(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, staffing information furnished by the facility, and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide per 10 residents on the day shift for two of four days reviewed from August 15, 2025 through August 18, 2025, failed to ensure a minimum of one nurse aide per 11 residents on the evening shift for three of four days reviewed from August 15, 2025 through August 18, 2025, and failed to ensure a minimum of one nurse aide per 15 residents on the night shift for two of four days reviewed from August 15, 2025 through August 18, 2025.
Findings include:
Review of facility census data revealed:
On August 15, 2025, the facility census was 105, which required 9.55 nurse aides during the evening shift. Review of the nursing time schedules revealed 8.80 nurse aides provided care on the evening shift. On August 15, 2025, the facility census was 105, which required 7.00 nurse aides on the night shift. Review of the nursing time schedules revealed 5.03 nurse aides provided care on the night shift.
On August 16, 2025, the facility census was 106, which required 10.60 nurse aides during the day shift. Review of the nursing time schedules revealed 9.03 nurse aides provided care on the day shift.
On August 17, 2025, the facility census was 106, which required 10.60 nurse aides during the day shift. Review of the nursing time schedules revealed 9.17 nurse aides provided care on the day shift. On August 17, 2025, the facility census was 106, which required 9.64 nurse aides during the evening shift. Review of the nursing time schedules revealed 8.93 nurse aides provided care on the evening shift.
On August 18, 2025, the facility census was 106, which required 9.64 nurse aides during the evening shift. Review of the nursing time schedules revealed 9.60 nurse aides provided care on the evening shift. On August 18, 2025, the facility census was 106, which required 7.07 nurse aides during the night shift. Review of the nursing time schedules revealed 5.40 nurse aides provided care on the night shift.
Interview with the Nursing Home Administrator on August 21, 2025, at 11:19 a.m. confirmed that the facility did not meet the required nurse aide-to-resident staffing ratios for the days listed above.
| | Plan of Correction - To be completed: 09/18/2025
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
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 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 two (2) months. 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 September 18, 2025.
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