(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 eight of 12 days reviewed from September 18, 2025 through September 29, 2025, failed to ensure a minimum of one nurse aide per 11 residents on the evening shift for three of 12 days reviewed from September 18, 2025 through September 29, 2025, and failed to ensure a minimum of one nurse aide per 15 residents on the night shift for three of 12 days reviewed from September 18, 2025 through September 29, 2025
Findings include:
On September 18, 2025, the facility census was 102 for the day shift which required 10.20 nurse aides to provide care. Review of the nursing time schedules revealed 8.87 nurse aides provided care on the day shift. On August 15, 2025, the facility census was 102 for the evening shift, which required 9.27 nurse aides to provide care. Review of the nursing time schedules revealed 8.20 nurse aides provided care on the evening shift.
On September 19, 2025, the facility census was 102 during the day shift, which required 10.20 nurse aides to provide care. Review of the nursing time schedules revealed 10.10 nurse aides provided care on the day shift on September 19, 2025.
On September 21, 2025, the facility census was 100 for the day shift, which required 10.00 nurse aides to provide care during the day shift. Review of the nursing time schedules revealed 8.43 nurse aides provided care on the day shift on September 21,2025.
On September 23, 2025, the facility census was 101 during the night shift, which required 6.73 nurse aides to provide care. Review of the nursing time schedules revealed 5.70 nurse aides provided care during the night shift on September 23, 2025.
On September 25, 2025, the facility census was 102 during the day shift, which required 10.20 nurse aides to provide care. Review of the nursing time schedules revealed 9.00 nurse aides provided care during the day shift on September 25, 2025.
On September 26, 2025, the facility census was 102 during the day shift, which required 10.20 nurse aides to provide care. Review of the nursing time schedules revealed 8.80 nurse aides provided care during the day shift on September 26, 2025. On September 26, 2025, the facility census was 102 during the night shift, which required 6.80 nurse aides to provide care. Review of the nursing time schedules revealed 6.03 nurse aides provided care during the night shift on September 26, 2025.
On September 27, 2025, the facility census was 101 during the day shift, which required 10.10 nurse aides to provide care. Review of the nursing time schedules revealed 7.23 nurse aides provided care during the day shift on September 27, 2025. On September 27, 2025, the census was 101 during the evening shift, which required 9.18 nurse aides to provide care. Review of the nursing time schedules revealed that 8.60 nurse aides provided care during the evening shift on September 27, 2025.
On September 28, 2025, the facility census was 102 during the day shift, which required 10.20 nurse aides to provide care. Review of the nursing time schedules revealed 10.07 nurse aides provided care during the day shift on September 28, 2025. On September 28, 2025, the facility census was 102 during the evening shift, which required 9.27 nurse aides to provide care. Review of the nursing time schedules revealed that 7.73 nurse aides provided care during the evening shift on September 28, 2025.
On September 29, 2025, the facility census was 102 during the day shift, which required 10.20 nurse aides to provide care. Review of the nursing time schedules revealed 10.00 nurse aides provided care during the day shift on September 29, 2025. On September 29, 2025, the facility census was 102 during the night shift, which required 6.80 nurse aides to provide care during the night shift on September 29, 2025. Review of the nursing time scheduled revealed 6.03 nurse aides provided care during the night shift on September 29, 2025.
Interview with the Nursing Home Administrator on October 23, at 10:29 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: 11/12/2025
The submission of this plan of correction does not constitute admission or agreement on the part of the provider with the deficiencies or conclusions contained in the Statement of Deficiencies. This plan of correction is prepared and executed solely to respond to the allegation of non-compliance cited during the survey ended on 10/23/2025.
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 November 12, 2025.
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