(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 time schedules and staff interview it was determined that the facility administrative staff failed to provide a minimum of one nurse aide (NA) per 12 residents during the day and/or evening shift, and/or one nurse aid per 20 residents during the night shift for 13 of 21 days (3/8/26, 3/10/26, 3/14/26, 3/15/26, 3/17/26, 3/18/26, 3/19/26, 3/20/26, 3/21/26, 3/22/26, 3/25/26, 3/27/26, and 3/28/26), affecting 19 shifts.
Findings include:
Review of the facility census data, nursing time schedules, and deployment sheets revealed the following nurse aide staffing shortages:
On 3/8/26, census 222, evening shift required 20.18 NAs, facility provided 18.13.
On 3/10/26, census 222, evening shift required 20.18 NAs, facility provided 19.20.
On 3/14/26, census 224, day shift required 22.40 NAs, facility provided 21.33.
On 3/14/26, census 224, evening shift required 20.36 NAs, facility provided 20.27.
On 3/15/26, census 223, day shift required 22.30 NAs, facility provided 19.20.
On 3/15/26, census 223, evening shift required 20.27 NAs, facility provided 19.20.
On 3/17/26, census 223, day shift required 22.30 NAs, facility provided 21.60.
On 3/17/26, census 223, evening shift required 20.27 NAs, facility provided 19.20.
On 3/18/26, census 225, day shift required 22.50 NAs, facility provided 22.40.
On 3/19/26, census 227, evening shift required 20.64 NAs, facility provided 20.27.
On 3/20/26, census 231, evening shift required 21.00 NAs, facility provided 19.07.
On 3/21/26, census 231, day shift required 23.10 NAs, facility provided 21.33.
On 3/21/26, census 231 evening shift required 21.00 NAs, facility provided 20.27.
On 3/22/25, census 231, day shift required 23.10 NAs, facility provided 22.40.
On 3/22/26, census 231, evening shift required 21.00 NAs, facility provided 19.20.
On 3/25/26, census 231, evening shift required 21.00 NAs, facility provided 19.20.
On 3/27/26, census 234, day shift required 23.40 NAs, facility provided 22.67.
On 3/27/26, census 234, evening shift required 21.27 NAs, facility provided 19.87.
On 3/28/26, census 234, day shift required 23.40 NAs, facility provided 21.33.
During an interview on 3/31/26, at 1:45 p.m. the Nursing Home Administrator confirmed that the facility failed to provide a minimum of one nurse aid per 12 residents during the day and evening shift, and/or one nurse aid per 20 residents during the night shift on 13 of 21 days listed above.
| | Plan of Correction - To be completed: 05/09/2026
1. The facility cannot retroactively correct this deficiency.
2. Education will be completed by the Nursing Home Administrator or designee with the Nursing Staff Scheduler on Certified Nurse Aide ratios.
3. Staffing meeting will be held up to five days per week with Nursing Home Administrator, Director of Nursing and Nursing Staff Scheduler, to review overall projected PPD and ratio requirements. If minimum standards are not met, actions will be implemented, including agency reach out, reaching out to staff currently working as well as those that are not in the facility.
4. The Department of Health staffing calculator tool will be used by staffing team as an audit to monitor staffing ratios and PPD.
5. Results will be reviewed at Quality Assurance Performance Improvement meetings by Director of Nursing, Administrator or designee for follow up, further actions and recommendations.
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