Observations:
Based on review of nursing schedules, review of staffing information furnished by the facility, and staff interview, it was determined that the facility failed to provide a minimum of one nurse aide (NA) per 15 residents on the night shift for one of four days reviewed for May 1 through May 4, 2025.
Findings include:
Review of facility census data revealed:
On May 3, 2025, the facility census was 101 during the night shift, which required 6.73 NA's during the night shift. Review of the nursing time schedules revealed that 6.33 NA's provided care during the night shift. There were no additional excess higher-level staff were available to compensate for this deficiency.
Interview with the Nursing Home Administrator on May 9, 2025, at 3:55 p.m. confirmed that the facility did not meet the required NA-to-resident staffing ratios for the day listed above.
| | Plan of Correction - To be completed: 07/10/2025
1. The administrator and/or designee will conduct a review of the last 14-days of the nursing schedules to determine compliance with proper Certificated Nursing Assistants ratios.
2. The administrator and/or designee will conduct reviews at least 5-days per week for two weeks then 3-days per week for one month to ensure. In the vent of extensive call-offs, higher level nursing will staff fill, if possible, we ask for volunteers with bonuses, then in extreme case, we will mandate and will stop admissions. We continue to recruit all levels of staff, Registered Nurses, Licensed Practical Nurses, Certified Nurser's Aides. We also have a schedule/staffing meeting each day to discuss staffing and census.
We have utilized a shift differential for evenings and night shifts and a weekend differential – this program is for all our nursing staff. We have increased our Registered Nurse Licensed Practical Nurse wages. Our Human Resources Director attends Job Fairs. We have established ourselves as a clinical site for both the Registered Nursing program at a local college and the Licensed Practical Nursing program at a local Career and Technology Center. We continue a bonus for: Open Shift Bonus 4hrs 8hrs Registered Nurses, Licensed Practical Nurses, Certified Nurser's Aides. Referral and Sign on Bonuses for: Registered Nurses, Licensed Practical Nurses, Certified Nurser's Aides. While we continue recruitment, we have established a Certified Nurse's Aide class through an outside contractor to develop more Certified Nurse's Aide.
3. The results of the audits, along with a Root Cause Analysis of any identified issues, will be brought to the Quality Assurance and Performance Improvement Committee for analysis and possible corrective actions.
4. Date certain 7/10/25
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