(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.
|
Observations:
Based on a review of nursing staffing hours and staff interviews, 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 the 20 days reviewed and failed to ensure a minimum of one nurse aide per 11 residents during the evening shift for seven of the 20 days reviewed.
Findings include:
A review of nursing care hours provided by the facility from November 28 to December 17, 2025, revealed the following NAs scheduled for resident census:
Day shift (requires one NA per 10 residents):
December 13, 2025, census of 69 with 5.83 NAs, required 6.90
December 14, 2025, census of 69 with 6.00 NAs, required 6.90
Evening shift (requires one NA per 11 residents):
November 29, 2025, census of 69 with 5.83 NAs, required 6.27
December 1, 2025, census of 69 with 5.57 NAs, required 6.27
December 3, 2025, census of 70 with 5.88 NAs, required 6.36
December 5, 2025, census of 70 with 6.11 NAs, required 6.36
December 12, 2025, census of 69 with 5.64 NAs, required 6.27
December 13, 2025, census of 69 with 5.54 NAs, required 6.27
December 15, 2025, census of 69 with 5.44 NAs, required 6.27
Interview with the Nursing Home Administrator and Director of Nursing on December 18, 2025, 1:25 PM confirmed that the facility did not meet regulatory nurse aide ratio as evidenced above.
| | Plan of Correction - To be completed: 01/21/2026
1. The facility acknowledges that previously documented nurse aide staffing ratios cannot be retroactively corrected.
2. The facility has implemented measures to ensure ongoing compliance with minimum nurse aide–to–resident staffing ratios. These measures include continued operation and oversight by the Recruitment and Retention Committee to support a stable workforce, increased recruitment efforts through expanded advertising initiatives, and utilization of agency staff, as necessary, to maintain required staffing levels.
3. The Director of Clinical Services or designee will provide education on minimum CNA staffing ratio requirements to all RN Supervisors, Human Resources Director, and the Clinical Scheduler.
4. The Director of Clinical Services or designee will audit daily staffing schedules five times per week for four (4) weeks to verify required nurse aide–to–resident ratios are consistently scheduled, document the results of each audit and identify any deficiencies requiring correction and present audit findings at the facility's QAPI Committee Meeting for review, analysis, and recommendations for continued improvement. The facility's QAPI Committee will reassess the monitoring schedule after four (4) weeks and determine whether additional oversight is necessary.
|
|
