(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 interview, it was determined the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 15 shifts out of 21 reviewed. Findings include:
A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide 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.
May 21, 2025, 6.17 NAs on the day shift, versus the required 7.2 for a census of 72
May 21, 2025, 4.63 NAs on the night shift, versus the required 4.87 for a census of 73
May 22, 2025, 6.13 NAs on the day shift, versus the required 7.2 for a census of 72
May 22, 2025, 5.73 NAs on the evening shift, versus the required 6.64 for a census of 73
May 22, 2025, 4.63 NAs on the night shift, versus the required 4.87 for a census of 73
May 23, 2025 6.4 NAs on the evening shift, versus the required 6.55 for a census of 72
May 23, 2025 4.6 NAs on the night shift, versus the required 4.8 for a census of 72
May 24, 2025, 6.13 NAs on the day shift, versus the required 7.2 for a census of 72
May 24, 2025 5.73 NAs on the evening shift, versus the required 6.55 for a census of 72
May 24, 2025 4.3 NAs on the night shift, versus the required 4.8 for a census of 72
May 25, 2025, 5.73 NAs on the day shift, versus the required 7.2 for a census of 72
May 25, 2025 6.27 NAs on the evening shift, versus the required 6.55 for a census of 72
May 25, 2025 4.03 NAs on the night shift, versus the required 4.8 for a census of 72
May 26, 2025, 5.93 NAs on the day shift, versus the required 7.2 for a census of 72
May 27, 2025, 6.7 NAs on the day shift, versus the required 7.2 for a census of 72
On the above dates mentioned no additional excess higher-level staff were available to compensate this deficiency.
An interview with the Director of Nursing, on May 30, 2025, at approximately 1:30 p.m., confirmed the facility had not met the required NA to resident ratios on the above dates.
| | Plan of Correction - To be completed: 07/18/2025
Facility cannot retroactively correct past CNA to resident ratios.
2. Facility is focusing on retention of existing nursing assistants and recruitment of new nursing assistants, through efforts of the Human Resources Manager and Nursing Administration. CNA pay rates increased as of 6/4/2025.
3. The scheduler has been re-educated regarding the CNA ratio regulatory requirements. Calculation of the daily CNA ratios will be completed and reviewed for accuracy by the scheduler/designee. Facility acquired OnShift applications for scheduling. Application alerts scheduler, DON, and Administrator when nursing ratios are not scheduled to be met so that corrections, additions etc. can be made to meet minimum requirements.
4. Daily ratios will be audited weekly X 4 weeks then monthly X 2 months. Audits will be reviewed at QAPI for compliance.
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