(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 facility nursing staffing documents and staff interview, it was determined that the facility failed to meet the Nurse Aide (NA) ratios of one NA per 10 residents on the day shift for five of seven days reviewed (6/09/26, 6/10/26, 6/11/26, 6/12/26 and 6/14/26); failed to meet the NA ratio of one NA per 11 residents on the evening shift for five of seven days reviewed (6/10/26, 6/12/26, 6/13/26, 6/14/26, and 6/15/26); and failed to meet the NA ratio of one NA per 15 residents on the overnight shift for five of seven days reviewed (6/11/26, 6/12/26, 6/13/26, 6/14/26, and 6/15/26).
Findings include:
Review of facility nursing staffing documents for the time period from, 6/09/26, through 6/15/26, revealed the following NA staffing shortages for the day shift where the NA ratios were not met:
6/09/26census of 666.00 NAs worked and 6.60 were required
6/10/26census of 664.00 NAs worked and 6.60 were required
6/11/26census of 666.56 NAs worked and 6.60 were required
6/12/26census of 666.00 NAs worked and 6.60 were required
6/14/26census of 656.00 NAs worked and 6.50 were required
Review of facility nursing staffing documents for the time period from 6/09/26, through 6/15/26, revealed the following NA staffing shortages for the evening shift where the NA ratios were not met:
6/10/26census of 664.50 NAs worked and 6.00 were required
6/12/26census of 664.75 NAs worked and 6.00 were required
6/13/26census of 684.50 NAs worked and 6.18 were required
6/14/26census of 653.00 NAs worked and 5.91 were required
6/15/26census of 654.25 NAs worked and 5.91 were required
Review of facility nursing staffing documents for the time period from 6/09/26, through 6/15/26, revealed the following NA staffing shortages for the overnight shift where the NA ratios were not met:
6/11/26census of 664.00 NAs worked and 4.40 were required
6/12/26census of 664.00 NAs worked and 4.40 were required
6/13/26census of 684.00 NAs worked and 4.53 were required
6/14/26census of 654.00 NAs worked and 4.33 were required
6/15/26census of 654.00 NAs worked and 4.33 were required
During an interview on 6/23/26, at 8:50 a.m. the Nursing Home Administrator confirmed that the facility did not meet the minimum NA ratios for the above days and shifts.
| | Plan of Correction - To be completed: 08/17/2026
1.Facility will meet nurse aide ratios. This has been identified and unable to be corrected in past. There has been no negative impact on resident care.
2. Facility will meet nurse aide ratios through the following:
a. Hiring more staff
b. Offering sign-on bonuses
c. Offering shift differential
d. Offering referral bonuses to existing staff members for new team members.
e. Staff appreciation events and promoting staff retention with acknowledging good attendance with rewards.
3. Nursing home administrator/NHA to in-service staff scheduler, director of nursing and assistant director of nursing on the state required minimum staffing ratios for nurse aides.
4. Director of Nursing and scheduler will review daily deployment schedules and make adjustments as necessary to meet ratios for nurse aides. Nurse Supervisor will call Per Diem staff when there are call-offs and/or sudden schedule changes. Licensed practical nurses may be used as CNAs if coverage in that discipline is meeting requirements. Director of Nursing may offer a pick-up bonus and incentives when attempting to fill an opening.
5. Audit will be conducted by Director of Nursing weekly for 3 weeks, then monthly thereafter to ensure the state required minimum for nurse aide staffing ratios are being met throughout the week, weekends and holidays.
6. Human Resources will schedule and have advertised open interview days at facility.
All audits will be reviewed through the quality assurance performance improvement process.
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