(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.
|
Observations:
Based on a review of nurse staffing and staff interview, it was determined the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 7 shifts out of 21 reviewed.
Findings include:
A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse aide staff of 1:10 on the day shift, 1:11 on the evening shift, and 1:15 on the night shift based on the facility's census.
April 28, 2025, 8.56 NAs on the day shift, versus the required 9.6, for a census of 96 April 28, 2025, 6 NAs on the night shift, versus the required 6.4, for a census of 96 May 1, 2025, 8.53 NAs on the evening shift, versus the required 8.91, for a census of 98 May 1, 2025, 5.06 NAs on the night shift, versus the required 6.53, for a census of 98 May 2, 2025, 5.97 NAs on the night shift, versus the required 6.47, for a census of 97 May 3, 2025, 8.25 NAs on the evening shift, versus the required 8.91, for a census of 98 May 3, 2025, 5.56 NAs on the night shift, versus the required 6.53, for a census of 98
On the above dates mentioned no additional excess higher-level staff were available to compensate this deficiency.
An interview with the Director of Nursing, on May 28, 2025, at approximately 1:30 p.m., confirmed the facility had not met the required NA to resident ratios on the above dates.
| | Plan of Correction - To be completed: 06/05/2025
The facility cannot retrospectively correct staffing hours. The facility scheduler staffs each day with adequate staff to meet the individual and overall staffing requirements. In the event of call offs, the facility has engaged additional staffing agencies to be used to supplement hours in RN, LPN and C.N.A. as well as overall staffing. The facility now offers additional shift pick up incentives to staff not only for full, but also partial shift pick up. The Administrator / designee will provide updated education to direct care staff on shift pick up incentives. The facility is holding a major /targeted recruitment effort in June 2025 with increased hiring incentives for sign on and referral of staff. The facility now also has the ability to reach out to a nearby sister facility for additional staff, as needed, to meet staffing requirements. The facility adHOC QAPI committee will review staffing levels daily during stand up meetings and report to the facility QAPI committee quarterly and more often as needed.
|
|