Observations:
Based on a review of the facility's staffing worksheet and staff interview, it was determined that the facility failed to provide one Nurse Assistant (NA) per 10 residents of the daylight shift for five of seven days (6/23/26, 6/25/26 and 6/26/26 through 6/28/26), one NA per 11 residents on the evening shift for one of seven days (6/24/26), and one NA per 15 residents for the night shift for five of seven days (6/22/26 through 6/26/26) as required.
Findings include:
A review of the facility's staffing worksheet for the time period of 6/22/26, through 6/28/26, revealed the following:
Daylight: Census Actual Hours Hours Required
6/23/26 9060.6372.00
6/25/26 8968.3471.20
6/26/26 8961.4071.20
6/27/26 8865.2070.40
6/28/26 8761.7769.90
Evening: Census Actual Hours Hours Required
6/24/26 9063.0465.45
Night: Census Actual Hours Hours Required
6/22/26 8845.7546.93
6/23/26 9046.8548.00
6/24/26 9038.7548.00
6/25/26 8937.4947.47
6/26/26 8946.7947.47
During an interview on 6/29/26 at 12:35 p.m., the Nursing Home Administrator confirmed that the facility failed to meet State NA staffing ratios on the above days as required.
| | Plan of Correction - To be completed: 08/17/2026
The Facility submits this plan of correction under the procedures established by the Department of Health in order to comply with the department's directive to change conditions which the department alleges are deficient under date and/or federal long term care regulations. This plan of correction should not be construed as either a waiver or the facility right to appeal or challenge the accuracy of severity of the alleged deficiencies or an admission of past or ongoing violation of state or federal regulatory requirements.
The Nursing schedule is created to ensure CNA staffing ratios reflects the current census per shift. Each shifts CNA staffing is adjusted based on census. When additional staff is needed to meet ratios, shifts are posted on our staffing portal, bonuses are offered, phone calls and text messages are sent to staff. The facility will utilize agency to assist with open shifts when needed. The facility attendance policy is followed for staff and disciplines occur per policy. Attendance is tracked on a calendar and reviewed weekly. The facility holds a monthly retention committee meeting and ads are posted on Indeed for open positions. Interviews are conducted immediately.
The Administrator or designee will educate the Nursing Admin, HR, the scheduler and RN Supervisors on nurse aid ratios and how to adjust. A staffing meeting will occur daily to review ratios with the NHA, DON, HR and scheduler. Daily new hire meetings will occur to update the status of new applicants, interviews, and the success or new employees. The 3-week DOH Staffing Calculator Tool will be updated daily to monitor hours. The Audits will be taken to QAPI for review.
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