(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 (NA) per 10 residents on the day shift for two of 21 days, failed to ensure a minimum of one NA per 11 residents on the evening shift for one day, and failed to ensure a minimum of one NA per 15 residents on the overnight shift for one of 21 days (24-hour periods) reviewed.
Findings Include:
Review of facility census data indicated that on October 23, 2025, the facility census was 88, which required 8.80 NA's during the day shift. Review of the nursing time schedules revealed 6.78 NA's provided care on the day shift on October 23, 2025.
Review of facility census data indicated that on October 23, 2025, the facility census was 88, which required 8.00 NA's during the evening shift. Review of the nursing time schedules revealed 7.53 NA's provided care on the evening shift on October 23, 2025.
Review of facility census data indicated that on October 25, 2025, the facility census was 87, which required 7.91 NA's during the day shift. Review of the nursing time schedules revealed 7.22 NA's provided care on the day shift on October 25, 2025.
Review of facility census data indicated that on November 1, 2025, the facility census was 88, which required 5.75 NA's during the night shift. Review of the nursing time schedules revealed 5.75 NA's provided care on the night shift on January 5, 2025.
No additional excess higher-level staff were available to compensate this deficiency.
Interview with the Nursing Home Administrator on November 12, 2025, at 4:00 p.m. confirmed that the facility did not meet the required NA-to-resident staffing ratios for the days listed above.
| | Plan of Correction - To be completed: 12/30/2025
1. The facility cannot retroactively correct nursing staffing hours and ratios.
2. The facility is focusing on the retention of existing nursing staff and recruiting new staff through the efforts of the staffing committee and human resource department.
3. The Executive Director (ED) re-educated the scheduler and nursing supervisors on the staffing ratios and hours per patient day (HPPD). Staffing meetings to review the calculations for nursing staff ratios and HPPD for accuracy.
4. The ED or Designees to conduct Quality Improvement (QI) monitoring of daily schedules to ensure the ratio of care/minimum PPD will be met. QI monitoring conducted via On Shift Daily Schedules reviewed 5X per week X 4 weeks, then weekly X 4 weeks. Findings were reported to the Quality Improvement Performance Improvement (QAPI) committee and updated as indicated. QI monitoring schedule modified based on findings.
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