(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.
|
Observations:
Based on staffing documentation review and staff interview, it was determined that the facility failed to ensure a required minimum of one Nurse Aide (NA) per 10 residents on day shift (May 30-31, 2026), one NA per 11 residents on evening shift (May 30-31, 2026), and one NA per 15 residents on night shift (May 30 and 31, 2026; and June 2, 2026).
Findings include:
Review of facility staffing ratio and resident census information for May 27, 2026 - June 2, 2026, revealed the following NA ratios, which did not meet the minimum NA ratio required for the resident census on the following shifts:
May 30, 2026 day shift - 202 residents and 17.87 NAs, which didn't meet the required ratio of 20.20.
May 30, 2026 evening shift - 202 residents and 17.70 NAs, which didn't meet the required ratio of 18.36.
May 30, 2026 night shift - 202 residents and 9.9 NAs, which didn't meet the required ratio of 13.47.
May 31, 2026 day shift - 200 residents and 16.57 NAs, which didn't meet the required ratio of 20.
May 31, 2026 evening shift - 200 residents and 14.03 NAs, which didn't meet the required ratio of 18.18.
May 31, 2026 night shift - 200 residents and 7.33 NAs, which didn't meet the required ratio of 13.33.
June 2, 2026 night shift - 198 residents and 10.13 NAs, which didn't meet the required ratio of 13.20.
During a phone interview with the Nursing Home Administrator on June 3, 2026, at 3:26 PM, he confirmed he was aware that the facility did not meeting the required staffing ratios.
| | Plan of Correction - To be completed: 07/21/2026
P5520
1. An immediate correction cannot be performed.
2. Calculation of shift CNA ratios will be completed and reviewed daily for accuracy and compliance by scheduler and DON/designee.
3. DON/Designee will re-educate nursing scheduler on CNA ratio requirements.
4. The facility has agency contracts in place in efforts to meet daily CNA ratio requirements. The facility has also incorporated sign-on bonuses in an effort to attract and retain new staff. The facility has also started offering "as needed" bonuses in efforts to meet daily CNA ratios requirements. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate CNA ratios as needed. The facility will monitor census each shift and make all attempts to adjust staffing to ensure CNA ratio requirements are met.
5. CNA ratios will be audited by DON/designee daily for 4 weeks, then 3 days per week x2 months or until substantial compliance is achieved. Results to QAPI.
6. Date of compliance 7.21.26
|
|
