Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) to resident ratios on multiple occasions over a 21-day period. Specifically, the review of nursing schedules from July 2 to July 22, 2025, showed that the day shift did not meet the minimum ratio of one NA per ten residents on five separate days. Additionally, the evening shift did not meet the minimum ratio of one NA per eleven residents on four days, and the night shift failed to meet the minimum ratio of one NA per fifteen residents on three days. These findings are based solely on the review of staffing schedules and do not include information about specific residents or their conditions.
Plan Of Correction
All residents received care in accordance with their plan of care and attending physician orders. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. Facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly x4 weeks then monthly for two months. Results will be taken to the QAPI for review and revision as needed.