(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 the 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 for the day shift for six of 21 days reviewed (2/07/26, 2/08/26, 2/09/26, 2/18/26, 2/20/26, and 2/22/26); failed to ensure a minimum of one NA per 11 residents for the evening shift for 12 of 21 days reviewed (2/06/26, 2/07/26, 2/08/26, 2/10/26, 2/11/26, 2/12/26, 2/14/26, 2/16/26, 2/17/26, 2/20/26, 2/22/26, and 2/23/26); and failed to ensure a minimum of one NA per 15 residents for the overnight shift for 11 of 21 days reviewed (2/04/25, 2/06/26, 2/07/26, 2/08/26, 2/09/26, 2/13/26, 2/14/26, 2/20/26, 2/21/26, 2/22/26, and 2/23/26).
Findings include:
Review of facility nursing staffing documents for the time period of 2/03/26, through 2/23/26, revealed the following NA staffing shortages for the day shift where the NA ratios were not met:
2/07/26 census of 99 residents 9.27 NA worked and 9.90 were required
2/08/26 census of 97 residents 7.36 NA worked and 9.70 were required
2/09/26 census of 96 residents 8.56 NA worked and 9.60 were required
2/18/26 census of 101 residents 9.27 NA worked and 10.10 were required
2/20/26 census of 101 residents 9.08 NA worked and 10.10 were required
2/22/26 census of 103 residents 9.75 NA worked and 10.30 were required
Review of facility nursing staffing documents for the time period of 2/03/26, through 2/23/26, revealed the following NA staffing shortages for the evening shift where the NA ratios were not met:
2/06/26 census of 100 residents 7.70 NA worked and 9.09 were required
2/07/26 census of 98 residents 7.86 NA worked and 8.91 were required
2/08/26 census of 97 residents 6.71 NA worked and 8.82 were required
2/10/26 census of 96 residents 8.14 NA worked and 8.73 were required
2/11/26 census of 97 residents 7.60 NA worked and 8.82 were required
2/12/26 census of 97 residents 8.14 NA worked and 8.82 were required
2/14/26 census of 98 residents 6.96 NA worked and 8.91 were required
2/16/26 census of 98 residents 6.18 NA worked and 8.91 were required
2/17/26 census of 99 residents 7.24 NA worked and 9.00 were required
2/20/26 census of 102 residents 7.19 NA worked and 9.27 were required
2/22/26 census of 102 residents 7.61 NA worked and 9.27 were required
2/23/26 census of 103 residents 8.51 NA worked and 9.36 were required
Review of facility nursing staffing documents for the time period of 2/03/26, through 2/23/26, revealed the following NA staffing shortages for the overnight shift where the NA ratios were not met:
2/04/26 census of 103 residents5.67 NA worked and 6.87 were required
2/06/26 census of 99 residents 4.93 NA worked and 6.60 were required
2/07/26 census of 98 residents 6.10 NA worked and 6.53 were required
2/08/26 census of 97 residents5.12 NA worked and 6.47 were required
2/09/26 census of 95 residents4.63 NA worked and 6.33 were required
2/13/26 census of 98 residents 5.46 NA worked and 6.53 were required
2/14/26 census of 98 residents 5.68 NA worked and 6.53 were required
2/20/26 census of 102 residents5.07 NA worked and 6.80 were required
2/21/26 census of 103 residents6.11 NA worked and 6.87 were required
2/22/26 census of 102 residents 6.49 NA worked and 6.80 were required
2/23/26 census of 103 residents 4.09 NA worked and 6.87were required
During an interview on 2/26/26, at 2:35 p.m. the Nursing Home Administrator confirmed the NA ratios were not met for the above dates and shifts.
| | Plan of Correction - To be completed: 04/10/2026
1. The facility cannot correct that nurse-aide staffing ratio was not met on (2/07/26, 2/08/26, 2/09/26, 2/18/26, 2/20/26, and 2/22/26) for the 7a to 3p shifts. The facility cannot correct that nurse aide staffing ratio was not met on evening shift (3p to 11p) for the following days (2/06/26, 2/07/26, 2/08/26, 2/10/26, 2/11/26, 2/12/26, 2/14/26, 2/16/26, 2/17/26, 2/20/26, 2/22/26. The facility cannot correct that nurse aide staffing ratio was not met on overnight (11p-7a) shift for the following days (2/04/25, 2/06/26, 2/07/26, 2/08/26, 2/09/26, 2/13/26, 2/14/26, 2/20/26, 2/21/26, 2/22/26, and 2/23/26). The facility cannot correct that nurse aide staffing ratio that was not met on days listed above as there were no adverse effects on the identified dates and no interruption to resident care. Residents remained safe and care and supervision were provided.
2.The scheduler will be re-educated regarding the state ratios by the Nursing Home Administer/designee.
3.Nursing Administration will be re-educated on staffing ratios by the Nursing Home Administrator/designee. A daily staffing meeting will be held daily to review the schedule with ratios. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing ratios, the scheduler/or designee will call off duty facility staff and will utilize external staffing support resources. The facility is actively recruiting staff via Indeed.com (employment/hiring website) for nursing staff (Certified Nurse's Aide, Licensed Practical Nurse, and Registered Nurses)
4.Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure staffing ratios are met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations
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