(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 staffing document review and staff interview, it was determined that the facility failed to ensure a required minimum of one Nurse Aide (NA) per 10 residents on the day shift for three of the 14 days reviewed (March 2, 8, and 24, 2025), as calculated by full time equivalent (FTE - Number of staff required calculated by determining the required number of hours of full-time shifts worked to meet the minimum staff to resident ratio).
Findings include:
A review of staffing information for the day shift of March 2, 2025, revealed a resident census of 138, which resulted in a minimum NA FTE of 13.80; submitted information revealed the facility provided 13.00.
A review of staffing information for the day shift of March 8, 2025, revealed a resident census of 138, which resulted in a minimum NA FTE of 13.40; submitted information revealed the facility provided 12.00.
A review of staffing information for the day shift of March 24, 2025, revealed a resident census of 132, which resulted in a minimum NA FTE of 13.20; submitted information revealed the facility provided 11.00.
Electronic mail correspondence with the Nursing Home Administrator on March 28, 2025, at 8:09 AM, revealed an acknowledgment of the facility not meeting the minimum staffing requirements.
| | Plan of Correction - To be completed: 05/02/2025
Correction does not constitute an admission of, or agreement with, the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve quality of care and to comply with all applicable state and federal regulatory requirements.
The facility cannot retroactively provide the minimum number of nurse aide hours for the cited deficiency.
Going forward, the facility will schedule staff to meet or exceed the mandated Nurse Aide ratios on each shift. The facility will make a good faith effort to utilize both internal and external resources to meet or exceed the Nurse AIde ratios on each shift.
The RDCS/designee re-educated the NHA, DON, PAyroll/HR and Scheduler on the staffing regulations in relation to minimum Nurse Aide staffing ratios on each shift. The facility will utilize PRN staff and external agency to supplement the staffing needs of the facility.
NHA/designee will audit the schedules and payroll to ensure the facility staffing needs meets or exceeds the minimum Nurse Aide ratios on each shift. Audits will be completed 5X/ week for 4 weeks, and then weekly x 2 months. The audits will be reviewed at QAPI committee meeting.
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