(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 facility nursing staffing documents and staff interview, it was determined that the facility failed to meet the Nurse Aide (NA) ratios of one NA per 10 residents on the day shift for 13 of 20 days reviewed (12/19/25, 12/20/25, 12/22/25, 12/24/25, 12/25/25, 12/26/25, 12/27/25, 12/28/25, 12/29/25, 12/30/25, 12/31/25, 1/01/26, and 1/04/25); failed to meet the ratio of one NA per 11 residents on the evening shift for 16 of 20 days reviewed (12/17/25, 12/18/25, 12/19/25, 12/20/25, 12/21/25, 12/22/25, 12/24/25, 12/25/25, 12/26/25, 12/28/25, 12/29/25, 12/30/25, 12/31/25, 1/01/26, 1/03/26, and 1/04/26); and failed to meet the ratio of one NA per 15 residents on the overnight shift for 14 of 20 days reviewed (12/16/25, 12/17/25, 12/20/25, 12/21/25, 12/23/25, 12/24/25, 12/25/25, 12/26/25, 12/27/25, 12/30/25, 12/31/25, 1/01/26, 1/03/26, and 1/04/26).
Findings include:
Review of nursing staffing documents for the time period from 12/16/25 through 1/04/26, revealed the following NA staffing shortages for the day shift:
12/19/25 facility census of 106 residents, 9.47 NAs worked and 10.60 were required.
12/20/25 facility census of 105 residents, 8.00 NAs worked and 10.50 were required.
12/22/25 facility census of 105 residents, 10.40 NAs worked and 10.50 were required.
12/24/25 facility census of 105 residents, 8.13 NAs worked and 10.50 were required.
12/25/25 facility census of 105 residents, 8.13 NAs worked and 10.50 were required.
12/26/25 facility census of 105 residents, 9.20 NAs worked and 10.50 were required.
12/27/25 facility census of 105 residents, 9.87 NAs worked and 10.50 were required.
12/28/25 facility census of 105 residents, 9.33 NAs worked and 10.50 were required.
12/29/25 facility census of 107 residents, 9.60 NAs worked and 10.70 were required.
12/30/25 facility census of 118 residents, 9.75 NAs worked and 10.80 were required.
12/31/25 facility census of 110 residents, 8.63 NAs worked and 11.00 were required.
1/01/26 facility census of 110 residents, 8.63 NAs worked and 11.00 were required.
1/04/26 facility census of 111 residents, 9.63 NAs worked and 11.10 were required.
Review of the nursing staffing documents for the time period from 12/16/25 through 1/04/26, revealed the following NA staffing shortages for the evening shift:
12/17/25 facility census of 106 residents, 9.47 NAs worked and 9.64 were required.
12/18/25 facility census of 106 residents, 7.87 NAs worked and 9.64 were required.
12/19/25 facility census of 106 residents, 6.53 NAs worked and 9.64 were required.
12/20/25 facility census of 105 residents, 6.27 NAs worked and 9.55 were required.
12/21/25 facility census of 105 residents, 8.00 NAs worked and 9.55 were required.
12/22/25 facility census of 105 residents, 7.47 NAs worked and 9.55 were required.
12/24/25 facility census of 105 residents, 5.87 NAs worked and 9.55 were required.
12/25/25 facility census of 105 residents, 6.00 NAs worked and 9.55 were required.
12/26/25 facility census of 105 residents, 4.40 NAs worked and 9.55 were required.
12/28/25 facility census of 105 residents, 7.73 NAs worked and 9.55 were required.
12/29/25 facility census of 107 residents, 7.87 NAs worked and 9.73 were required.
12/30/25 facility census of 108 residents, 7.63 NAs worked and 9.82 were required.
12/31/25 facility census of 110 residents, 5.63 NAs worked and 10.00 were required.
1/01/26 facility census of 110 residents, 7.63 NAs worked and 10.00 were required.
1/03/26 facility census of 111 residents, 9.50 NAs worked and 10.09 were required.
1/04/26 facility census of 111 residents, 7.75 NAs worked and 10.09 were required.
Review of nursing staffing documents for the time periods from 12/16/25 through 1/04/26, revealed the following NA staffing shortages for the overnight shift:
12/16/25 facility census of 109 residents, 4.71 NAs worked and 7.27 were required.
12/17/25 facility census of 106 residents, 5.33 NAs worked and 7.07 were required.
12/20/25 facility census of 105 residents, 6.27 NAs worked and 7.00 were required.
12/21/25 facility census of 105 residents, 6.00 NAs worked and 7.00 were required.
12/22/25 facility census of 105 residents, 5.60 NAs worked and 7.00 were required.
12/24/25 facility census of 105 residents, 6.40 NAs worked and 7.00 were required.
12/25/25 facility census of 105 residents, 5.73 NAs worked and 7.00 were required.
12/26/25 facility census of 105 residents, 4.80 NAs worked and 7.00 were required.
12/27/25 facility census of 105 residents, 5.73 NAs worked and 7.00 were required.
12/30/25 facility census of 108 residents, 6.33 NAs worked and 7.20 were required.
12/31/25 facility census of 110 residents, 6.38 NAs worked and 7.33 were required.
1/01/26 facility census of 110 residents, 4.38 NAs worked and 7.33 were required.
1/03/26 facility census of 111 residents, 6.88 NAs worked and 7.40 were required.
1/04/26 facility census of 111 residents, 5.63 NAs worked and 7.40 were required.
During an interview on 1/07/26, at 1:10 p.m. the Nursing Home Administrator confirmed that the facility failed to meet the minimum NA ratio requirements on the above shifts and dates.
| | Plan of Correction - To be completed: 02/27/2026
The deficient practice in nurse aide ratios has been identified and unable to be corrected in past. There has been no negative impact on resident care.
1. Nursing home administrator/NHA or designee to in-service staffing coordinator, director of nursing, and assistant director of nursing on the state required minimum staffing ratios for nurse aides.
2. Nursing Home Administrator/NHA or designee to conduct staffing meetings 3 times/week to ensure the state required minimum staffing ratios for nurses' aides are met throughout the week, weekends and holidays.
3. NHA/ designee to review staffing sheets 3x weekly to ensure the state required minimum staffing ratios for nurses aides are met for the day/ shifts prior. Staffing meeting includes discussion of open shifts, vacation coverage, review of current nursing staff schedule and what is needed to meet state required nurses aide ratio, interviews scheduled, new hires and orientation date.
NHA/ designee to utilize corporate hiring and recruitment platform and Indeed for job applicants, attend job fairs, corporate talent acquisition specialist, employee referral bonus program and tuition reimbursement for recruitment efforts. Nurses aides are offered call-in bonus pay and incentive programs for picking up additional shifts.
4. NHA/designee to meet 3x week with Director of Nursing/DON or designee and staffing coordinator to review nursing assistant ratios. Staffing meeting and audit will continue to ensure sustained compliance.
5. DON/designee will educate the nursing supervisors and charge nurses on process of calling nursing staff in when call-offs occur.
All audits will be reviewed through the quality performance improvement process.
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