(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 seven of 21 days reviewed, one NA per 11 residents during the evening shift for one of the 21 days reviewed, and one NA per 15 residents during the night shift for 14 of 21 days reviewed.
Findings include:
Review of nursing staff care hours provided by the facility revealed the following staff scheduled for the following resident census:
Day shift (requires one NA per 10 residents):
August 18, 2024, 10.73 NAs for a census of 115; requires 11.50 NAs August 20, 2024, 11.38 NAs for a census of 117; requires 11.70 NAs August 21, 2024, 11.39 NAs for a census of 116; requires 11.60 NAs September 4, 2024, 11.23 NAs for a census of 115; requires 11.50 NAs September 6, 2024, 10.89 NAs for a census of 117; requires 11.70 NAs September 7, 2024, 10.79 NAs for a census of 118; requires 11.80 NAs September 8, 2024, 10.72 NAs for a census of 117; requires 11.70 NAs
Evening shift (requires one NA per 11 residents):
September 7, 2024, 10.28 NAs for a census of 118; requires 10.73 NAs
Night shift (requires one NA per 15 residents):
August 18, 2024, 6.49 NAs for a census of 115; requires 7.67 NAs August 19, 2024, 6.53 NAs for a census of 116; requires 7.73 NAs August 20, 2024, 7.47 NAs for a census of 117; requires 7.80 NAs August 21, 2024, 6.38 NAs for a census of 116; requires 7.73 NAs August 22, 2024, 7.05 NAs for a census of 115; requires 7.67 NAs August 23, 2024, 6.45 NAs for a census of 116; requires 7.73 NAs August 24, 2024, 6.92 NAs for a census of 116; requires 7.73 NAs September 3, 2024, 6.27 NAs for a census of 116; requires 7.73 NAs September 4, 2024, 6.62 NAs for a census of 114; requires 7.60 NAs September 5, 2024, 6.59 NAs for a census of 116; requires 7.73 NAs September 6, 2024, 6.26 NAs for a census of 118; requires 7.87 NAs September 7, 2024, 6.95 NAs for a census of 118; requires 7.87 NAs September 8, 2024, 6.13 NAs for a census of 116; requires 7.73 NAs September 9, 2024, 6.69 NAs for a census of 115; requires 7.67 NAs
An interview with the Nursing Home Administrator on September 10, 2024, at 1:14 PM confirmed the facility did not meet the minimum regulatory NA-to-resident ratio as evidenced above.
The findings were reviewed with the Nursing Home Administrator and Director of Nursing on September 10, 2024, at 1:23 PM.
| | Plan of Correction - To be completed: 10/30/2024
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.
5520 1. Findings of nursing aide nursing staff care ratios cannot be retroactively corrected. 2. Facility will provide a minimum of 1 nurse aide per 10 residents on the day, one nurse aide per 11 residents during evening and one nurse aide per 15 residents overnight. 3. Scheduler will be educated on the requirements of 1 nurse aide of per 10 residents on the day, one nurse aide per 11 residents during evening and one nurse aide per 15 residents overnight. 4. NHA/designee will conduct random audits to verify that nurse aide dayshift, evening and overnight ratios meet the requirements weekly for 4 weeks. Audit results will be presented to the QAPI meeting for review and recommendations.
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