(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 facility staffing data, it was determined that the facility failed to ensure a minimum of one nurse aide per 12 residents on both day and evening shifts, and one nurse aide per 20 residents on night shift for the days of January 3 through and including January 17, 2024.
Findings include:
Review of the days of January 3 through and including January 17, 2024, revealed the following dates on day shift did not meet the requirement of one nurse aide per 12 residents: January 1, 3, 4, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17, 2024.
Review of the days of January 3 through and including January 17, 2024. revealed the following dates on evening shift did not meet the requirement of one nurse aide per 12 residents: January 3, 5, 7, 8, 10, 11, 12, 15, 16, and 17, 2024.
Review of the days of January 3 through and including January 17, 2024, revealed the following date on night shift did not meet the requirement of one nurse aide per 20 residents: January 3, 6, 9, and 12, 2024.
The facility staffing ratios being below state minimum standard were relayed to the Nursing Home Administrator on January 18, 2024, at 11:45 a.m.
| | Plan of Correction - To be completed: 02/19/2024
1. Facility cannot retroactively correct the CNA staffing ratio below minimum requirements 2. NHA, DON, and staffing scheduler have weekeday meetings to ensure CNA staffing ratios are above minimum requirement of 1:12 for day and evening shifts and 1:20 for night shifts 3. NHA, or designee, will educate staffing scheduler and DON on maintaining at least the minimum required CNA staffing ratios. 4. NHA, or designee, will perform audits or have discussions daily with DON and staffing scheduler to ensure CNA staffing ratios are at, or above state minimum required ratios. Results of audits will be presented at monthly Quality Assurance and Improvement Plan meetings for review and recommendations.
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