(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.
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Observations:
Based on review of nursing schedules and staffing information furnished by the facility, as well as staff interviews, it was determined that the facility failed to ensure a minimum of one nurse aide per 10 residents on the day shift for four of 21 days, and failed to ensure a minimum of one nurse aide per 15 residents on the overnight shift for three of 21 days (24-hour periods) reviewed for the period of October 14 through October 27, 2024, and November 18 through November 24, 2024.
Findings include:
Staffing information provided by the facility, dated October 14 through October 27, 2024, and November 18 through November 24, 2024, revealed that on October 15, 2024, the facility census was 116, which required 11.60 nurse aides during the day shift. Review of the nursing time schedules revealed 10.91 nurse aides provided care during the day shift on October 15, 2024.
Review of facility census data indicated that on October 19, 2024, the facility census was 115, which required 7.67 nurse aides during the overnight shift. Review of the nursing time schedules revealed 6.98 nurse aides provided care during the overnight shift on October 19, 2024.
Review of facility census data indicated that on October 20, 2024, the facility census was 115, which required 11.50 nurse aides during the day shift and 7.67 nurse aides during the overnight shift. Review of the nursing time schedules revealed 11.30 nurse aides provided care during the day shift and 7.00 nurse aides provided care during the overnight shift on October 20, 2024.
Review of facility census data indicated that on October 27, 2024, the facility census was 113, which required 11.30 nurse aides during the day shift. Review of the nursing time schedules revealed 10.17 nurse aides provided care during the day shift on October 27, 2024.
Review of facility census data indicated that on November 18, 2024, the facility census was 117, which required 11.70 nurse aides during the day shift. Review of the nursing time schedules revealed 11.22 nurse aides provided care during the day shift on November 18, 2024. The facility census was 118, which required 7.87 nurse aides during the overnight shift. Review of the nursing time schedules revealed 7.37 nurse aides provided care during the overnight shift on November 18, 2024.
No additional excess higher-level staff were available to compensate this deficiency.
Interview with the Executive Director on December 3, 2024, at 3:40 p.m. confirmed that the facility did not meet the required nurse aide-to-resident staffing ratios for the days listed above.
| | Plan of Correction - To be completed: 12/23/2024
The Director of Nursing, Scheduler and Human Resource Director will be educated on the state requirement for nursing hours including the Certified Nurse Assistants to resident ratios by the Administrator/designee.
Staffing meetings will be held 5 days a week to review the Certified Nurse assistant ratio from the previous day and the projected Certified Nurse Assistant ratio for the current day, as well as the upcoming week to ensure appropriate staffing levels by the Nursing Home Administrator/ designee. If projected staffing ratios do not meet minimum then the facility will reach out to current staff and local staffing agencies to enlist to meet the minimum requirement. Facility will continue to recruit staff through all platforms. Staffing sheets will be audited each business day for the previous day(s) hours ongoing. These results will be reported to the Quality Assurance Performance Improvement committee monthly for further recommendations.
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