(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.
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Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for 20 of 21 days reviewed.
Findings include:
Review of nursing schedules for 21 days from January 11 through January 31, 2025, revealed the following:
The facility failed to meet the minimum NA to resident ratio of one NA for ten residents on day shift (7:00 a.m. to 3:00 p.m.) on January 11, 13, 14, 15, 16, 17, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, 30, and 31, 2025.
The facility failed to meet the minimum NA to resident ratio of one NA for 11 residents on evening shift (3:00 p.m. to 11:00 p.m.) on January 13, 17, 19, 20, 21, 22, 24, 25, 26, 27, 28, 29, 30, and 31, 2025.
The facility failed to meet the minimum NA to resident ratio of one NA for 15 residents on night shift (11:00 p.m. to 7:00 a.m.) on January 11, 15, 16, 17, 18, 19, 20, 23, 24, 25, 26, 27, 29, 30, and 31, 2025.
In an interview conducted on February 2, 2025, at 2:00 p.m., the Nursing Home Administrator confirmed that the facility failed to meet the required staffing ratio for nurse aides on the previously mentioned dates and shifts.
| | Plan of Correction - To be completed: 02/18/2025
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.
P5520 Nurse Aide Ratio
1. All residents received care in accordance with their plan of care and attending physician orders.
2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs the center follows staffing procedures including exhausting all possible replacements from internal staffing pool and contracted agency staff. Center continues to offer incentives, coordinate staffing schedules, and replace call offs per protocol while actively continuing to hire for all open positions and additional pool staff.
3. All registered nurses and the scheduler have been educated on the 7/01/2024 nurse aide ratio and the importance of maintaining the schedule as posted.
4. To monitor and maintain ongoing compliance the DON/designee will audit staffing weekly x4 weeks then monthly for 2 months. Results will be reviewed by the QAPI Committee for recommendations as needed.
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