Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
A review of nursing schedules for a 21-day period revealed that the facility did not meet the required minimum nurse aide (NA) to resident ratios on several occasions. Specifically, the facility failed to provide at least one NA for every ten residents during the day shift on two days, one NA for every eleven residents during the evening shift on six days, and one NA for every fifteen residents during the night shift on one day. These findings were based on direct examination of the facility's staffing schedules and reflect noncompliance with the mandated staffing levels for nurse aides during the specified shifts and dates. No information regarding the medical history or condition of individual residents was provided in the report.
Plan Of Correction
1. C.N.A. ratios for the dates noted in the survey cannot be corrected as this is a past event. 2. Calculation of shift C.N.A. ratios will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. The facility continues to attend job fairs and nursing schools to recruit direct care staff, in addition to other ongoing recruiting initiatives. Facility continues with an employee referral program to recruit staff also. Agency staff are being utilized in an effort to reach daily shift ratios. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate C.N.A. ratios as needed. 4. C.N.A. ratios will be audited by scheduler and DON daily for 4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results will be reported to QAPI committee. 5. Date of correction is 08/20/2025. P 5520