(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 nursing time schedules and staff interview it was determined that the facility administrative staff failed to provide a minimum of one nurse aide (NA) per 12 residents during the day and/or evening shift, and/or one nurse aid per 20 residents during the night shift for 17 of 21 days (10/19/25, 10/20/25, 10/24/25, 10/25/25, 10/26/25, 10/27/25, 10/28/25, 10/29/25, 10/30/25, 10/31/25, 11/1/25, 11/2/25, 11/3/25, 11/4/25, 11/5/25, 11/6/26, and 11/7/25).
Findings include:
Review of the facility census data, nursing time schedules, and deployment sheets revealed the following nurse aide staffing shortages:
On 10/19/25, census 68. Day shift required 6.80 NAs, facility provided 4.50.
On 10/20/25, census 68. Night shift required 4.53 NAs, facility provided 4.03.
On 10/24/25, census 68. Evening shift required 6.18 NAs, facility provided 5.00.
On 10/25/25, census 69. Night shift required 4.60 NAs, facility provided 4.00.
On 10/26/25, census 68. Day shift required 6.80 NAs, facility provided 6.00.
On 10/26/26, census 68. Evening shift required 6.18 NAs, facility provided 4.00.
On 10/26/25, census 68. Night shift required 4.53 NAs, facility provided 4.00.
On 10/27/25, census 68. Night shift required 4.53 NAs, facility provided 4.00.
On 10/28/25, census 68. Day shift required 6.80 NAs, facility provided 6.00.
On 10/28/25, census 68. Evening shift required 6.18 NAs, facility provided 5.00.
On 10/29/25, census 69. Evening shift required 6.27 NAs, facility provided 5.00.
On 10/30/25, census 69. Evening shift required 6.27 NAs, facility provided 5.50.
On 10/30/25, census 69. Night shift required 4.60 NAs, facility provided 4.00.
On 10/31/25, census 69. Day shift required 6.90 NAs, facility provided 6.30.
On 10/31/25, census 69. Evening shift required 6.27 NAs, facility provided 5.50.
On 11/1/25, census 68. Day shift required 6.80 NAs, facility provided 4.50.
On 11/1/25, census 68. Evening shift required 6.18 NAs, facility provided 5.00.
On 11/2/25, census 68. Day shift required 6.80 NAs, facility provided 5.00.
On 11/2/25, census 68. Evening shift required 6.18 NAs, facility provided 6.00.
On 11/3/25, census 68. Evening shift required 6.18 NAs, facility provided 5.00.
On 11/3/25, census 68. Night shift required 4.53 NAs, facility provided 4.00.
On 11/4/25, census 68. Day shift required 6.80 NAs, facility provided 6.00.
On 11/4/25, census 68. Evening shift required 6.18 NAs, facility provided 5.00.
On 11/5/25, census 67. Evening shift required 6.09 NAs, facility provided 4.87.
On 11/6/25, census 67. Evening shift required 6.09 NAs, facility provided 5.00.
On 11/7/25, census 67. Day shift required 6.70 NAs, facility provided 6.00.
On 11/7/25, census 67. Evening shift required 6.09 NAs, facility provided 6.00.
During an interview on 12/3/25, at 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide a minimum of one nurse aide per 12 residents during the day and evening shift, and/or one nurse aid per 20 residents during the night shift on 17 of 21 days (10/19/25, 10/20/25, 10/24/25, 10/25/25, 10/26/25, 10/27/25, 10/28/25, 10/29/25, 10/30/25, 10/31/25, 11/1/25, 11/2/25, 11/3/25, 11/4/25, 11/5/25, 11/6/26, and 11/7/25).
| | Plan of Correction - To be completed: 01/12/2026
1. The facility will ensure state-required nurse aide ratios are met for all shifts. The facility cannot retroactively correct the cited deficiency.
2. The facility will ensure that nurse aide staffing ratios are met every shift.
3. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5510 and ensuring nurse aide staffing ratios are met each shift. Daily shift staffing ratios will be reviewed at daily staffing meeting. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist as needed.
4. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure nurse aide staffing ratios are being met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.
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