Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required minimum staffing levels for nurse aides (NAs) on multiple occasions, as evidenced by a review of nursing staffing hours and staff interviews. During the day shift, the facility did not ensure a minimum of one NA per 12 residents on three out of seven days reviewed. Specifically, on April 20, 2025, there were 18.12 NAs for 322 residents, requiring 32.80 NAs; on April 21, 2025, there were 24.99 NAs for 329 residents, requiring 32.70 NAs; and on April 22, 2025, there were 28.93 NAs for 333 residents, requiring 33.30 NAs. Similarly, during the evening shift, the facility did not meet the required staffing levels on four out of seven days. On April 20, 2025, there were 17.20 NAs for 328 residents, requiring 29.82 NAs; on April 21, 2025, there were 21.69 NAs for 327 residents, requiring 29.73 NAs; on April 22, 2025, there were 25.51 NAs for 333 residents, requiring 30.27 NAs; and on April 23, 2025, there were 28.11 NAs for 330 residents, requiring 30.00 NAs. Additionally, during the night shift, the facility did not ensure a minimum of one NA per 20 residents on two out of seven days. On April 20, 2025, there were 18.08 NAs for 328 residents, requiring 21.07 NAs, and on April 23, 2025, there were 18.05 NAs for 333 residents, requiring 22.00 NAs. These deficiencies were confirmed with the Nursing Home Administrator on April 29, 2025.
Plan Of Correction
Facility will ensure that we will abide by the DOH guidelines for CNA staffing ratios. Staffing directors will be educated to ensure that we are abiding with DOH guidelines for CNA staffing ratios. NHA/designee will audit 3X weekly X4 weeks and then monthly X2 months to ensure that facility is abiding by DOH CNA staffing ratios. Results will be reviewed during the facilities monthly QAPI Meeting X3 months to determine the need for further review.