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 two of 21 days reviewed.
Findings include:
Review of nursing schedules for 21 days from July 11, 2026, through July 31, 2026, revealed the following:
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 July 16, 2026, and July 30, 2026.
| | Plan of Correction - To be completed: 10/01/2026
1. Facility is unable to correct past deficiency.
2. The facility has an active recruitment/retention plan to fill open positions which includes contracts with Staffing Agencies. The facility is actively issuing progressive discipline as needed for excessive absences.
3. Staff Scheduler and DON will be educated on what the ratio for NA to resident is, the importance of meeting C.N.A ratios, and that the facility is actively recruiting C.N.As and/or per diem staff.
Agency will be utilized for open shifts as needed and available.
Calculation of daily shift ratios will be completed and reviewed daily during Daily Labor Meeting for accuracy by the scheduler and DON, Admin. If call offs occur, C.N.A's that are working in ancillary departments will be moved to an assignment, if possible.
4.The DON or designee will conduct an audit of the C.N.A ratios to ensure ratios are being met weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and re-evaluation.
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