Observations:
Based on review of facility nursing staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one Nurse Aide (NA) per 10 residents on the day shift for one of 14 days reviewed (6/06/26); failed to ensure one NA per 11 residents on the evening shift for one of 14 days (6/12/26); and failed to ensure a minimum of one NA per 15 residents on the overnight shift for five of 14 days reviewed for staffing (6/16/26).
Findings include:
Review of facility nursing staffing documents for the time period of 6/03/26, through 6/16/26, revealed following NA shortage for the day shift:
6/06/26 facility census of 41 residents 4.00 NAs worked and 4.10 were required.
Review of facility nursing staffing documents for the time period of 6/03/26, through 6/16/26, revealed following NA shortage for the evening shift:
6/12/26 facility census of 42 residents 3.13 NAs worked and 3.82 were required.
Review of facility nursing staffing documents for the time period of 76/03/26, through 6/16/26, revealed following NA shortage for the night shift:
6/16/26 facility census of 41 residents 2.13 NAs worked and 2.73 were required.
During an email confirmation on 6/22/26, at 2:27 p.m. the Nursing Home Administrator confirmed that the facility was unable to provide all required staffing information requested during the survey and failed to meet the minimum NA ratio requirements on the above shifts and dates.
| | Plan of Correction - To be completed: 08/23/2026
1.Daily audits of the staffing sheet to assure that the minimum nurse aid ratios are met will be conducted by the DON (Director of Nursing) or designee.
2. A daily staffing meeting will occur with the Administrator, Director of Nursing, and RN Supervisor that covers such topics as current day CNA (Certified Nurse Aide) PPD (hours per patient day) and ratios, prior and next day PPD and ratio review, any disciplines that need handed out to staff, any interviews scheduled for the current day, and the status of onboarding/check ins/orientation checklist/check-ins for any new hires.
3. RN (Registered Nurse) Supervisors have the authority to make changes to the schedule as needed (in cases of CNA staffing ratios below the minimum requirement) so the minimum CNA staffing ratio is achieved for each shift; the Director of Nursing will provide the RN Supervisor with a copy of the staffing/PPD grid for each shift, which they will then use to ensure that the minimum CNA ratios are met based on the number of residents in the building and the number of CNA's scheduled per shift.
4. Requisitions for both per-diem and full-time CNA's have been submitted to help alleviate staffing concerns for all three shifts.
5. The facility is currently utilizing a member of the management staff (Medical Records Director) who is a trained Certified Nursing Assistant to cover CNA shortages on 2nd and 3rd shift, three to four days per week, where the CNA ratios are currently at the lowest levels.
6. All results from above will be reviewed at the facility's QAPI (Quality Assurance and Performance Improvement) meetings for 3 quarters.
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