(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 a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for 14 of 21 days reviewed.
Findings include:
Review of nursing schedules for 21 days from October 23, 2025, through November 12, 2025, revealed the following:
The facility failed to meet the minimum NA to resident ratio of one NA for ten residents on day shift (7:00 a.m. to 3:00 p.m.) on October 25, 2025, and November 1, 2, 8, and 11, 2025.
The facility failed to meet the minimum NA to resident ratio of one NA for 11 residents on evening shift (3:00 p.m. to 11:00 p.m.) on October 30 and 31, 2025, and November 2 and 10, 2025.
The facility failed to meet the minimum NA to resident ratio of one NA for 15 residents on night shift (11:00 p.m. to 7:00 a.m.) on October 24, 25, 30, and 31, 2025, and November 1, 2, 3, 5, 7 through 10, and 12, 2025.
| | Plan of Correction - To be completed: 12/10/2026
1. Facility cannot retroactively correct NA to resident ratios.
2. Master schedule to be reviewed weekly to assure that NA ratios are met.
3. Community will continue to use hiring platforms and local advertising sites to advertise and will continue to utilize in house Department of Education approved NA training program to train prospective future CNA's. Slate Belt is also applying to become a testing site for CNA's via The Department of Education in an effort to make it easier for potential CNA's to obtain certification.
4. NHA/designee will audit staff deployments sheets weekly times 4 weeks and monthly times 1 to ensure proper ratios per shift.
5. Findings will be forwarded to QAPI for review and recommendations.
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