(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 that the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 9 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 and 1:11 on the evening shift based on the facility's census.
April 3, 2025 - 6.39 nurse aides on the day shift, versus the required 8.80 for a census of 88.
April 3, 2025 - 7.50 nurse aides on the evening shift, versus the required 8.09 for a census of 89.
April 4, 2025 - 7.87 nurse aides on the day shift, versus the required 8.90 for a census of 89.
April 4, 2025 - 7.23 nurse aides on the evening shift, versus the required 8.18 for a census of 90.
April 5, 2025 - 8.63 nurse aides on the day shift, versus the required 9 for a census of 90.
April 6, 2025 - 6.73 nurse aides on the day shift, versus the required 9 for a census of 90.
April 6, 2025 - 7.47 nurse aides on the evening shift, versus the required 8.18 for a census of 90.
April 7, 2025 - 8.90 nurse aides on the day shift, versus the required 9 for a census of 90.
April 7, 2025 - 7.90 nurse aides on the evening shift, versus the required 8 for a census of 88.
On the above dates mentioned no additional excess higher-level staff were available to compensate this deficiency.
An interview with the Nursing Home Administrator on April 9, 2025, at 2:10 PM, confirmed the facility had not met the required nurse aide to resident ratios on the above dates.
| | Plan of Correction - To be completed: 05/20/2025
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.
The facility cannot retroactively correct the Nursing Assistant ratios.
The facility focuses on retention of existing nursing assistants and recruitment of new nursing assistants through efforts of including but not limited to the staffing meetings and holding Nursing Assistant training courses in house.
Bi-Weekly staffing meetings will be held to address good faith efforts towards meeting Nursing Assistant ratios.
The HR/scheduler will make a good faith effort to recruit higher level staff to accommodate the ratios.
Calculation of the daily nursing assistant ratios will be completed and reviewed for accuracy by the scheduler/designee.
Daily ratios will be audited weekly x4 then monthly x2.
The audits will be reviewed x 2 months at monthly QAPI.
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