Failure to Meet Minimum Nurse Aide Staffing Requirements
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) staffing levels on multiple occasions, as evidenced by a review of staffing documents and staff interviews. Specifically, on two separate day shifts, the number of NA hours provided was less than what was required for the census present. Similarly, on two evening shifts and one night shift, the facility did not provide the mandated NA coverage based on the resident census. The Nursing Home Administrator confirmed during an interview that the facility did not have the required number of NAs on these shifts, as outlined by the regulation effective July 1, 2024. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
1. The facility cannot correct that the facility failed to provide one nurse assistant (NA) per 10 residents on the daylight shift on 8-4-25 & 8-11-25 and one nursing assistant per 11 residents on the evening shift on 8-3-25 & 8-10-25 and one nursing assistant per 15 residents on the night shift on 8-11-25 as required. 2. The facility will ensure that nurse aide staffing ratios of 1:10 on day shift, 1:11 on evening shift, and 1:15 on night shift. Open positions will continue to be posted on various platforms. We will continue with a weekly retention and recruitment meeting. We have help wanted signs on our property. We posted an ad in our local township summer 2025 newsletter that gets distributed to over 3000 homes and businesses in our township. We have reached out to the union to inquire about financial benefits for the members to pursue CNA training and CCAC to explore CNA class options to partner with CCAC and to post help wanted ads on the college bulletin boards. We offer a sign-on bonus and bonuses as incentives to our staff to pick up shifts. We offer "Refer a Friend" bonus to our staff. We utilize staffing agencies to fill needed shifts. We will continue to review referrals to ensure we can meet their needs prior to accepting. 3. The Nursing Home Administrator will re-educate the Director of Nursing, HR Director/Scheduler, and RN Supervisors on regulation P5520 and ensuring nurse aide staffing ratios are met each shift. Staffing ratios will be reviewed at our daily staffing meeting to ensure ratios are scheduled to be met. The RN Nursing Supervisors will continue to review shift staffing ratios on evenings and weekends. If the facility's projections to meet ratios fall below required ratios due to call-offs, No Call No Shows, etc., the RN Supervisors will be responsible to ask currently working staff to pick up a shift, call our off-duty personnel, and/or call extra support staff via staffing agencies to assist as necessary. 4. The HR Director/designee will audit staffing sheets daily for three months to ensure nurse aide staffing ratios are being met. The audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits. 5. Date of compliance: 9-16-2025