(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 staffing document review and staff interview, it was determined that the facility failed to ensure a required minimum of one Nurse Aide (NA) per 12 residents on the day shift for three of seven days reviewed (July 16, 18, and 19, 2026) as calculated by full time equivalent (FTE - number of staff required calculated by determining the required number of hours of full-time shifts worked to meet the minimum staff to resident ratio).
Findings include:
Review of staffing information for the day shift on July 16, 2026, revealed a resident census of 358, resulting in a minimum NA FTE of 35.80; the submitted information indicated the facility provided 34.05.
Review of staffing information for the day shift on July 18, 2026, revealed a resident census of 356, resulting in a minimum NA FTE of 35.60; the submitted information indicated the facility provided 32.78.
Review of staffing information for the day shift on July 19, 2026, revealed a resident census of 357, resulting in a minimum NA FTE of 35.70; the submitted information indicated the facility provided 33.28.
An interview with the Nursing Home Administrator on July 20, 2026, at 12:45 PM, confirmed the facility did not meet the NA staffing requirements on those dates.
| | Plan of Correction - To be completed: 08/04/2026
This provided submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.
CNA staffing ratios for dayshift were not met on the following dates: 7/16/26, 7/18/26 and 7/19/26
The facility has robust retention and recruitment activities in place. Nursing leadership did all things reasonably possible to meet the required ratios through bonuses, day off on another day, split shifts, extra day pay. All unscheduled staff were contacted and supplemental staffing agencies were contacted to send replacement staff with little avail. Ancillary staff were available and assisted in various tasks such as call bell attendant, delivery and removal of meal trays, delivery of water, bed making and performance of other tasks within their scope of practice. There were no negative outcomes to residents. The facility will continue to ensure schedule reflects the required staffing ratios and address call offs.
The NHA/designee will educate the staffing coordinators and nursing supervisors on the required ratios for CNA's .
To monitor and maintain ongoing compliance, the DON/designee will audit 5 schedules weekly x 4 Weeks to ensure CNA ratios are being met every shift. Audit results will be reviewed with QAPI Committee meeting monthly to determine the need for further audits.
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