designee of CNA staff ratio on 50% of days to ensure compliance with ratios.