(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 nursing schedules, review of staffing information furnished by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one nurse aide per 10 residents on the day shift for seven of 19 days, and failed to ensure a minimum of one nurse aide per 11 residents on the evening shift for eight of 19 days, and failed to ensure a minimum one nurse aide per 15 residents on the night shift for 14 of 19 days reviewed for July 23, 2026, through August 10, 2026.
Findings include:
Review of facility census data indicated that on July 28, 2026, the facility census was 59, which required 5.90 NA's during the day shift. Review of the nursing time schedules revealed 4.23 NA's provided care on the day shift on July 28, 2026. Review of facility census data indicated that on July 31, 2026, the facility census was 60, which required 6.00 NA's during the day shift. Review of the nursing time schedules revealed 5.93 NA's provided care on the day shift on July 31, 2026. Review of facility census data indicated that on August 1, 2026, the facility census was 60, which required 6.00 NA's during the day shift. Review of the nursing time schedules revealed 3.93 NA's provided care on the day shift on August 1, 2026. Review of facility census data indicated that on August 4, 2026, the facility census was 63, which required 6.30 NA's during the day shift. Review of the nursing time schedules revealed 5.20 NA's provided care on the day shift on August 4, 2026. Review of facility census data indicated that on August 5, 2026, the facility census was 63, which required 6.30 NA's during the day shift. Review of the nursing time schedules revealed 6.13 NA's provided care on the day shift on August 5, 2026. Review of facility census data indicated that on August 8, 2026, the facility census was 62, which required 6.20 NA's during the day shift. Review of the nursing time schedules revealed 6.07 NA's provided care on the day shift on August 8, 2026. Review of facility census data indicated that on August 9, 2026, the facility census was 62, which required 6.30 NA's during the day shift. Review of the nursing time schedules revealed 5.53 NA's provided care on the day shift on August 9, 2026.
Review of facility census data indicated that on July 24, 2026, the facility census was 59, which required 5.36 NA's during the evening shift. Review of the nursing time schedules revealed 5.17 NA's provided care on the evening shift on July 24, 2026. Review of facility census data indicated that on July 26, 2026, the facility census was 60, which required 5.45 NA's during the evening shift. Review of the nursing time schedules revealed 4.97 NA's provided care on the evening shift on July 26, 2026. Review of facility census data indicated that on July 28, 2026, the facility census was 58, which required 5.27 NA's during the evening shift. Review of the nursing time schedules revealed 4.80 NA's provided care on the evening shift on July 28, 2026. Review of facility census data indicated that on July 31, 2026, the facility census was 60, which required 5.45 NA's during the evening shift. Review of the nursing time schedules revealed 4.47 NA's provided care on the evening shift on July 31, 2026. Review of facility census data indicated that on August 2, 2026, the facility census was 60, which required 5.45 NA's during the evening shift. Review of the nursing time schedules revealed 4.93 NA's provided care on the evening shift on August 2, 2026. Review of facility census data indicated that on August 3, 2026, the facility census was 63, which required 5.73 NA's during the evening shift. Review of the nursing time schedules revealed 5.03 NA's provided care on the evening shift on August 3, 2026. Review of facility census data indicated that on August 4, 2026, the facility census was 63, which required 5.73 NA's during the evening shift. Review of the nursing time schedules revealed 4.20 NA's provided care on the evening shift on August 4, 2026. Review of facility census data indicated that on August 6, 2026, the facility census was 63, which required 5.73 NA's during the evening shift. Review of the nursing time schedules revealed 4.77 NA's provided care on the evening shift on August 6, 2026.
Review of facility census data indicated that on July 23, 2026, the facility census was 59, which required 3.93 NA's during the overnight shift. Review of the nursing time schedules revealed 3.07 NA's provided care on the overnight shift on July 23, 2026. Review of facility census data indicated that on July 25, 2026, the facility census was 59, which required 3.93 NA's during the overnight shift. Review of the nursing time schedules revealed 3.77 NA's provided care on the overnight shift on July 25, 2026. Review of facility census data indicated that on July 27, 2026, the facility census was 59, which required 3.93 NA's during the overnight shift. Review of the nursing time schedules revealed 3.23 NA's provided care on the overnight shift on July 27, 2026. Review of facility census data indicated that on July 30, 2026, the facility census was 59, which required 3.93 NA's during the overnight shift. Review of the nursing time schedules revealed 3.03 NA's provided care on the overnight shift on July 30, 2026. Review of facility census data indicated that on July 31, 2026, the facility census was 60, which required 4.00 NA's during the overnight shift. Review of the nursing time schedules revealed 3.07 NA's provided care on the overnight shift on July 31, 2026. Review of facility census data indicated that on August 2, 2026, the facility census was 60, which required 4.00 NA's during the overnight shift. Review of the nursing time schedules revealed 3.03 NA's provided care on the overnight shift on August 2, 2026. Review of facility census data indicated that on August 3, 2026, the facility census was 63, which required 4.20 NA's during the overnight shift. Review of the nursing time schedules revealed 2.63 NA's provided care on the overnight shift on August 3, 2026. Review of facility census data indicated that on August 4, 2026, the facility census was 63, which required 4.20 NA's during the overnight shift. Review of the nursing time schedules revealed 4.07 NA's provided care on the overnight shift on August 4, 2026. Review of facility census data indicated that on August 5, 2026, the facility census was 62, which required 4.13 NA's during the overnight shift. Review of the nursing time schedules revealed 3.13 NA's provided care on the overnight shift on August 5, 2026. Review of facility census data indicated that on August 6, 2026, the facility census was 63, which required 4.20 NA's during the overnight shift. Review of the nursing time schedules revealed 3.10 NA's provided care on the overnight shift on August 6, 2026. Review of facility census data indicated that on August 7, 2026, the facility census was 62, which required 4.13 NA's during the overnight shift. Review of the nursing time schedules revealed 4.10 NA's provided care on the overnight shift on August 7, 2026.Review of facility census data indicated that on August 8, 2026, the facility census was 62, which required 4.13 NA's during the overnight shift. Review of the nursing time schedules revealed 3.10 NA's provided care on the overnight shift on August 8, 2026. Review of facility census data indicated that on August 9, 2026, the facility census was 61, which required 4.07 NA's during the overnight shift. Review of the nursing time schedules revealed 3.13 NA's provided care on the overnight shift on August 9, 2026. Review of facility census data indicated that on August 10, 2026, the facility census was 61, which required 4.07 NA's during the overnight shift. Review of the nursing time schedules revealed 3.67 NA's provided care on the overnight shift on August 10, 2026.
No additional excess higher-level staff were available to compensate for these deficiencies.
Interview with the Director of Nursing on August 11, 2026, at 3:50 p.m. confirmed that the facility was not meeting the staffing ratios.
| | Plan of Correction - To be completed: 09/15/2026
Unable to retroactively correct staffing ratios for Certified Nurse Aides (CNAs) on dates noted.
Residents who receive nursing care services have the potential to be affected.
Recruitment and retention activities-
1.) Generous Sign on Bonus
2.) Flexible Scheduling
3.) Benefits Package for full-time employees
4.) Recent wage analysis and increase.
5.) "Kudos" recognition program
6.) Staff appreciation activities
7.) Referral bonus
8.) Agency Contracts
9.) Administrative Coverage
10.) Collaborate with other skilled nursing facilities in the area to inquire what recruitment and retention activities they are utilizing
11.) Attend Job Fairs
12.) Staff educated on arriving on time for their shift and staying for their entire shift
13.) Call off policy reviewed with staff.
Monitoring will be captured through auditing staff schedules.
Audit will be conducted daily for 12 weeks.
The audits will be conducted by the Staffing Coordinator or designee.
Results of the audits will be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
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