(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 nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide (NA) per 10 residents during the day shift for two of six days reviewed, one NA per 11 residents during the evening shift for five of six days reviewed, and one NA per 15 residents during the night shift for three of six days reviewed.
Findings include:
Review of nursing staff care hours provided by the facility revealed the following nurse aides scheduled for the resident census:
Day shift (requires one NA per 10 residents):
November 17, 2024, 6.03 NAs for a census of 65, requires 6.50 NAs
November 20, 2024, 6.00 NAs for a census of 65, requires 6.50 NAs
Evening shift (requires one NA per 11 residents):
November 15, 2024, 5.49 NAs for a census of 62, requires 5.64 NAs
November 16, 2024, 2.97 NAs for a census of 63, requires 5.73 NAs
November 17, 2024, 5.12 NAs for a census of 65, requires 5.91 NAs
November 18, 2024, 5.48 NAs for a census of 64, requires 5.82 NAs
November 20, 2024, 5.88 NAs for a census of 65, requires 5.91 NAs
Night shift (requires one NA per 15 residents):
November 17, 2024, 3.29 NAs for a census of 65, requires 4.33 NAs
November 18, 2024, 4.03 NAs for a census of 64, requires 4.27 NAs
November 19, 2024, 4.13 NAs for a census of 65, requires 4.33 NAs
Interview with the Nursing Home Administrator and Director of Nursing on November 20, 2024, at 12:42 PM confirmed that the facility did not meet regulatory NA-to-resident ratios as evidenced above.
| | Plan of Correction - To be completed: 01/19/2025
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider with the statement of deficiencies. The plan of correction is prepared and/or executed because it is required by provision of Federal and State regulations.
The facility cannot retroactively correct.
The facility will conduct audits of the schedule prior to posting to evaluate nursing staffing ratios.
The facility has temporally closed a hall. The facility is making reasonable attempts to acquire new staff, including offering competitive pay rates, sign on and referral bonuses, email blasts, hiring signage and the utilization of supplemental agency staff.
The scheduler is aware of the requirement of meeting the minimum staffing ratios as per regulation.
The DON or designee will monitor daily staffing to ensure staffing ratios are met. Any concerns will be discussed with the ED on a daily basis. Trends identified will be reported to the QAPI Committee monthly for further recommendations.
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