(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 a review of nurse staffing and staff interview, it was determined the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 33 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 1:10 on the day shift, based on the facility's census:
November 6, 2025, 4.6 NA's on the day shift, versus the required 5.50, for a census of 55
November 7, 2025, 4.27 NA's on the day shift, versus the required 5.50, for a census of 55
November 8, 2025, 3.10 NA's on the day shift, versus the required 5.50, for a census of 55
November 9, 2025, 5.07 NA's on the day shift, versus the required 5.30, for a census of 53
November 10, 2025, 3.73 NA's on the day shift, versus the required 5.30, for a census of 53
November 14, 2025, 3.0 NA's on the day shift, versus the required 5.4, for a census of 54
November 15, 2025, 4.10 NA's on the day shift, versus the required 5.4, for a census of 54
November 16, 2025, 4.67 NA's on the day shift, versus the required 5.5, for a census of 55
November 17, 2025, 4.4 NA's on the day shift, versus the required 5.5, for a census of 55
November 18, 2025, 5.27 NA's on the day shift, versus the required 5.30, for a census of 53
November 19, 2025, 4.73 NA's on the day shift, versus the required 5.40, for a census of 54
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 1:11 on the evening shift, based on the facility's census:
November 6, 2025, 4.63 NA's on the evening shift, versus the required 5.0, for a census of 55
November 8, 2025, 4.0 NA's on the evening shift, versus the required 4.82, for a census of 53
November 9, 2025, 3.63 NA's on the evening shift, versus the required 4.91, for a census of 54
November 10, 2025, 4.2 NA's on the evening shift, versus the required 4.82, for a census of 53
November 11, 2025, 2.53 NA's on the evening shift, versus the required 4.82, for a census of 53
November 13, 2025, 3.17 NA's on the evening shift, versus the required 4.73, for a census of 52
November 14, 2025, 4 NA's on the evening shift, versus the required 4.91, for a census of 54
November 15, 2025, 3.73 NA's on the evening shift, versus the required 4.91, for a census of 54
November 16, 2025, 3.53 NA's on the evening shift, versus the required 5.0, for a census of 55
November 17, 2025, 4.47 NA's on the evening shift, versus the required 5, for a census of 55
November 18, 2025, 3.87 NA's on the evening shift, versus the required 4.82, for a census of 53
November 19, 2025, 4.60 NA's on the evening shift, versus the required 4.91, for a census of 54
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 1:15 on the night shift, based on the facility's census:
November 6, 2025, 3.33 NA's on the night shift, versus the required 3.67, for a census of 55
November 7, 2025, 3.17 NA's on the night shift, versus the required 3.67, for a census of 55
November 8, 2025, 2.97 NA's on the night shift, versus the required 3.53, for a census of 55
November 9, 2025, 3.0 NA's on the night shift, versus the required 3.60, for a census of 54
November 10, 2025, 3.3 NA's on the night shift, versus the required 3.53, for a census of 53
November 14, 2025, 2.53 NA's on the night shift, versus the required 3.6, for a census of 54
November 15, 2025, 3.2 NA's on the night shift, versus the required 3.67, for a census of 55
November 16, 2025, 3.23 NA's on the night shift, versus the required 3.67, for a census of 55
November 18, 2025, 3.07 NA's on the night shift, versus the required 3.60, for a census of 54
November 19, 2025, 3.0 NA's on the night shift, versus the required 3.60, for a census of 54
On the above dates mentioned no additional excess higher-level staff were available to compensate this deficiency.
An interview with the Director of Nursing, on November 20, 2025, at 12:00 p.m., confirmed the facility had not met the required NA to resident ratios on the above dates.
| | Plan of Correction - To be completed: 12/16/2025
1. The facility cannot retroactively correct CNA staffing ratio.
2. DON/designee will conduct an initial audit of the past two weeks scheduled to determine if CNA staffing ratio is in compliance.
3. DON/designee will re-educate the scheduler on the proper CNA staffing ratio. The facility will continue to recruit and attempt to hire new staff. The facility will hold labor meetings Monday-Friday to verify CNA staffing ratio is made.
4. DON/designee will conduct random audits of facility CNA staffing ratios weekly for four weeks, then monthly for two months thereafter to verify proper CNA staffing ratios.. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
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