(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 review of facility nursing staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one Nurse Aide (NA) per 10 residents on the day shift for 18 of 21 days reviewed (10/30/25, 10/31/25, 11/01/25, 11/02/25, 11/03/25, 11/04/25, 11/05/25, 11/06/25, 11/07/25, 11/08/25, 11/09/25, 11/10/25, 11/11/25, 11/12/25, 11/14/25, 11/16/25, 11/17/25, and 11/18/25); failed to ensure one NA per 11 residents on the evening shift for 18 of 21 days reviewed (10/30/25, 10/31/25, 11/01/25, 11/02/25, 11/03/25, 11/04/25, 11/05/25, 11/08/25, 11/09/25, 11/10/25, 11/11/25, 11/13/25, 11/14/25, 11/15/25, 11/16/25, 11/17/25, 11/18/25, and 11/19/25); and failed to ensure one NA per 15 residents on the overnight shift for seven of 21 days reviewed (10/30/25, 11/01/25, 11/08/25, 11/09/25, 11/13/25, 11/15/25, and 11/18/25).
Findings include:
Review of facility nursing staffing documents for the time period from 10/30/25, through 11/19/25, revealed the following NA shortages for the day shift:
10/30/25 facility census of 73 residents 7.04 NA's worked and 7.30 were required.
10/31/25 facility census of 74 residents 6.82 NA's worked and 7.40 were required.
11/01/25 facility census of 74 residents 4.18 NA's worked and 7.40 were required.
11/02/25 facility census of 73 residents 5.67 NA's worked and 7.30 were required.
11/03/25 facility census of 73 residents 6.14 NA's worked and 7.30 were required.
11/04/25 facility census of 73 residents 6.92 NA's worked and 7.30 were required.
11/05/25 facility census of 72 residents 6.32 NA's worked and 7.20 were required.
11/06/25facility census of 73 residents 6.86 NA's worked and 7.30 were required.
11/07/25 facility census of 73 residents 6.72 NA's worked and 7.30 were required.
11/08/25 facility census of 73 residents 4.71 NA's worked and 7.30 were required.
11/09/25facility census of 71 residents 6.14 NA's worked and 7.10 were required.
11/10/25facility census of 71 residents 6.45 NA's worked and 7.10 were required.
11/11/25 facility census of 70 residents 6.49 NA's worked and 7.00 were required.
11/12/25facility census of 69 residents 6.05 NA's worked and 6.90 were required.
11/14/25 facility census of 62 residents 5.48 NA's worked and 6.20 were required.
11/16/25 facility census of 62 residents 5.59 NA's worked and 6.20 were required.
11/17/25facility census of 63 residents 6.25 NA's worked and 6.30 were required.
11/18/25facility census of 61 residents 5.45 NA's worked and 6.10 were required.
Review of facility nursing staffing documents for the time period from 10/30/25, through 11/19/25, revealed the following NA shortages for the evening shift:
10/30/25 facility census of 75 residents 4.72 NA's worked and 6.82 were required.
10/31/25 facility census of 74 residents 5.55 NA's worked and 6.73 were required.
11/01/25 facility census of 74 residents 4.92 NA's worked and 6.73 were required.
11/02/25 facility census of 73 residents 5.08 NA's worked and 6.64 were required.
11/03/25facility census of 73 residents 4.67 NA's worked and 6.64 were required.
11/04/25 facility census of 73 residents 5.51 NA's worked and 6.64 were required.
11/05/25facility census of 72 residents 5.07 NA's worked and 6.55 were required.
11/08/25 facility census of 71 residents 4.83 NA's worked and 6.45 were required.
11/09/25 facility census of 71 residents 3.83 NA's worked and 6.45 were required.
11/10/25facility census of 70 residents 5.47 NA's worked and 6.36 were required.
11/11/25 facility census of 69 residents 6.07 NA's worked and 6.27 were required.
11/13/25facility census of 63 residents 5.17 NA's worked and 5.73 were required.
11/14/25 facility census of 61 residents 5.33 NA's worked and 5.55 were required.
11/15/25 facility census of 62 residents 5.18 NA's worked and 5.64 were required.
11/16/25facility census of 62 residents 5.12 NA's worked and 5.64 were required.
11/17/25 facility census of 61 residents 5.08 NA's worked and 5.55 were required.
11/18/25 facility census of 63 residents 5.23 NA's worked and 5.73 were required.
11/19/25 facility census of 62 residents 4.96 NA's worked and 5.64 were required.
Review of facility nursing staffing documents for the time period from 10/30/25, through 11/19/25, revealed the following NA shortages for the overnight shift:
10/30/25 facility census of 75 residents 4.05 NA's worked and 5.00 were required.
11/01/25 facility census of 74 residents 4.19 NA's worked and 4.93were required.
11/08/25 facility census of 71 residents 4.19 NA's worked and 4.73 were required.
11/09/25 facility census of 71 residents 4.15 NA's worked and 4.73 were required.
11/13/25 facility census of 63 residents 4.07 NA's worked and 4.20 were required.
11/15/25 facility census of 62 residents 4.07 NA's worked and 4.13 were required.
11/18/25 facility census of 63 residents 4.04 NA's worked and 4.20 were required.
During an interview on 11/24/25, at 9:40 a.m. the Nursing Home Administrator confirmed the accuracy of the facility provided staffing information and confirmed the facility failed to meet the minimum NA to resident ratio on the above dates and shifts.
| | Plan of Correction - To be completed: 12/23/2025
"The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements."
1.The facility cannot correct that the nurse aide staffing ratio was not met on 10/30/25, 10/31/25, 11/1/25, 11/2/25, 11/3/25, 11/4/25, 11/5/25, 11/6/25, 11/7/25, 11/8/25, 11/9/25, 11/10/25, 11/11/25, 11/12/25, 11/14/25, 11/15/25, 11/16/25, 11/17/25, 11/18/25 and 11/19/25.
2.The scheduler will be re-educated regarding the state ratios by the Nursing Home Administrator/designee.
3.Nursing supervisors will be re-educated on staffing ratios by the Nursing Home Administrator/designee.
4.Twice a day staffing meetings will be held to review the schedule with ratios Monday through Friday. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing ratios the scheduler/or designee will call off duty facility staff and will utilize pick-up bonuses.
5.Certified Nurse Aide positions are posted in recruitment.
6.Nursing Home Administrator/designee will audit staffing daily for three weeks and monthly for three months to ensure staffing ratios are being met.
7.An employee referral program has been developed.
8.Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
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