Failure to Meet Nurse Aide to Resident Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios on multiple occasions over a period of 21 days. Specifically, the facility did not maintain the minimum ratio of one NA per ten residents during the day shift on nine separate days, one NA per eleven residents during the evening shift on three days, and one NA per fifteen residents during the night shift on five days. These deficiencies were identified through a review of nursing schedules for the periods of January 1 through 7, 2025, March 9 through 16, 2025, and April 24 through 30, 2025. The facility's administrator confirmed the failure to meet the required staffing ratios during an interview conducted on April 30, 2025.
Plan Of Correction
1. The facility has reviewed and adjusted staffing schedules to ensure compliance with minimum NA-to-resident ratios for all shifts. 2. A comprehensive review of the resident census and care needs was conducted to verify that current NA staffing levels meet or exceed regulatory requirements. A proactive system was developed to forecast NA staffing needs based on anticipated resident census and staff availability trends. 3. All nursing administrative staff will receive training on regulatory NA staffing requirements and the importance of timely shift coverage. 4. Daily audits of NA to resident ratios will be conducted weekly. Findings from audits will be reviewed during monthly Quality Assurance and Performance Improvement (QAPI) meetings, and QAPI will determine further action planning and discontinuation.