(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 8 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, 1:11 on the evening shift, and 1:15 on the night shift based on the facility's census per the regulation that was effective July 1, 2024.
May 23, 2025 - 3.85 nurse aides on the night shift, versus the required 4.33 for a census of 65.
May 27, 2025 - 3.85 nurse aides on the night shift, versus the required 7.20 for a census of 63.
July 2, 2025 - 5.13 nurse aides on the evening shift, versus the required 5.13 for a census of 65.
July 3, 2025 - 5.33 nurse aides on the evening shift, versus the required 5.91 for a census of 65.
July 3, 2025 - 2.97 nurse aides on the night shift, versus the required 4.33 for a census of 65.
July 4, 2025 - 6.00 nurse aides on the day shift, versus the required 6.50 for a census of 65.
July 5, 2025 - 3.80 nurse aides on the night shift, versus the required 4.27 for a census of 64.
July 6, 2025 - 3.33 nurse aides on the night shift, versus the required 4.07 for a census of 61.
On the above dates mentioned no additional excess higher-level staff were available to compensate this deficiency.
An interview with the Nursing Home Administrator on July 8, 2025, at approximately 11:45 AM, confirmed the facility had not met the required nurse aide to resident ratios on the above dates.
| | Plan of Correction - To be completed: 08/12/2025
1.The facility cannot retroactively correct past Nursing Aide ratios
2.The facility will continue to take measures to adequately provide nurse-aid staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff with the required nurse aide to resident ratios. These measures include, continuing our retention committee, increased advertising efforts, and utilization of agency staff.
3.The DON/designee will continue to educate minimum staffing ratios to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios.
4.The DON/designee will audit schedules to ensure that the minimum number of nurse aide staff to resident ratios have been scheduled. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.
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