Observations: Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for 13 of 21 days reviewed.
Findings include:
Review of nursing schedules for 21 days from November 20 through December 10, 2024, revealed the following:
The facility failed to meet the minimum NA to resident ratio of one NA for 10 residents on day shift (7:00 a.m. to 3:00 p.m.) on November 30 and December 7 and 8, 2024.
The facility failed to meet the minimum NA to resident ratio of one NA for 11 residents on evening shift (3:00 p.m. to 11:00 p.m.) on November 22, 23, 28, and 30, and December 8 and 9, 2024.
The facility failed to meet the minimum NA to resident ratio of one NA for 15 residents on night shift (11:00 p.m. to 7:00 a.m.) on November 23, 25, 27, and 29, and December 1, 5, and 6, 2024.
| | Plan of Correction - To be completed: 01/23/2025
Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements. 1) The facility cannot retroactively correct the past C.N.A Ratios 2) Moving forward, the facility will continue to make good faith effort to schedule staff to meet or exceed the mandated ratios of One NA to 10 residents on day shift; one NA to 11 residents on evening shift and one NA to 15 residents on night shift. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. The facility contracts with agencies to supply aides to meet requirements but call offs and no-show result in unmet ratios. The facility is working to hire and train staff to achieve the minimum staffing ratios for nurse aides. The facility offers bonuses to staff to encourage staff to pick up additional shifts. 3)To prevent this from reoccurring, the RDCS re-educated the NHA; DON and Scheduler on the updated staffing regulations in relation to the minimum ratio of one NA to 10 residents on days, one NA to 11 residents on evenings and one NA to 15 residents on nights.. The staffing is reviewed each day for the subsequent day(s) by the NHA and/or DON to ensure adequate staff to meet or exceed the minimum ratios. Needs are posted each week for internal staff to pick up extra shifts as well as posted with outside agencies. 4) To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum NA ratios. Audits will be completed 5x weekly x4 weeks; 3x weekly x1 month and weekly x1 month. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
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