(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.
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Observations: Based upon review of staffing schedules and records, it was determined the facility failed to meet the State minimum ratio requirement for nurse aides for 3 staffing weeks reviewed.
Findings include:
Review of facility staffing schedules and records dated January 7, 2024 through January 27, 2024 revealed the facility did not meet the State minimum ratio requirement for nurse aides on the following dates: January 7, 2024 - 7-3, 3-11 and 11-7 shifts; January 8, 2024 - 11-7 shift; January 9, 2024 - 3-11 shift; January 10, 2024 - 7-3 and 3-11 shift; January 11, 2024 - 7-3, 3-11 and 11-7 shifts; January 12, 2024 - 7-3 and 3-11 shifts; January 13, 2024 - 3-11 and 11-7 shifts; January 14, 2024 - 7-3 and 3-11 shifts; January 15, 2024 - 3-11 shift; January 16, 2024 - 3-11 shift; January 17, 2024 - 11-7 shift no aides; January 18, 2024 - 3-11 shift; January 19, 2024 - 7-3, 3-11 and 11-7 shifts; January 20, 2024 - 7-3, 3-11 and 11-7 shifts; January 21, 2024 - 7-3 and 3-11 shifts; January 22, 2024 - 3-11 and 11-7 shifts; January 23, 2024 - 3-11 shift; January 24, 2024 - 7 -3 and 11-7 shifts; January 25, 2024 - 7-3, 3-11 and 11-7 shifts; January 26, 2024 - 7-3, 3-11 and 11-7 shifts and January 27, 2024 - 7-3, 3-11 and 11-7 shifts.
Interview with Nursing Home Administrator on February 6, 2024, at 11:00 a.m. confirmed the above information.
| | Plan of Correction - To be completed: 04/24/2024
1. Facility can not retroactively correct.
2. All residents had the potential to be affected; however, there were no adverse resident outcomes as a result of this deficient practice.
3. Licensed staff have been re-educated on staffing requirements by the DON and/or designee. An ongoing systemic change put in place is the review of staffing in daily meeting.
4. The Administrator or designee will audit the schedule for four weeks and then monthly for two months to ensure appropriate coverage.
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