(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 review of facility nursing staffing documents and staff interview, it was determined that the facility failed to meet the Nurse Aide (NA) ratios for one NA per 10 residents on day shift for five of 14 days reviewed (8/10/24, 8/11/24, 8/12/24, 8/17/24 and 8/18/24); and the NA ratio for one NA per 11 residents on the evening shift for two of 14 days reviewed (8/15/24 and 8/18/24); and the NA ratio for one NA per 15 residents on the overnight shift for nine of 14 days reviewed (8/09/24, 8/10/24, 8/12/24, 8/13/24, 8/14/24, 8/15/24, 8/16/24, 8/17/24, and 8/18/24).
Findings include:
Review of facility nursing staffing ratio information for the time period from 8/06/24, through 8/19/24, revealed the following NA staffing shortage for the day shift where the NA ratios were not met:
8/10/24census of 110 residents10.05 NAs worked and 11.00 were required
8/11/24census of 109 residents9.67 NAs worked and 10.90 were required
8/12/24census of 109 residents9.01 NAs worked and 10.90 were required
8/17/24census of 110 residents10.29 NAs worked and 11.00 were required
8/18/24census of 111 residents9.76 NAs worked and 11.10 were required
Review of facility nursing staffing ratio information for the time period from 8/06/24, through 8/19/24, revealed the following NA staffing shortage for the evening shift where the NA ratios were not met:
8/15/24census of 110 residents9.26 NAs worked and 10.00 were required
8/18/24census of 111 residents10.04 NAs worked and 10.09 were required
Review of facility nursing staffing ratio information for the time period from 8/06/24, through 8/19/24, revealed the following NA staffing shortage for the overnight shift where the NA ratios were not met:
8/09/24census of 110 residents6.06 NAs worked and 7.33 were required
8/10/24census of 110 residents5.62 NAs worked and 7.33 were required
8/12/24census of 109 residents5.53 NAs worked and 7.27 were required
8/13/24census of 110 residents5.58 NAs worked and 7.33 were required
8/14/24census of 109 residents5.60 NAs worked and 7.27 were required
8/15/24census of 110 residents5.98 NAs worked and 7.33 were required
8/16/24census of 109 residents6.74 NAs worked and 7.27 were required
8/17/24census of 110 residents4.84 NAs worked and 7.33 were required
8/18/24census of 111 residents5.55 NAs worked and 7.40 were required
During an interview on 8/27/24, at 1:50 p.m. the Nursing Home Administrator confirmed that the facility did not meet the minimum NA ratios for the above days and shifts.
| | Plan of Correction - To be completed: 09/30/2024
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.
The facility is unable to retroactively correct the state general nursing hours for 8/6/24, 8/9/24, 8/10/24, 8/11/24, 8/12/24, 8/13/24, 8/14/24, 8/15/24, 8/16/24, 8/17/24, 8/18/24, and 8/19/24.
The facility will schedule a minimum of 1 nurse aide per 10 residents on day shift, 1 nurse aide per 11 residents on evening shift and 1 nurse aide per 15 residents on night shift.
NHA or designee will educate the scheduling coordinator and RN supervisors on the requirements of nurse aide ratios of 1 nurse aide per 10 residents on day shift, 1 nurse aide per 11 residents on evening shift and 1 nurse aide per 15 residents on night shift.
Calloffs will be monitored by NHA/DON and/or designee. Staff will be offered bonuses and staffing agencies will be utilized to facilitate replacement/procurement of staff.
Licensed/certified staff from administrative/ancillary departments will be utilized to supplement direct care staffing when necessary.
Audits of daily shift ratios will be completed by the NHA/designee weekly x3 weeks and monthly x3 months. Findings and records of staffing audits will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring or changes needed.
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