(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.
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Observations:
Based on a review of nursing time schedules and staff interview, it was determined that the facility failed to meet the minimum nursing staff to resident ratios for 7 of 15 shifts reviewed. (March 6, 2025-March 10, 2025).
Findings include:
A review of the nursing schedules from March 6, 2025, through March 10, 2025, revealed that the facility failed to meet the minimum nursing staff to resident ratios of one nurse aide (NA) per 10 residents on day shift for March 7, 2025; March 8, 2025; March 9, 2025.
A review of the nursing schedules from March 6, 2025, through March 10, 2025, revealed that the facility failed to meet the minimum nursing staff to resident ratios of one nurse aide (NA) per 11 residents on evening shift for March 7, 2025; and March 9, 2025.
A review of the nursing schedules from March 6, 2025, through March 10, 2025, revealed that the facility failed to meet the minimum nursing staff to resident ratios of one nurse aide (NA) per 15 residents on overnight shift for March 6, 2025; and March 8, 2025.
On March 6, 2025, the facility had only 20.53 hours of Nurse Aide Service on the Overnight Shift, versus the minimum required 24 hours of Nurse Aide Service for a census of 48.
On March 7, 2025, the facility had only 31.85 hours of Nurse Aide Service on the Day Shift, versus the minimum required 36 hours of Nurse Aide Service for a census of 48.
On March 7, 2025, the facility had only 32.35 hours of Nurse Aide Service on the Evening Shift, versus the minimum required 32.73 hours of Nurse Aide Service for a census of 48.
On March 8, 2025, the facility had only 31.66 hours of Nurse Aide Service on the Day Shift, versus the minimum required 31.75 hours of Nurse Aide Service for a census of 49.
On March 8, 2025, the facility had only 19.47 hours of Nurse Aide Service on the Overnight Shift, versus the minimum required 24.50 hours of Nurse Aide Service for a census of 48.
On March 9, 2025, the facility had only 31.42 hours of Nurse Aide Service on the Day Shift, versus the minimum required 37.50 hours of Nurse Aide Service for a census of 50.
On March 9, 2025, the facility had only 32.23 hours of Nurse Aide Service on the Evening Shift, versus the minimum required 34.09 hours of Nurse Aide Service for a census of 50.
In an interview on March 19, 2025, at 2:23 p.m., the Administrator and Director of Nursing confirmed that the facility did not meet the minimum nursing staff to resident ratios for the above-mentioned dates.
| | Plan of Correction - To be completed: 06/15/2025
1.The facility reviewed the CNA ratios from March 6, 2025 through March 10, 2025. No grievance or residents care were affected on those dates due to staffing ratios.
2.Other days were reviewed to see if ratios were met and if care levels were affected.
3.Scheduling coordinator will be educated on CNA ratios for day shift, evening shift, and night shift.
Facility will attempt with every reasonable resource to ensure ratios are met
4.DON/designee will conduct daily audits to verify CNA ratios for all shifts weekly x 4 weeks. Results will be presented to QAPI
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