(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 nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for 17 of 17 days reviewed.
Findings include:
Review of nursing schedules from September 5, 2024, through September 21, 2024, revealed the following:
The facility failed to meet the minimum NA to resident ratio of one NA for 10 residents on day (7:00 a.m. to 3:00 p.m.) shift on September 5, 7, 9, 13, 18, 19, 20, and 21, 2024.
The facility failed to meet the minimum NA to resident ratio of one NA for 11 residents on evening (3:00 p.m. to 11:00 p.m.) shift on September 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21, 2024.
The facility failed to meet the minimum NA to resident ratio of one NA for 15 residents on night (11:00 p.m. to 7:00 a.m.) shift on September 5, 8, 12, 14, 15, 16, 17, 18, 19, 20, and 21, 2024.
| | Plan of Correction - To be completed: 12/04/2024
1. C.N.A. ratios for the dates noted in the survey cannot be corrected as this is a past event. 2. Calculation of shift C.N.A. ratios will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. The facility has attended job fairs and nursing schools to recruit direct care staff, in addition to other ongoing recruiting initiatives. We are using recruitment lists to call area CNAs to consider joining our facility. Facility has introduced an employee referral program to recruit staff also. Agency staff are being utilized in an effort to reach daily shift ratios. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate C.N.A. ratios as needed. 4. C.N.A. ratios will be audited by scheduler and DON daily for 4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results will be reported to QAPI committee. 5. Date of correction is December 4, 2024.
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