(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 a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 12 shifts out of 42 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 1:12 on the day, evening shifts and 1:20 on the night shift based on the facility's census.
November 28, 2023 - 6 nurse aides on the evening shift, versus the required 7 for a census of 78. November 29, 2023 - 6 nurse aides on the evening shift, versus the required 7 for a census of 78. November 30, 2023 - 6 nurse aides on the evening shift, versus the required 7 for a census of 77. December 1, 2023 - 6 nurse aides on the evening shift, versus the required 7 for a census of 78. December 2, 2023 - 6 nurse aides on the evening shift, verses the required 7 for a census of 78. December 2, 2023 - 3 nurse aides on the night shift, versus the required 4 for a census of 79. December 3, 2023 - 4 nurse aides on the evening shift, versus the required 7 for a census of 78. December 4, 2023 - 5 nurse aides on the evening shift, versus the required 7 for a census of 78. December 23, 2023 - 6 nurse aides on the evening shift, versus the required 7 for a census of 80. December 24, 2023 - 5 nurse aides on the day shift, versus the required 7 for a census of 80. December 24, 2023 - 4 nurse aides on the evening shift, versus the required 7 for a census of 79. December 25, 2023 - 6 nurse aides on the evening shift, versus the required 7 for a census of 79.
An interview with the Nursing Home Administrator on December 28, 2023, at approximately 2:15 PM, confirmed the facility had not met the required nurse aide to resident ratios the shifts on the above dates.
| | Plan of Correction - To be completed: 02/20/2024
The facility cannot retroactively correct the deficiency.
The Nursing Staffing Coordinator will be re-educated regarding the ratios for nurse aides. The facility will focus on retention of existing nurse aides and recruitment of new nurse aides through efforts of the facility Recruitment & Retention Committee.
Calculation of the daily nurse aide ratios will be completed and reviewed for accuracy by the scheduler/designee. Daily ratios will be audited weekly x4 then monthly x2. The audits will be taken to QAPI for further action planning as needed.
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