Failure to Meet Minimum Nurse Aide Staffing Requirements
Penalty
Summary
The facility failed to meet the required minimum nurse aide staffing levels as mandated by regulation. Specifically, staffing documents reviewed for the period from 7/3/25 through 7/7/25 showed that the facility did not provide at least one nurse aide per 10 residents during the day shift on all five days reviewed, with actual nurse aide hours consistently falling short of the required hours. Additionally, on one night shift, the facility did not provide the required one nurse aide per 15 residents, with actual hours again below the mandated level. These findings were confirmed by the Director of Nursing during an interview, who acknowledged the facility's failure to meet the nurse aide staffing requirements on the identified shifts.
Plan Of Correction
1. The facility cannot correct that the nurse aide staffing ratio was not met on the day shift on five of five days (7/3/25 through 7/7/25) and one NA per 15 residents on the night shift on one of five days (7/4/25) as required. There were no adverse effects to the residents on the identified dates. 2. The facility will ensure that staffing ratios are met every shift. 3. Nursing administration and the nursing scheduler will be re-educated by the Nursing Home Administrator/designee on ensuring staffing ratios are met each shift. A daily staffing meeting will be held by administration to monitor staffing ratios. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing ratios, the scheduler/designee will call off-duty facility staff and will utilize external staffing support resources. 4. The Nursing Home Administrator/designee will audit staffing daily for three weeks and monthly for three months to ensure staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.