(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 nursing schedules, staffing information furnished by the facility, and staff interviews, it was determined that the facility failed to provide one nurse aide (NA) per 10 residents on the day shift for three of 16 days, failed to provide one NA per 11 residents on the evening shift for three of 16 days, and failed to provide one NA per 15 residents on the night shift for 10 of 16 days reviewed for June 15, 2026, through June 30, 2026.
Findings include:
Review of facility census data revealed:
On June 21, 2026, the facility census was 122, during the day shift, which required 12.20 NA's during the day shift. Review of the nursing time schedules revealed 11.32 NA's provided care on the day shift.
On June 28, 2026, the facility census was 121, during the day shift, which required 12.10 NA's during the day shift. Review of the nursing time schedules revealed 11.95 NA's provided care on the day shift.
On June 30, 2026, the facility census was 121, during the day shift, which required 12.10 NA's during the day shift. Review of the nursing time schedules revealed 12.04 NA's provided care on the day shift.
On June 16, 2026, the facility census was 121, during the evening shift, which required 11.00 NA's during the evening shift. Review of the nursing time schedules revealed 10.38 NA's provided care on the evening shift.
On June 18, 2026, the facility census was 121, during the evening shift, which required 11.00 NA's during the evening shift. Review of the nursing time schedules revealed 10.79 NA's provided care on the evening shift.
On June 21, 2026, the facility census was 122, during the evening shift, which required 11.09 NA's during the evening shift. Review of the nursing time schedules revealed 10.68 NA's provided care on the evening shift.
On June 15, 2026, the facility census was 121, during the night shift, which required 8.07 NA's during the night shift. Review of the nursing time schedules revealed 7.29 NA's provided care on the night shift.
On June 16, 2026, the facility census was 121, during the night shift, which required 8.07 NA's during the night shift. Review of the nursing time schedules revealed 7.29 NA's provided care on the night shift.
On June 19, 2026, the facility census was 123, during the night shift, which required 8.20 NA's during the night shift. Review of the nursing time schedules revealed 8.02 NA's provided care on the night shift.
On June 20, 2026, the facility census was 122, during the night shift, which required 8.13 NA's during the night shift. Review of the nursing time schedules revealed 7.86 NA's provided care on the night shift.
On June 21, 2026, the facility census was 122, during the night shift, which required 8.13 NA's during the night shift. Review of the nursing time schedules revealed 6.82 NA's provided care on the night shift.
On June 22, 2026, the facility census was 121, during the night shift, which required 8.07 NA's during the night shift. Review of the nursing time schedules revealed 7.88 NA's provided care on the night shift.
On June 24, 2026, the facility census was 122, during the night shift, which required 8.13 NA's during the night shift. Review of the nursing time schedules revealed 8.04 NA's provided care on the night shift.
On June 26, 2026, the facility census was 121, during the night shift, which required 8.07 NA's during the night shift. Review of the nursing time schedules revealed 7.51 NA's provided care on the night shift.
On June 29, 2026, the facility census was 121, during the night shift, which required 8.07 NA's during the night shift. Review of the nursing time schedules revealed 7.22 NA's provided care on the night shift.
On June 30, 2026, the facility census was 121, during the night shift, which required 8.07 NA's during the night shift. Review of the nursing time schedules revealed 7.91 NA's provided care on the night shift.
However, there were no additional excess higher-level staff available to compensate for these deficiencies.
Interview with the Director of Nursing on July 6, 2026, at 3:59 p.m. confirmed that the facility did not meet the required NA-to-resident staffing ratios for the days listed above.
| | Plan of Correction - To be completed: 07/29/2026
In preparation and/or execution of this plan of correction does not constitute 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.
1. All residents received care in accordance with their plan of care and attending physician orders.
2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. Facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff.
3. Facility nursing licensed staff have been educated on the 7/1/2024 Nursing Ratios and Patient Per Day requirements and the importance of maintaining the schedule as posted.
4. To monitor and maintain ongoing compliance the Director Of Nursing or designee will audit staffing weekly x4 weeks then monthly for two months.
Results will be taken to the Quality Assurance & Performance Improvement for review and revision as needed.
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