(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 nurse staffing and staff interviews, it was determined the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 11 shifts out of 21 shifts reviewed.
Findings include:
A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide the minimum nurse aide staff of 1:10 on the day shift, 1:11 on the evening shift, and 1:15 on the night shift based on the facility's census:
February 25, 2026, 10.33 NAs on the day shift, versus the required 11.50, for a census of 115.
February 25, 2026, 8.90 NAs on the evening shift, versus the required 10.45, for a census of 115.
February 25, 2026, 6.53 NAs on the night shift, versus the required 7.67, for a census of 115.
February 26, 2026, 9.60 NAs on the evening shift, versus the required 10.36, for a census of 114.
February 27, 2026, 8.73 NAs on the evening shift, versus the required 10.27, for a census of 113.
February 28, 2026, 8.93 NAs on the day shift, versus the required 11.20, for a census of 112.
February 28, 2026, 7.87 NAs on the evening shift, versus the required 10.18, for a census of 112.
March 1, 2026, 8.63 NAs on the day shift, versus the required 11.20, for a census of 112.
March 1, 2026, 8.60 NAs on the evening shift, versus the required 10.09, for a census of 111.
March 2, 2026, 9.47 NAs on the day shift, versus the required 11.10, for a census of 111.
March 3, 2026, 6.63 NAs on the night shift, versus the required 7.40, for a census of 111.
On the above dates mentioned, no additional excess higher-level staff were available to compensate for this deficiency.
An interview with the Nursing Home Administrator on March 10, 2026, at 2:00 PM, confirmed the facility had not met the required NA to resident ratios on the above dates.
| | Plan of Correction - To be completed: 04/25/2026
Recruitment of nursing staff will continue via facility website, Indeed, recruiting group, social media websites, local newspaper, job fairs and off site recruiters. Agency utilized for open shifts. Retention efforts made with any resignation.
Calculation of daily PPD and shift ratios will be completed and reviewed daily for accuracy by the scheduler/back up scheduler, DON/ADON and NHA. All efforts will be made to meet PPD and staffing ratios. If call offs occur, all efforts will be made to attempt to fill that position.
Scheduler and back up scheduler will be educated on staffing according to the PPD and ratio requirement.
Daily PPD and ratios will be audited weekly x4, then monthly x2. Results to QA for review and recommendations.
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