Observations:
Based on a review of staffing documents provided by the facility and staff interview, it was determined that the facility failed to provide one nurse assistant (NA) per 10 residents on the daylight shift on five of 12 days (11/22/25 through 11/24/25, 11/28/25 and 11/29/25), one NA per 11 residents on the second shift on eight of 12 days (11/21/25 through 11/23/25, 11/25/25 and 11/27/25 through 11/30/25) and one NA per 15 residents on the night shift on five of 12 days (11/20/25, 11/21/25 and 11/27/25 through 11/29/25) as required.
Findings include:
A review of facility staffing documents provided by the facility from 11/20/25 through 12/1/25, revealed the facility failed to provide NA on the following shifts as required:
Daylight shift:
DateCensusActual hours Hours required
11/22/258642.4864.50
11/23/258654.2964.50
11/24/258757.2965.25
11/28/258864.3966.00
11/29/258960.3666.75
Evening shift:
DateCensusActual hoursHours required
11/21/258651.6358.64
11/22/258646.1558.64
11/23/258653.6058.64
11/25/258954.6560.68
11/27/258652.5558.64
11/28/258858.2760.00
11/29/258946.4960.68
11/30/258955.7660.68
Night shift:
DateCensusActual hoursHours required
11/20/258631.3843.00
11/21/258639.7843.00
11/27/258640.1243.00
11/28/258840.1544.00
11/29/258932.2244.50
During an interview on 12/3/25 at 10:05 a.m., the Nursing Home Administrator confirmed that the facility failed to provide NA's in the facility on the above shifts as required.
| | Plan of Correction - To be completed: 01/07/2026
The Facility submits this Plan of Correction under the procedures established by the Department of Health in order to comply with the Departments 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 or the facility right to appeal or challenge the accuracy of severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.
The Nursing schedule is created to ensure CNA staffing ratios reflects the current census per shift. Each shifts CNA staffing is adjusted based on census. When additional staff is needed to meet ratios, shifts are posted on our staffing portal, bonuses are offered, phone calls and text messages are sent to staff. The facility will utilize agency to assist with open shifts when needed. The facility attendance policy is followed for staff and disciplines occur per policy. Attendance is tracked on a calendar and reviewed weekly. The facility holds a monthly retention committee meeting and ads are posted on Indeed for open positions. Interviews are conducted immediately. We have a dedicated recruiter to assisting with recruiting and hiring new nursing staff.
The Administrator or designee will educate the Nursing Admin, HR, the scheduler and RN Supervisors on the staffing PPD and how to adjust. A staffing meeting will occur daily to review ratios with the NHA, DON, and scheduler. Daily recruiting calls occur to update the status of new applicants and interviews. The 3 week DOH Staffing Calculator Tool will be updated daily to monitor hours. The Audits will be taken to QAPI for review.
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