(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 meet the Nurse Aide (NA) ratio of one NA per 11 residents on the evening shift for three of seven days reviewed (7/16/26, 7/20/26, and 7/21/26); and failed to meet the NA ratio of one NA per 15 residents on the overnight shift for six of seven days reviewed (7/16/26, 7/17/26, 7/18/26, 7/20/26, 7/21/26, and 7/22/26).
Findings include:
Review of facility nursing staffing documents for the time period 7/16/26, through 7/22/26, revealed the following NA staffing shortages for the evening shift where the NA ratios were not met:
7/16/26 census of 56 residents 4.65 NAs worked and 5.09 were required
7/20/26 census of 55 residents 4.35 NAs worked and 5.00 were required
7/21/26census of 56 residents 4.80 NAs worked and 5.09 were required
Review of facility nursing staffing documents for the time period 7/16/26, through 7/22/26, revealed the following NA staffing shortages for the overnight shift where the NA ratios were not met:
7/16/26 census of 56 residents 3.32 NAs worked and 3.73 were required
7/17/26 census of 55 residents 3.20 NAs worked and 3.67 were required
7/18/26 census of 56 residents 3.72 NAs worked and 3.73 were required
7/20/26 census of 57 residents 3.24 NAs worked and 3.80 were required
7/21/26 census of 58 residents 3.73 NAs worked and 3.87 were required
7/22/26 census of 58 residents 3.70 NAs worked and 3.87 were required
During a telephone interview on 7/29/26, at 10:45 a.m. the Nursing Home Administrator confirmed that the facility did not meet the minimum NA ratios for the above days and shifts.
| | Plan of Correction - To be completed: 09/17/2026
No residents were negatively affected by the facility not meeting the NA ratio on the listed dates.
1)The facility will meet minimum nurse aide to resident ratio each day by calculating out projected ratios needed at current census levels.
2) The Nursing Home Administrator will educate the Director of Nursing, Assistant Director of Nursing, Nursing Supervisors and Scheduler on required ratios to ensure facility is meeting ratios. Nursing Home administrator or designee will educate on the process for replacing call offs.
3) System changes to help ensure proper staffing ratios are met include, continue to offer extra shift bonus to current staff for picking up shifts, ensure all vacant positions are in recruitment. Offer a referral bonus for staff referring employees to the facility.
4) The Director of Nursing or designee will audit to ensure that the facility meets the required minimum number of nurse aide to resident staffing ratio by reviewing the current working schedule and assignment sheets prior to the day and after the day is complete to ensure compliance. Audits will be completed daily for one month and weekly for two months. Audits will be reviewed as part of the facilities Quality Assurance and Performance Improvement committee and monitored for tracking and trending
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