(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 nurse staffing and staff interviews, it was determined the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 13 shifts out of 21 shifts reviewed.
Findings include:
A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide the minimum nurse aide staff of 1:10 on the day shift, 1:11 on the evening shift, and 1:15 on the night shift based on the facility's census:
February 5, 2026, 10.0 NAs on the day shift, versus the required 10.50, for a census of 105.
February 5, 2026, 8.0 NAs on the evening shift, versus the required 9.55, for a census of 105.
February 6, 2026, 9.0 NAs on the day shift, versus the required 10.50, for a census of 105.
February 6, 2026, 7.63 NAs on the evening shift, versus the required 9.45, for a census of 104.
February 6, 2026, 6.50 NAs on the night shift, versus the required 6.93, for a census of 104.
February 7, 2026, 9.25 NAs on the evening shift, versus the required 9.55, for a census of 105.
February 7, 2026, 6.0 NAs on the night shift, versus the required 6.93, for a census of 104.
February 9, 2026, 6.50 NAs on the evening shift, versus the required 9.55, for a census of 105.
February 9, 2026, 5.0 NAs on the night shift, versus the required 7.0, for a census of 105.
February 10, 2026, 10.0 NAs on the day shift, versus the required 10.5, for a census of 105.
February 10, 2026, 8.50 NAs on the evening shift, versus the required 9.45, for a census of 104.
February 11, 2026, 8.0 NAs on the evening shift, versus the required 9.45, for a census of 104.
February 11, 2026, 5.0 NAs on the night shift, versus the required 6.93, for a census of 104.
On the above dates mentioned, no additional excess higher-level staff were available to compensate for this deficiency.
An interview with the Nursing Home Administrator on February 12, 2026, at 2:30 PM, confirmed the facility had not met the required NA to resident ratios on the above dates.
| | Plan of Correction - To be completed: 03/06/2026
P5520 CNA Staffing Ratios
1. The facility is unable to correct
CNA staffing ratios for February 5-6-7-9-10-11, 2026.
2. No other dates were identified during the survey.
3. To prevent this from reoccurring, the DON/designee completed education with the nursing supervisors and scheduler to ensure the CNA staffing ratios are adequate for the census. Staffing will be based on current census and supervisors or scheduler will contact other
staff to cover call offs.
NHA,DON, HR and/or Scheduler will meet daily during the week to review staffing
needs, call offs ,ppd & ratios.
Facility is using Nurse Aide Training program to recruit and train new Nursing Assistants.
4. To monitor or maintain ongoing compliance, the DON/designee will audit the schedule weekly x 4 weeks and biweekly x 4 to ensure the CNA staffing ratio has been met. Results will be reviewed at the QAPI
5. 3/6/2026
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