(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 a review of nurse staffing and staff interview, it was determined the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 34 shifts out of 63 reviewed.
Findings include:
A review of the facility's weekly staffing records revealed on the following dates the facility failed to provide minimum nurse aide staff of 1:10 on the day shift, 1:11 on the evening shift, and 1:15 on the night shift based on the facility's census.
February 19, 2025 - 4.93 nurse aides on the night shift, versus the required 5.27 for a census of 79. February 20, 2025 - 4.40 nurse aides on the night shift, versus the required 5.27 for a census of 79. February 21, 2025 - 8.13 nurse aides on the day shift, versus the required 8.2 for a census of 82. February 21, 2025 - 6.40 nurse aides on the evening shift, versus the required 7.45 for a census of 82. February 21, 2025 - 5 nurse aides on the night shift, versus the required 5.47 for a census of 82. February 22, 2025 - 6.53 nurse aides on the day shift, versus the required 8.3 for a census of 83. February 22, 2025 - 9.93 nurse aides on the evening shift, versus the required 7.55 for a census of 83. February 22, 2025 - 4 nurse aides on the night shift, versus the required 5.53 for a census of 83. February 23, 2025 - 6.80 nurse aides on the day shift, versus the required 8.30 for a census of 83. February 23, 2025 - 4 nurse aides on the night shift, versus the required 5.53 for a census of 83. February 24, 2025 - 7.67 nurse aides on the evening shift, versus the required 7.73 for a census of 85. February 24, 2025 - 5.27 nurse aides on the night shift, versus the required 5.67 for a census of 85. February 25, 2025 - 8 nurse aides on the day shift, versus the required 8.6 for a census of 86. February 25, 2025 - 7 nurse aides on the evening shift, versus the required 7.82 for a census of 86. February 25, 2025 - 4.4 nurse aides on the night shift, versus the required 5.73 for a census of 86. February 26, 2025 - 8.13 nurse aides on the day shift, versus the required 8.4 for a census of 84. February 26, 2025 - 6 nurse aides on the evening shift, versus the required 7.64 for a census of 84. February 26, 2025 - 5 nurse aides on the night shift, versus the required 5.6 for a census of 84. February 28, 2025 - 4.27 nurse aides on the night shift, versus the required 5.53 for a census of 83. March 1, 2025 - 8 nurse aides on the day shift, versus the required 8.30 for a census of 83. March 1, 2025 - 4.27 nurse aides on the night shift, versus the required 5.53 for a census of 83. March 2, 2025 - 7.4 nurse aides on the day shift, versus the required 8.3 for a census of 83. March 2, 2025 - 7.55 nurse aides on the evening shift, versus the required 6.87 for a census of 83. March 2, 2025 - 3 nurse aides on the night shift, versus the required 5.53 for a census of 83. March 3, 2025 - 7.87 nurse aides on the day shift, versus the required 8.4 for a census of 84. March 3, 2025 - 3.87 nurse aides on the night shift, versus the required 5.6 for a census of 84. March 4, 2025 - 5 nurse aides on the night shift, versus the required 5.6 for a census of 84. March 5, 2025 - 5 nurse aides on the night shift, versus the required 5.47 for a census of 82. March 6, 2025 - 8 nurse aides on the day shift, versus the required 8.2 for a census of 82. March 6, 2025 - 5 nurse aides on the night shift, versus the required 5.47 for a census of 82. March 7, 2025 - 4 nurse aides on the night shift, versus the required 5.53 for a census of 83. March 8, 2025 - 5 nurse aides on the night shift, versus the required 5.53 for a census of 83. March 9, 2025 - 5.47 nurse aides on the night shift, versus the required 5.53 for a census of 83. March 10, 2025 - 8 nurse aides on the night shift, versus the required 8.30 for a census of 83.
On the above dates listed, no additional excess higher-level staff were available to compensate this deficiency.
An interview with the Nursing Home Administrator on March 11, 2025, at approximately 4:00 PM, confirmed the facility had not met the required nurse aide to resident ratios on the above dates.
| | Plan of Correction - To be completed: 06/03/2025
Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.
1) The facility cannot retroactively correct the past Nurse Aide staff ratios.
2) Moving forward, the facility will continue to make good faith effort to schedule staff to meet or exceed the mandated ratios of One NA to 10 residents on day shift; one NA to 11 residents on evening shift and one NA to 15 residents on night shift. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. The facility contracts with agencies to supply aides to meet requirements but call offs and no-show result in unmet ratios. The facility is working to hire and train staff to achieve the minimum staffing ratios for nurse aides. The facility offers bonuses to staff to encourage staff to pick up additional shifts.
3)To prevent this from reoccurring, the RDCS re-educated the NHA; DON and Scheduler on the updated staffing regulations in relation to the minimum ratio of one NA to 10 residents on days, one NA to 11 residents on evenings and one NA to 15 residents on nights. The staffing is reviewed each day for the subsequent day(s) by the NHA and/or DON to ensure adequate staff to meet or exceed the minimum ratios. Needs are posted each week for internal staff to pick up extra shifts as well as posted with outside agencies.
4) To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum NA ratios. Audits will be completed 5x weekly x4 weeks; 3x weekly x1 month and weekly x1 month. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
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