(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 review of facility nursing staffing documents and staff interview, it was determined that the facility failed to meet the Nurse Aide (NA) ratios for one NA per 10 residents on day shift for four of seven days reviewed (5/9/25, 5/10/25, 5/11/25, and 5/12/25); and failed to meet the NA ratio for one NA per 11 residents on the evening shift for six of seven days reviewed (5/6/25, 5/7/25, 5/8/25, 5/9/25, 5/11/25, and 5/12/25); and failed to meet the NA ratio for one NA per 15 residents on the overnight shift for six of seven days reviewed (5/6/25, 5/7/25, 5/8/25, 5/9/25, 5/10/25, and 5/11/25).
Findings include:
Review of facility nursing staffing documents for the time period from 5/6/25, through 5/12/25, revealed the following NA staffing shortages for the day shift where the NA ratios were not met:
5/09/25census of 118 residents10.53 NAs worked and 11.80 were required
5/10/25census of 117 residents9.00 NAs worked and 11.70 were required
5/11/25census of 117 residents7.00 NAs worked and 11.70 were required
5/12/25census of 117 residents9.00 NAs worked and 11.70 were required
Review of facility nursing staffing documents for the time period from 5/6/25, through 5/12/25, revealed the following NA staffing shortages for the evening shift where the NA ratios were not met:
5/06/25census of 116 residents9.50 NAs worked and 10.55 were required
5/07/25census of 115 residents7.00 NAs worked and 10.45 were required
5/08/25census of 115 residents9.00 NAs worked and 10.45 were required
5/09/25census of 118 residents8.00 NAs worked and 10.73 were required
5/11/25census of 117 residents10.63 NAs worked and 10.64 were required
5/12/25census of 117 residents8.50 NAs worked and 10.64 were required
Review of facility nursing staffing documents for the time period from 5/6/25, through 5/12/25, revealed the following NA staffing shortages for the overnight shift where the NA ratios were not met:
5/06/25census of 116 residents7.00 NAs worked and 7.73 were required
5/07/25census of 115 residents7.00 NAs worked and 7.67 were required
5/08/25census of 115 residents6.00 NAs worked and 7.67 were required
5/09/25census of 118 residents6.00 NAs worked and 7.87 were required
5/10/25census of 117 residents6.53 NAs worked and 7.80 were required
5/11/25census of 117 residents5.00 NAs worked and 7.80 were required
During a telephone interview on 5/15/25, at 9:20 a.m. the Nursing Home Administrator confirmed that the facility did not meet the minimum NA ratios for the above days and shifts.
| | Plan of Correction - To be completed: 06/11/2025
"The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements."
1. The facility cannot correct that the nurse aide staffing ratio was not met on 5/6, 5/7, 5/8, 5/9, 5/10, 5/11, and 5/12/25.
2. System changes will be put into place to ensure minimum requirements to be put into place will include:
3. Facility currently has multiple nursing staff members in the onboarding process to start employment at the facility.
4. All nursing positions are actively posted in recruitment.
5. Bonuses are offered on an as needed basis.
6. Call offs will continue to be monitored, and disciplines will be issued, as appropriate.
7. When call offs occur, all available staff members will be called to ask it they will fill the vacancy to ensure the appropriate staffing levels.
8. On a daily basis, the facility reviews the ability to take admissions based on the staffing numbers.
9. All RN's and staffing coordinator will be educated on staffing ratios. By NHA (Nursing Home Administrator) or Designee.
10. Daily meetings will be held to review schedule with ratio's.
11. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing ratios the nursing supervisor/or designee will call off duty facility staff, will notify Director of Nursing and will utilize pick-up bonuses.
DON (Director of Nursing) or designee will monitor staffing ratios by reviewing the current working schedule and assignment sheets prior to the day and after the day is complete to ensure compliance daily x 10 days then weekly x 6 weeks, then once monthly x2 to ensure compliance.
This will be reviewed at the Quarterly QAPI (Quality Assurance/Performance Improvement) meetings.
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