(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 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 7 shifts out of 21 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 per the regulation that was effective July 1, 2024.
February 1, 2026- 6.08 nurse aides on the night shift, versus the required 7.33 for a census of 110.
February 2, 2026- 6.48 nurse aides on the night shift, versus the required 7.33 for a census of 110.
February 3, 2026- 5.45 nurse aides on the night shift, versus the required 7.40 for a census of 111.
February 4, 2026- 6.17 nurse aides on the night shift, versus the required 7.40 for a census of 111.
February 5, 2026- 6.53 nurse aides on the night shift, versus the required 7.53 for a census of 113.
February 7, 2026- 9.29 nurse aides on the day shift, versus the required 11.30 for a census of 113.
February 7, 2026- 7.27 nurse aides on the night shift, versus the required 7.53 for a census of 113.
On the above dates mentioned no additional excess higher-level staff were available to compensate for this deficiency.
The above findings were reviewed with the Nursing Home Administrator on February 11, 2026, at 08:50AM, that the facility had not met the required nurse aide to resident ratios on the above dates.
| | Plan of Correction - To be completed: 04/07/2026
Unable to immediately correct the identified practice.
A labor management meeting will take place
after morning report, to include but not limited to the NHA, DON, Scheduler, Human Resources and Regional Director of Operations. at this time a review of actual ratios of the previous day will be discussed and review of current and next day ratios.
Nursing leadership will be educated to identify ratios needed to be compliant, and what necessary steps need to be taken to prevent ratio deficient practices.
The facility continues to work with a recruitment agency to assist in recruitment efforts.
Trends of ratios from the daily labor management meetings will be discussed at the QAPI meetings
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