(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 day and evening shift for ten of thirteen days of facility staffing reviewed.
Findings include:
Review of the staffing for the days of January 5, 2024 through January 17, 2024, revealed the following dates and shifts did not meet the requirement of one nurse aide per 12 residents:
January 5, 2024 3-11 shift January 6, 2024 7-3 and 3-11 shifts January 7, 2024 7-3 and 3-11 shifts January 10, 2024 3-11 shift January 11, 2024 7-3 and 3-11 shift January 12, 2024 7-3 and 3-11 shift January 13, 2024 7-3 shift January 14, 2024 7-3 and 3-11 shift January 15, 2024 7-3 and 3-11 shift January 16, 2024 7-3 and 3-11 shift
Interview with the Nursing Home Administrator on January 18, 2024 at 12:30 p.m. confirmed that the aide staffing ratios were not met on the above days and shifts.
| | Plan of Correction - To be completed: 04/01/2024
1. The facility is unable to retroactively provide minimum CNA ratio for 1/18/2024. 2. A facility wide audit was completed to ensure ratios were met. Continue to recruit with increased CNA sign on bonuses, and wages are competitive with surrounding areas. Agency to assist with staffing ratios while hiring.
3. The DON and recruitment were re-educated on ensuring that the nursing care ratios are provided and that the facility is actively recruiting CNAs.
4. The DON or designee will conduct an audit of the nursing care ratios to ensure it is provided weekly X4 weeks then monthly X2 months. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.
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