(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 on review of nursing schedules and staffing information provided by the facility, and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide per 12 residents on the evening shift for six of six days, and failed to ensure a minimum of one nurse aide per 20 residents on the overnight shift for two of six days (24-hour periods) reviewed.
Findings include:
Nursing time schedules provided by the facility for the days of May 22 through May 27, 2024, revealed that the facility provided one nurse aide per 15 residents on May 22, 23, 24 and 26, 2024, and provided one nurse aide per 17 residents on May 25 and 27, 2024, during the evening shift.
Nursing time schedules provided by the facility for the days of May 22 through May 27, 2024, revealed that the facility provided one nurse aide per 21 residents on May 22 and 23, 2024, during the overnight shift.
Interview with the Nursing Home Administrator on May 29, 2024, at 1:15 p.m. confirmed that the facility did not meet the required nurse aide-to-resident staffing ratios for the days listed above.
| | Plan of Correction - To be completed: 07/09/2024
Preparation and/or execution of this Plan of Correction does not constitute admission or agreement by the Provider of the truth or facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of federal and state law.
This Plan of Correction constitutes the facility's credible allegation of compliance.
S5510
The facility cannot retroactively correct nursing hours and ratios.
The facility will continue to focus on recruitment and retention of nursing staff; participate in job fairs to actively recruit new nursing assist team members and utilize outside agency contracts as needed.
The Nursing Home Administrator (NHA) to re-educate the scheduler on the staffing ratios and hours per patient day (HPPD). Staffing meetings to be held to review the calculations for nursing staff ratios and HPPD for accuracy.
The NHA/Designee to conduct Quality Improvement (QI) monitoring of daily schedules to review ratios of care and minimum HPPD being met. QI monitoring to include review of Daily schedules x4 weeks and once a month as needed. Findings to be reported to the Quality Assurance Performance Improvement (QAPI) committee and update as indicated.
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