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 four shifts out of 21 shifts 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.
February 6, 2026 -5.78 nurse aides on the night shift versus the required 6.80 for a census of 102.
February 7, 2026 -9.34 nurse aides on the day shift versus the required 10.20 for a census of 102.
February 7, 2026 -5.41 nurse aides on the night shift versus the required 6.80 for a census of 102.
February 8, 2026 -7.88 nurse aides on the day shift versus the required 10.20 for a census of 102.
On the above dates mentioned, no additional excess higher-level staff were available to compensate for this deficiency.
An interview with the Nursing Home Administrator (NHA) on February 10, 2026, at 11:54 AM confirmed the facility had not met the required nurse aide to resident ratios on the above dates.
| | Plan of Correction - To be completed: 03/03/2026
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared solely because it is by the provisions of federal and state law. The plan of correction represents the facility's credible allegation of compliance as of March 3, 2026.
The facility cannot retroactively correct the deficiency cited by the surveyor related to maintaining the required staffing ratio for nurse aides on 14 of 63 shifts reviewed.
The facility recognizes all residents have the potential to be affected. Please see sections 3 and 4 for system changes and monitoring.
The nursing staff scheduler will be re-educated by the Nursing Home Administrator on the required nurse staffing ratio for nurse aides. Recruitment of nursing staff will continue via facility website, indeed, social media websites, job fairs and off-site recruiters. Agency will be utilized for open shifts as needed and available.
Calculation of daily shift ratios will be completed and reviewed for accuracy by the scheduler, DON, or NHA. All efforts will be made to meet the staffing ratio. If call offs occur, all efforts will be made to attempt to fill that position.
Daily ratios will be audited weekly for 4 weeks and then monthly for 2 months.
Results will be forwarded to the QA committee monthly for review and recommendations
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