(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 14 of 21 days reviewed; failed to ensure a minimum of one NA per 11 residents during the evening shift for eight of 21 days reviewed; and failed to ensure a minimum of one NA per 15 residents during the overnight shift for 21 of 21 days reviewed.
Findings include:
Review of nursing staff care hours provided by the facility for April 20 through 26, 2025, April 27 to May 3, 2025, and May 8 to 14, 2025, revealed the following NAs scheduled for resident census:
Day shift (requires one NA per 10 residents):
April 20, 2025, 9.87 NAs for a census of 112; requires 11.20 NAs April 22, 2025, 9.00 NAs for a census of 111; requires 11.10 NAs April 24, 2025, 11.00 NAs for a census of 116; requires 11.60 NAs
April 28, 2025, 10.00 NAs for a census of 112; requires 11.20 NAs April 29, 2025, 10.08 NAs for a census of 112; requires 11.20 NAs April 30, 2025, 11.02 NAs for a census of 112; requires 11.20 NAs May 3, 2025, 9.50 NAs for a census of 113; requires 11.30 NAs
May 8, 2025, 9.56 NAs for a census of 114; requires 11.40 NAs May 9, 2025, 10.00 NAs for a census of 114; requires 11.40 NAs May 10, 2025, 9.23 NAs for a census of 113; requires 11.30 NAs May 11, 2025, 10.00 NAs for a census of 114; requires 11.40 NAs May 12, 2025, 11.00 NAs for a census of 114; requires 11.40 NAs May 13, 2025, 10.00 NAs for a census of 113; requires 11.30 NAs May 14, 2025, 10.37 NAs for a census of 112; requires 11.20 NAs
Evening shift (requires one NA per 11 residents):
April 23, 2025, 10.12 NAs for a census of 115; requires 10.45 NAs
May 1, 2025, 10.20 NAs for a census of 114; requires 10.36 NAs
May 8, 2025, 9.59 NAs for a census of 114; requires 10.36 NAs May 9, 2025, 9.13 NAs for a census of 114; requires 10.36 NAs May 10, 2025, 8.82 NAs for a census of 114; requires 10.36 NAs May 11, 2025, 7.70 NAs for a census of 114; requires 10.36 NAs May 12, 2025, 8.98 NAs for a census of 114, requires 10.36 NAs May 14, 2025, 10.00 NAs for a census of 112, requires 10.18 NAs
Overnight shift (requires one NA per 15 residents):
April 20, 2025, 6.00 NAs for a census of 110; requires 7.33 NAs April 21, 2025, 6.00 NAs for a census of 110; requires 7.33 NAs April 22, 2025, 6.24 NAs for a census of 113; requires 7.53 NAs April 23, 2025, 6.08 NAs for a census of 116; requires 7.73 NAs April 24, 2025, 6.08 NAs for a census of 115; requires 7.67 NAs April 25, 2025, 6.00 NAs for a census of 112; requires 7.47 NAs April 26, 2025, 6.12 NAs for a census of 113; requires 7.53 NAs
April 27, 2025, 6.58 NAs for a census of 112; requires 7.47 NAs April 28, 2025, 7.24 NAs for a census of 112; requires 7.47 NAs April 29, 2025, 6.37 NAs for a census of 112; requires 7.47 NAs April 30, 2025, 6.43 NAs for a census of 113; requires 7.53 NAs May 1, 2025, 6.12 NAs for a census of 112; requires 7.47 NAs May 2, 2025, 6.37 NAs for a census of 112; requires 7.47 NAs May 3, 2025, 5.81 NAs for a census of 113; requires 7.53 NAs
May 8, 2025, 6.37 NAs for a census of 114; requires 7.60 NAs May 9, 2025, 6.00 NAs for a census of 113; requires 7.53 NAs May 10, 2025, 5.98 NAs for a census of 114; requires 7.60 NAs May 11, 2025, 6.16 NAs for a census of 114; requires 7.60 NAs May 12, 2025, 6.37 NAs for a census of 113; requires 7.53 NAs May 13, 2025, 5.57 NAs for a census of 112; requires 7.47 NAs May 14, 2025, 5.23 NAs for a census of 111; requires 7.40 NAs
During a meeting with the Nursing Home Administrator and Director of Nursing on May 15, 2025, at 12:52 PM they confirmed that the facility did not meet regulatory nurse aide ratios as evidenced above.
| | Plan of Correction - To be completed: 07/10/2025
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.
P5520 1. Findings of nurse aide nursing staff care ratios cannot be retroactively corrected. 2. Facility will provide a minimum of one nurse aide per 10 residents during day shift and one nurse aide per 11 residents on evening shift and one nurse aide per 15 residents on overnight shift. Staffing team will meet daily Monday-Friday to review staffing needs and create plans to ensure nurse aide coverage. 3. Scheduling manager will be educated on the requirements there must be a minimum of one nurse aide per 10 residents during day shift and a minimum of one nurse aide per 11 residents on evening shift and one nurse aide per 15 residents on overnight shift. 4. Director of Nursing or Designee will conduct random audits to verify that nurse aide day shift, evening shift ratios and overnight shift meet the requirements weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at the QAPI meeting for review and recommendations.
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