Failure to Meet Minimum CNA Staffing Requirements
Penalty
Summary
The facility failed to meet the daily average minimum staffing requirement for Certified Nurse Assistants (CNAs) during the first quarter of Fiscal Year 2025. A review of the State Minimum Nursing Staff for Long Term Care Facilities showed that on several days, the facility's daily average CNA hours fell below the required 2.0 hours per resident per day. Specifically, the daily average CNA hours recorded were 1.9411, 1.9316, 1.9837, and 1.8799 on different days within the quarter. This deficiency was confirmed during an interview with the Director of Nursing (DON), who acknowledged the findings. The report does not mention any specific residents affected or provide details about their medical history or condition at the time of the deficiency. The deficiency is classified as a Class III violation.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement of the provider of the truth of the alleged or conclusion set forth in the CMS measured star ratings. The plan of correction is prepared and executed solely because it is required by Federal and State Laws. N63- What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The staffing coordinator and Nurse Managers have been re-educated on ensuring that Certified Nursing Assistant minimum daily hour of direct care is at least 2.0 per resident per day. No residents were affected by the deficient practice. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: Audit completed for the past 30 days, and no deficient practice identified. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: Nursing Home Administrator educated the Director of Nursing and those responsible for staffing on the requirements of meeting the daily per patient day direct care hours.