(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 February 4 through and including February 24, 2024.
Findings include:
Review of the days of February 4 through and including February 24, 2024, revealed the following dates on day shift did not meet the requirement of one nurse aide per 12 residents: February 11, 13, 15, and 16 2024.
Review of the days of February 4 through and including February 24, 2024. revealed the following dates on evening shift did not meet the requirement of one nurse aide per 12 residents: February 17, and 18, 2024.
Review of the days of February 4 through and including February 24, 2024, revealed the following date on night shift did not meet the requirement of one nurse aide per 20 residents: February 8, 11, 12, 14, 16, 17, 18, 19, and 22, 2024.
The facility staffing ratios being below state minimum standard were relayed to the Nursing Home Administrator on February 27, 2024, at 12:45 p.m.
| | Plan of Correction - To be completed: 05/13/2024
Development and/or execution of
this plan of correction does not
constitute admission or agreement
by this provider of the truth in the
statement of deficiency. The plan of
correction is prepared and/or
executed by provision of federal
and/or state regulation.
5510
1. The ratios noted in the survey
findings cannot be corrected as this
is a past event.
2. Calculation of shift ratios will be
completed and reviewed daily for
accuracy by the scheduler or designee.
3. The facility has developed
internal incentives to retain and
attract staff and meet shift ratio
requirements. Facility scheduler,
DON, HR and NHA have a daily
staffing meeting (5 days per week) to review schedules including compliance with ratios. For staff call offs, every effort will be made to replace the call off using resources available including
communicating with staff to replace the vacancy. Staffing patterns are projected at least one week in advance to enable ongoing efforts to fill any vacant shifts.
4. Ratios will be monitored daily
by Scheduler and/or DON or
designee. Audits of ratios will be
completed by DON or designee daily
for 4 weeks then 3 days per week x 2
months or until substantial compliance is achieved. Results of audits will be reviewed by the QAPI Committee.
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