(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 nursing schedules, review of staffing information furnished by the facility, and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide (NA) per 10 residents on the day shift for two of four days reviewed for August 29, 2026, through September 1, 2026
Findings Include:
Review of facility census data indicated that on June 8, 2026, the facility census was 97, which required 9.70 (97 residents divided by 10) NA's during the daylight shift. Review of the nursing time schedules revealed 8.23 NA's provided care on the daylight shift on August 1, 2026.
On August 29, 2026, the facility census was 113, which required 11.30 NA's during the daylight shift; however, review of the time schedule revealed that 10.51 NA's provided care on the day shift.
On August 31, 2026, the facility census was 114, which required 11.40 NA's during the daylight shift; however, review of the time schedule revealed that 9.84 NA's provided care on the day shift.
No additional excess higher-level staff were available to compensate for these deficiencies.
Interview with the Nursing Home Administrator on September 3, 2026, at 1:22 p.m. confirmed that the facility did not meet the required NA-to-resident staffing ratios for the days listed above.
| | Plan of Correction - To be completed: 09/25/2026
1. Actions taken for the situation identified:
The facility cannot retroactively address the incidents. No residents were adversely affected.
2. How the facility will act to protect residents in similar situations:
The facility will schedule, monitor and manage the nursing staff ratios to meet the requirements. Staffing will be modified to try to account for call offs.
3. System changes and measures to be taken:
The Nursing Home Administrator has reviewed the required ratios with the Director of Nursing and other staff responsible for nursing staff scheduling. Daily staffing meetings are being held two times daily to review the scheduled staffing hours per patient day and ratios for the current and upcoming day(s) to ensure that the facility meets the requirements.
4. Monitoring mechanisms to assure compliance:
The Nursing Home Administrator/designee will conduct audits of the nursing staff ratios to determine compliance weekly for four (4) weeks then monthly for one month. Noted areas of non-compliance will be addressed upon discovery. Audit results will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings, and further action plans and audits will continue until substantial compliance is achieved. Ongoing self-monitoring will help to ensure facility continues to meet quality standards.
5. Date Corrective Action will be completed:
Substantial compliance is expected by 09/25/2026
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