(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.
|
Observations:
Based on review of nursing schedules, staffing information furnished by the facility, and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide per 10 residents on the day shift for one of 21 days reviewed from February 1, 2026, through February 21, 2026, failed to ensure a minimum of one nurse aide per 11 residents on the evening shift for two of 21 days reviewed from February 1, 2026, through February 21, 2026, and failed to ensure a minimum of one nurse aide per 15 residents on the night shift for one of 21 days reviewed from February 1, 2026, through February 21, 2026.
Findings include:
Review of facility census data revealed:
On February 9, 2026, the facility census was 121, which required 11.00 nurse aides during the evening shift. Review of the nursing schedules revealed 10.56 nurse aides provided care on the evening shift.
On February 10, 2026, the facility census was 122, which required 11.09 nurse aides during the evening shift. Review of the nursing schedules revealed 10.07 nurse aides provided care on the evening shift.
On February 12, 2026, the facility census was 123, which required 12.30 nurse aides during the day shift. Review of the nursing schedules revealed 5.97 nurse aides provided care on the day shift.
On February 13, 2026, the facility census was 121, which required 8.07 nurse aides during the night shift. Review of the nursing schedules revealed 7.75 nurse aides provided care on the night shift.
Interview with the Nursing Home Administrator on February 26, 2026, at 5:30 p.m. confirmed that the facility did not meet the required nurse aide-to-resident staffing ratios for the days listed above.
| | Plan of Correction - To be completed: 04/10/2026
With an assessment of facility residents, it was determined by the Director of Nursing that no residents experienced a negative outcome based on the facility not meeting staffing ratio.
The Scheduler will be re-educated by the Administrator on the required Certified Nursing Assistant staffing ratios on all three shifts: 1:10 on dayshift, 1:11 on evening shift, and 1:15 on night shift.
In order to ensure the issue does not recur, staffing ratios will be monitored at the daily staffing meeting to include a review of C.N.A. ratios for the prior day, current day, and the next day.
The facility has developed a Recruitment/Retention plan to assist in recruiting adequate hands-on C.N.A.s to maintain consistent staffing levels to meet the required staff to resident ratios.
The Staffing Ratio spreadsheet and Recruitment and Retention plan will be submitted to the Quality Assurance and Performance Improvement committee to be reviewed and approved to ensure the issue does not recur over time.
|
|
