Staffing Deficiency in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides during the period from March 28 through April 6, 2025. Specifically, the facility did not maintain the minimum staffing ratio of one nurse aide per 10 residents during the day shift on six occasions, one nurse aide per 11 residents during the evening shift on eight occasions, and one nurse aide per 15 residents during the night shift on four occasions. These deficiencies were identified through a review of facility staffing data and were communicated to the Nursing Home Administrator during a telephone interview on April 14, 2025.
Plan Of Correction
1. All residents will receive care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler will review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from the internal staffing pool and contracted agency staff. The facility continues to coordinate staffing schedules and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All nursing leadership staff have been educated on Nursing staffing Ratios and HPPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.