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, which specifies a minimum of one nurse aide per 10 residents during the day, one per 11 residents during the evening, and one per 15 residents overnight. Review of nursing time schedules, census data, and deployment sheets revealed that, over a 21-day period, the facility did not provide the required number of nurse aides on 20 days. Specific shortfalls were documented for both day and evening shifts, as well as overnight shifts, with the number of nurse aides consistently falling below the required ratios for the resident census on multiple occasions. During an interview, the DON confirmed the facility's failure to provide the mandated minimum nurse aide coverage on these days. The report details the exact census and staffing numbers for each shift, showing repeated instances where the number of nurse aides scheduled was insufficient according to the regulatory requirements. No information is provided regarding the impact on individual residents or their medical conditions at the time of the deficiency.
Plan Of Correction
The facility cannot correct that the nurse aide staffing ratio was not met on the day shift on seventeen of twenty-one days (8/26/25 thru 9/15/2025). The ratio was one NA per 11 residents on the evening shift on twelve of twenty-one days (8/29/25 thru 9/1/25 and 9/5/25 thru 9/15/25). On the night shift, the ratio was one NA per 15 residents on six of twenty-one days (9/6, 9/9, 9/10, 9/12, 9/13, and 9/15/25). These staffing issues occurred as required. There were no adverse effects to the residents on the identified dates. The facility will ensure that staffing ratios are met every shift. 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 or designee will call off-duty facility staff and will utilize external staffing support resources. 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.