(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 a review of the facility's staffing worksheet, provided by the facility for the time period of 6/24/26, through 6/30/26, and staff interviews, it was determined that the facility failed to provide one Nurse Assistant (NA) per 10 residents on the daylight shift for four of seven days (6/26/26, 6/27/26, 6/29/26, and 6/30/26) as required.
A review of the facility's staffing worksheet, provided by the facility for the time period of 6/24/26, through 6/30/26, revealed the following:
Daylight shift
Date Census Minimum Hours Actual Hours Minimum FTE Actual FTE
6/26/26 217 173.60 170.72 21.70 21.34
6/27/26 219 175.20 170.24 21.90 21.28
6/29/26 221 176.72 176.72 22.10 22.09
6/30/26 219 175.20 166.24 21.90 20.78
During an interview on 7/1/26, at 10:30 am the Nursing Home administrator confirmed that the facility failed to provide one NA per 10 residents on the daylight shift on 6/26/26, 6/27/26, 6/29/26 and 6/30/26, as required.
| | Plan of Correction - To be completed: 08/13/2026
The facility cannot retroactively correct this deficiency. No identified residents were affected as a result of this deficiency. All residents have the potential to be affected by this deficiency.
Education will be completed by the Nursing Home Administrator or designee to RN Supervisors ensuring understanding of PPD Calculations and process to cover call offs.
Staffing meeting will be held five days per week excluding holdays with Nursing home administrator, Director of Nursing, and Nursing Staff Scheduler, to review PPD and ratio requirements are met if not, actions will be implemented, including agency reach out, reaching out to staff currently working as well as those that are not in the facility.
The Department of Health staffing calculator tool will be used as an audit to monitor staffing ratios and PPD, weekly x4 and then monthly X3 by the Nursing Staff Scheduler by the Nursing Staff Scheduler, or designee.
Results will be forwarded to QAPI for review and recommendation. Date of Compliance by 08/13/2026.
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