Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) staffing ratios across multiple shifts over a 21-day period. Specifically, the day shift did not meet the required ratio of one NA per 10 residents on ten occasions, the evening shift failed to meet the ratio of one NA per 11 residents on 17 occasions, and the overnight shift did not meet the ratio of one NA per 15 residents on five occasions. These deficiencies were identified through a review of the facility's nursing staffing documents and confirmed by the Nursing Home Administrator during an interview. The staffing shortages were documented with specific census numbers and the number of NAs that worked versus the number required. For example, on 3/31/25, with a census of 88 residents, only 6.90 NAs worked during the day shift when 8.80 were required. Similarly, on 4/18/25, during the overnight shift, only 3.81 NAs worked when 5.60 were required for a census of 84 residents. These consistent staffing shortages indicate a failure to comply with the mandated staffing ratios, impacting the facility's ability to provide adequate care to its residents.
Plan Of Correction
The facility must maintain the minimum of one Nurse Aide for every 10 residents during the day shift, one Nurse Aide for every 11 residents during the evening, and one Nurse Aide per 15 residents overnight. To ensure that these regulatory requirements are met, the following action plan will be implemented: The scheduler was reeducated on 4/28/25 to ensure that they understand the regulatory staffing requirements for nursing assistants. The nursing assistant schedule will be reviewed by the scheduler and Director of Nursing to ensure that nursing assistant ratios are met prior to posting of the schedule. In the event of call-offs by staff, all other staff will be contacted to cover any open shifts to ensure ratios are met. Bonuses will be offered as an incentive for employees to cover shifts. In addition, the facility utilizes a recruitment company to attract additional staff. An audit will be developed and completed by the Director of Nursing or Designee 3 times per week for 4 weeks, then 2 times a week for 3 weeks, then weekly ongoing, to ensure that nursing assistant ratios are met for all shifts. The audit will be monitored by the Administrator. Results of the audit will be presented at the Quality Assurance monthly meeting and recommendations will be implemented.