Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) staffing levels as mandated by regulation. Specifically, on one day during the day shift, the number of NAs present was below the required ratio of one NA per 10 residents. On five separate days during the evening shift, the facility did not provide the minimum of one NA per 11 residents. Additionally, on two nights, the night shift did not meet the minimum requirement of one NA per 15 residents. These deficiencies were confirmed through a review of nursing time schedules, facility census data, and staff interviews, including confirmation by the Director of Nursing. There was no indication that additional higher-level staff were present to compensate for the NA shortages on these shifts. No information was provided regarding specific residents affected, their medical history, or their condition at the time of the deficiency.
Plan Of Correction
The Center continues to have retention and recruitment activities in place, which met on 7.16.2025. Nursing leadership did all things reasonably possible to meet the required ratios through bonuses, a day off on another day, and split shifts. We call/text unscheduled staff were contacted, and supplemental staffing were contacted to send replacement staff. Ancillary staff were available and assisted in various tasks such as call bell attendant, delivery and removal of meal trays, delivery of water, bed making, and performance of other tasks within their scope of practice. The facility will continue to ensure the schedule reflects the required staffing ratios and address call-offs. Our Human Resource Clerk is scheduled to attend the Career link job fair and meet with the organizer on 7/21/25. An off-shift scheduler continues to perform scheduling duties after hours to maintain ratio. Staff and supplemental staffing have been reminded of the importance of them reporting to work as assigned. A weekend Manager program has been implemented, which will add extra monitoring on the weekends. No residents were affected. To monitor and maintain ongoing compliance, the DON/designee will audit 5 staffing sheets x 4 weeks to ensure CNA ratios are being met on day and night shifts. Audit results will be reviewed with QAPI Committee meeting monthly to determine the need for further audits.