(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 9 shifts out of 21 reviewed.
Findings include:
A review of the facility's weekly staffing records revealed 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.
January 30, 2025 - 4.33 nurse aides on the evening shift, versus the required 4.36 for a census of 48.
January 30, 2025 - 2.97 nurse aides on the night shift, versus the required 3.2 for a census of 48.
January 31, 2025 - 4.13 nurse aides on the day shift, versus the required 4.80 for a census of 48.
January 31, 2025 - 4.27 nurse aides on the evening shift, versus the required 4.36 for a census of 48.
January 31, 2025 - 3.13 nurse aides on the evening shift, versus the required 3.20 for a census of 48.
February 1, 2025 - 4.6 nurse aides on the day shift, versus the required 4.7 for a census of 47.
February 3, 2025 - 3.9 nurse aides on the evening shift, versus the required 4.27 for a census of 47.
February 3, 2025 - 3 nurse aides on the night shift, versus the required 3.13 for a census of 47.
February 4, 2025 - 2.97 nurse aides on the night shift, versus the required 3.27 for a census of 49.
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 February 13, 2025, at approximately 2:15 PM, confirmed the facility had not met the required nurse aide to resident ratios on the above dates.
| | Plan of Correction - To be completed: 03/04/2025
Step 1.
The facility cannot retroactively provide the minimum number of Nurse Aide hours for cited dates.
Step 2.
Moving forward, the facility will continue to schedule staff to meet or exceed the mandated Nurse Aide ratio hours. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios.
Step 3.
To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum staffing of Nurse Aide for the facility.
Step 4.
To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum Nurse Aide hours needed for the facility. Audits will be completed 5x/ week x4 weeks, and then weekly x2 months. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
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