Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse (NA) to resident ratios for two 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 11 residents on the evening shift (3:00 p.m. to 11:00 p.m.) on November 8, 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 November 9, 2025.
| | Plan of Correction - To be completed: 12/31/2025
Dates/shifts of non-compliance were
reviewed. No adverse reactions and/or
injurious events to residents
occurred on the dates in question.
The overall PPD maintained at or well
above regulated levels.
On 12/4/25, the NHA, D.O.N. and scheduler reviewed the budgeted staffing
template, and the allotted nursing
hours, to ensure appropriate ratios
are budgeted and retained. No
deviance was found related to the
budget and ratios.
The facility's master schedule has
always included the required ratios.
Bi-weekly recruitment calls with
recruiter will continue to
ensure vacant positions are posted
and advertised.
Call-offs are routinely monitored and
addressed, as needed, per facility
attendance policy.
Director of Nursing and/or designee
will re-educate/in-service RN
Supervisors on the following:
1.posted staffing schedules
2 the process of posting shifts on primary and secondary nursing agencies for PRN shifts.
(previously 1 nursing agency)
3. All licensed nurses can perform
direct care to supplement NA hours.
All open shifts are posted 6-8 weeks in
advance for PRN/FT/PT staff to sign-up
for the open shifts.
On-call RN Supervisory coverage is
in place and is utilized when
warranted.
The current census, pending
discharges, patient referrals and
staffing are reviewed/discussed each
weekday morning and afternoon
with the NHA, D.O.N., nurse scheduler
present.
The ability to accept/decline
admissions is discussed among the
NHA, DON, and scheduler M-F in the morning and afternoon, as it relates to staffing and/or census changes. Weekend staffing is reviewed on a Friday.
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