Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) to resident ratios for all 21 days reviewed, as evidenced by a review of nursing time schedules from July 24, 2025, to August 13, 2025. Specifically, the facility did not provide at least one NA for every ten residents during the day shift on multiple dates, including July 24, 25, 26, 27, 28, 30, 31, and August 1, 2, 3, 4, 6, 9, 10, and 11, 2025. Additionally, the facility did not meet the minimum requirement of one NA for every eleven residents during the evening shift on all days from July 24 through August 7, and again from August 9 through 13, 2025. These findings are based solely on the documented nursing schedules and do not reference any specific residents or their conditions.
Plan Of Correction
This is unable to be corrected as it is a past event. The use of an outside Recruiting Group has assisted with filling vacancies and qualified ancillary staff assist with NA coverage. Daily staffing huddles occur in which census, open holes, call offs etc. are addressed. Education to be completed with Nsg Administration, Scheduling and HR on the importance of maintaining DOH guidelines as it pertains to NA ratio. Audits to be completed daily by NHA/designee x4 weeks, then bi-weekly x2 weeks, then monthly x2 with results to QAPI meeting. Unable to correct past event.