(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 nursing time schedules, it was determined that the facility failed to provide the minimum nurse aide (NA) to resident ratios for 18 of 21 days reviewed.
Findings include:
Review of nursing schedules for 21 days from October 29, 2025, through November 18, 2025, revealed the following:
The facility failed to meet the minimum NA to resident ratio of one NA for ten residents on the day shift (7:00 a.m. to 3:00 p.m.) on November 1, 2, 3, 4, 5, 6, 8, 9, 11, 12, 13, 17, 18, 2025.
The facility failed to meet the minimum NA to resident ratio of one NA for eleven residents on the evening shift (3:00 p.m. to 11:00 p.m.) on November 9, 2025.
The facility failed to meet the minimum NA to resident ratio of one NA for 15 residents on the night shift (11:00 p.m. to 7:00 a.m.) on October 31, 2025, November 6, 7, 8, 9, 12, 14, 15, 16, 17, and 18, 2025.
| | Plan of Correction - To be completed: 02/09/2026
1) Findings of nursing aide nursing staff care ratios cannot be retroactively corrected.
2) Facility will provide a minimum of 1 nurse aide per 10 residents on the day, one nurse aide per 11 residents during evening and one nurse aide per 15 residents overnight.
3) HR assistant will be educated on the requirements of 1 nurse aide of per 10 residents on the day, one nurse aide per 11 residents during evening and one nurse aide per 15 residents overnight.
4) NHA/designee will conduct random audits to verify that nurse aide dayshift, evening and overnight ratios meet the requirements weekly for 4 weeks. Audit results will be presented to the QAPI meeting for review and recommendations.
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