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 of one NA per 10 residents on the day shift for two of five days reviewed (5/17/26, and 5/19/26); and failed to meet the ratio of one NA per 11 residents on the evening shift for three of five days reviewed (5/15/26, 5/16/26, and 5/17/26); and failed to meet the ratio of one NA per 15 residents on the overnight shift for two of five days reviewed (5/16/26, and 5/17/26).
Findings include:
Review of nursing staffing documents for the time period from 5/15/26 through 5/19/26, revealed the following NA staffing shortages for the day shift:
5/17/26 facility census of 139 residents, 13.19 NAs worked and 13.90 were required.
5/19/26 facility census of 137 residents, 13.46 NAs worked and 13.70 were required.
Review of the nursing staffing documents for the time period from 5/15/26 through 5/19/26, revealed the following NA staffing shortages for the evening shift:
5/15/26 facility census of 138 residents, 12.43 NAs worked and 12.55 were required.
5/16/26 facility census of 139 residents, 12.50 NAs worked and 12.64 were required.
5/17/26 facility census of 139 residents, 12.26 NAs worked and 12.64 were required.
Review of nursing staffing documents for the time period from 5/15/26 through 5/19/26, revealed the following NA staffing shortages for the overnight shift:
5/16/26 facility census of 139 residents, 9.17 NAs worked and 9.13 were required.
5/17/26 facility census of 139 residents, 8.12 NAs worked and 9.18 were required.
During a telephone interview on 5/27/26, at 10:00 a.m. the Nursing Home Administrator confirmed that the facility failed to meet the minimum NA ratio requirements on the above shifts and dates.
| | Plan of Correction - To be completed: 06/24/2026
"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 5/15, 5/16, 5/17, and 5/19/26.
2. System changes will be put into place to ensure minimum requirements are met changes 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. Call offs are monitored by Human Resources, Director of Nursing, and Nursing Home Administrator.
7. When call-offs occur, all available staff members will be called to ask if they will fill the vacancy to ensure the appropriate staffing levels.
8. On a daily basis, the NHA (Nursing Home Administrator) or DON (Director of Nursing) or Designee reviews the ability to take admissions based on the staffing numbers.
9. All RN's (Registered Nurse) and staffing coordinator will be educated on staffing ratios. By NHA (Nursing Home Administrator) or Designee.
10. Daily meetings will be held, with DON, NHA, and staffing coordinator, 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 QAPI (Quality Assurance/Performance Improvement) meetings.
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