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 five days (4/30/25 through 5/4/25), one NA per 11 residents on the second shift on one of five days (5/2/25) and one NA per 15 residents on the night shift on two of five days (5/3/25 and 5/4/25) as required.
Findings include:
A review of facility staffing documents provided by the facility from 4/30/25 through 5/4/25, revealed the facility failed to provide NA on the following shifts as required:
Daylight shift:
DateCensusActual hours Hours required
4/30/258460.8763.00
5/1/258456.4563.00
5/2/258258.0261.50
5/3/258352.6162.25
5/4/258258.9661.50
Evening shift:
DateCensusActual hoursHours required
5/2/258251.7555.91
Night shift:
DateCensusActual hoursHours required
5/3/258339.6341.50
5/4/258232.5241.00
During an interview on 5/6/25 at 3:55 p..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: 06/11/2025
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 CNA schedule is created to ensure staffing ratios reflect the current census per shift. Each shifts 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 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.
The Administrator or designee will educate the Nursing Admin, the scheduler and RN Supervisors on the staffing ratio grid and how to adjust. A staffing meeting will occur daily to review ratios with the NHA, DON, and scheduler. 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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