(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 staffing documents provided by the facility and staff interview it was determined that the facility failed to provide one nurse assistant (NA) per 10 residents on the day shift on four of six days (4/26/25 through 4/29/25) one NA per 11 residents on the second shift on four of six (4/25/25, and 4/27/25 through 4/29/25) as required.
Findings include:
A review of facility staffing documents provided by the facility from 4/24/25 through 4/29/25, revealed the facility failed to provide NA on the following shifts as required:
Day shift: CensusActual hoursHours required
4/26/25149105.00111.75
4/27/2514997.50111.75
4/28/25149105.00111.75
4/29/25150105.00112.50
Evening shift:
DateCensusActual hoursHours required
4/25/2514888.00100.91
4/27/2514990.00101.59
4/28/2514998.00101.59
4/29/2515090.50102.27
During an interview on 5/5/25 at 3:20 p.m., the Nursing Home Administrator confirmed that the facility failed to provide NA's in the facility on the above shifts as required.
| | Plan of Correction - To be completed: 06/16/2025
Plan of Correction:
There were no adverse effects to the residents of our facility as a result of the decreased nurse aide to resident ratios on:4/25/25, 4/26/25, 4/27/25, 4/28/25, and 4/29/25.
The Director of Nursing, Human Resources, and the Scheduler will be re-educated on the new July 1 nurse aide to resident ratios by the Nursing Home Administrator/Designee. To ensure sufficient nursing aide staffing ratios to comply with state laws, staffing meetings will be held 3 days a week to review staffing and the projected nursing assistant staff ratios for the current day, as well as the upcoming week. If projected staffing levels are below the required minimum staffing ratios, then the facility will reach out to current staff and to the staffing agencies to enlist staff to meet the minimum staffing and ratio requirement.
Facility will continue to recruit CNAs through all platforms and utilize bonuses and outside staffing agencies. Audits of nurse aide ratios will be completed weekly x4 by the NHA/designee to ensure nurse aide ratios are met. Results of the audits will be reported to our QAPI committee monthly for review and recommendations.
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