Observations:
Based on a review of nurse staffing and staff interview, it was determined the facility failed to ensure the minimum registered nurse to resident ratio was provided on each shift for 6 shifts out of 7 reviewed.
Findings include:
A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum registered nurse (RN) staff of 1:250 on the night shift, based on the facility's census:
February 12, 2025, 0 RNs on the night shift, versus the required 1, for a census of 28.
February 13, 2025, 0 RNs on the night shift, versus the required 1, for a census of 28.
February 14, 2025, 0 RNs on the night shift, versus the required 1, for a census of 28.
February 15, 2025, 0 RNs on the night shift, versus the required 1, for a census of 28.
February 17, 2025, 0 RNs on the night shift, versus the required 1, for a census of 28.
February 18, 2025, 0 RNs on the night shift, versus the required 1, for a census of 26.
An interview was conducted with the Nursing Home Administrator on February 19, 2025, at approximately 2:00 PM, to review the above findings and confirmed the facility had not met the required RN to resident ratios on the above dates.
| | Plan of Correction - To be completed: 03/11/2026
1. There were no ill effects suffered by the residents due to the facility's failure to meet the ratio for residents to RN for 6 shifts.
2. A facility wide audit was completed to ensure ratios were met. RN sign on bonuses and wages are competitive with surrounding areas. The facility has agency contracts and uses bonuses for employees to pick up shifts.
3.The DON and Corporate HR were re-educated on staffing ratios and ensuring the facility is actively recruiting to fill any open positions. The DON will review census and staffing ratios to ensure ratios are being met.
4.The DON or designee will conduct an audit of nursing care ratios weekly x 4 weeks then monthly x2 months to ensure ratios are being met. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.
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