Non-Compliance with Nurse Aide Staffing Ratios
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios as mandated by the regulation effective July 1, 2024. A review of nursing schedules from November 20 through December 10, 2024, revealed that the facility did not comply with the minimum staffing requirements on multiple occasions. Specifically, the day shift ratio of one NA per 10 residents was not met on November 30 and December 7 and 8, 2024. The evening shift ratio of one NA per 11 residents was not met on November 22, 23, 28, and 30, and December 8 and 9, 2024. Additionally, the night shift ratio of one NA per 15 residents was not met on November 23, 25, 27, and 29, and December 1, 5, and 6, 2024. These deficiencies were identified based on a review of the nursing time schedules for the specified period.
Plan Of Correction
Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements. 1) The facility cannot retroactively correct the past C.N.A Ratios. 2) Moving forward, the facility will continue to make good faith effort to schedule staff to meet or exceed the mandated ratios of One NA to 10 residents on day shift; one NA to 11 residents on evening shift and one NA to 15 residents on night shift. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. The facility contracts with agencies to supply aides to meet requirements but call offs and no-show result in unmet ratios. The facility is working to hire and train staff to achieve the minimum staffing ratios for nurse aides. The facility offers bonuses to staff to encourage staff to pick up additional shifts. 3) To prevent this from reoccurring, the RDCS re-educated the NHA; DON and Scheduler on the updated staffing regulations in relation to the minimum ratio of one NA to 10 residents on days, one NA to 11 residents on evenings and one NA to 15 residents on nights. The staffing is reviewed each day for the subsequent day(s) by the NHA and/or DON to ensure adequate staff to meet or exceed the minimum ratios. Needs are posted each week for internal staff to pick up extra shifts as well as posted with outside agencies. 4) To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum NA ratios. Audits will be completed 5x weekly x4 weeks; 3x weekly x1 month and weekly x1 month. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Penalty
The facility did not meet required NA staffing ratios on one reviewed day shift. Review of nursing schedules over a multi-week period showed that on a specific day shift, the number of NAs scheduled did not meet the mandated minimum of one NA per ten residents. During a subsequent interview, the DON confirmed that the facility failed to comply with the required NA-to-resident ratio for that shift.
Facility administrative staff did not consistently meet required minimum nurse aide staffing ratios on the night shift, as shown by a review of nursing schedules and census data over a multi-week period. On multiple nights, the total nurse aide hours provided were below the calculated hours needed to maintain at least one nurse aide per 15 residents, resulting in several shifts where required coverage was not achieved. The Nursing Home Administrator acknowledged that the facility failed to provide the mandated minimum nurse aide staffing on these night shifts.
The facility did not meet required minimum NA staffing ratios on multiple day, evening, and night shifts during a reviewed period. Staffing records showed that, with a census of approximately 58–59 residents, actual NA hours on several day and evening shifts, and one night shift, were below the hours needed to achieve mandated ratios of 1 NA per 10 residents on days, 1 NA per 11 residents on evenings, and 1 NA per 15 residents overnight. The DON confirmed that the required number of NAs was not provided on the identified shifts.
Surveyors found that on two reviewed days, the facility did not provide the required minimum number of nurse aides on the day shift relative to the number of residents. Staffing records showed that the nurse aide-to-resident ratio fell below the mandated standard, and the NHA acknowledged that the required nurse aide staffing ratios were not met on those days.
Surveyors found that the facility repeatedly failed to meet required NA-to-resident staffing ratios on multiple day, evening, and night shifts. Review of census and staffing schedules showed that the number of NAs scheduled and providing care was consistently below the minimum required based on the number of residents, with shortfalls documented on numerous shifts across several weeks. There were no additional higher-level staff available to offset these NA shortages, and the Administrator confirmed that the required staffing ratios were not met on the identified shifts.
The facility did not maintain the required NA-to-resident staffing ratios on multiple reviewed shifts, as shown by weekly staffing records and staff interviews. For a census of 28 residents, the facility was required to staff specific minimum NA levels on day and evening shifts but instead scheduled fewer NAs than mandated, and no additional higher-level staff were present to offset the shortfall. The NHA acknowledged that the required NA-to-resident ratios were not met on the identified shifts.
Failure to Meet Minimum NA-to-Resident Ratio on a Day Shift
Penalty
Summary
The facility failed to meet state-required minimum nurse aide (NA) staffing ratios for one of 22 reviewed days. Review of nursing schedules covering March 1 to 17, 2026, and April 26 to 30, 2026, showed that on March 8, 2026, during the day shift (7:00 a.m. to 3:00 p.m.), the facility did not provide the required minimum of one NA per ten residents. For all other reviewed days and shifts, the report does not identify additional ratio failures. In an interview on May 1, 2026, at 9:25 a.m., the Director of Nursing (DON) acknowledged that the facility failed to meet the required NA-to-resident ratio on that specific day shift. No additional information is provided in the report regarding specific residents, their medical conditions, or any clinical events occurring as a result of the staffing shortfall. The deficiency is based solely on the documented staffing schedules and the DON’s confirmation of noncompliance with the mandated NA staffing ratio for the identified day shift.
Plan Of Correction
Sufficient staff was originally scheduled but dropped due to call outs. DON will educate schedulers and supervisors to add open shift to staff and agency requests when staff call out. Supervisors and / or schedulers round the units and ask additional staff to work as needed as call outs occur. Schedulers will monitor staffing numbers and report to DON daily.
Failure to Maintain Minimum Night Shift Nurse Aide Staffing Ratios
Penalty
Summary
Facility administrative staff failed to meet state-required minimum nurse aide staffing ratios on the night shift on five of 21 reviewed days. Review of nursing schedules and census data from 4/5/26 through 4/25/26 showed that on 4/14/26, the night shift required 52.00 hours of nurse aide care but only 48.50 hours were provided; on 4/18/26, 52.00 hours were required but 43.00 hours were provided; on 4/23/26, 50.00 hours were required but 41.25 hours were provided; on 4/24/26, 50.50 hours were required but 36.50 hours were provided; and on 4/25/26, 51.00 hours were required but only 47.00 hours were provided. These shortfalls meant the facility did not maintain the mandated minimum of one nurse aide per 15 residents during the overnight shift on those dates. During an interview on 5/1/26 at approximately 12:00 p.m., the Nursing Home Administrator confirmed that the facility failed to provide the required minimum nurse aide staffing on the night shift on these five days. No specific residents, medical histories, or clinical conditions were identified in the report; the deficiency is based on staffing hours and ratios compared to the required standard for nurse aide coverage on the night shift.
Plan Of Correction
1. The Facility will continue to take measures to adequately provide staff to ensure the needs of residents are met. 2. The Facility will continue to take measures to adequately provide staff to meet the required certified nursing assistant to resident ratios on dayshift, evening shift, and night shift. 3. The Director of Nursing/designee will provide re-education on minimum staffing ratios to RN Supervisors, HR, and Scheduling who are responsible to monitor staffing and staffing ratios. 4. The Director of Nursing/designee will audit the daily schedules to monitor the minimum number of staff to resident ratios are being met. If ratios are not met the Director of Nursing/designee will make attempts to meet the number of staff to resident ratios. These audits will be conducted daily for 14 days and then weekly X 3 weeks. Audit results will be reviewed in Quality Assurance Performance Improvement Committee x 2 months.
Failure to Meet Minimum Nurse Aide Staffing Ratios Across Multiple Shifts
Penalty
Summary
The facility failed to meet state-required minimum nurse aide (NA) staffing ratios on multiple shifts over a nine-day review period. Review of facility staffing documents from 4/20/26 through 4/28/26 showed that on the day shift, the facility did not provide at least one NA per 10 residents on four days, with census counts of 58–59 residents and actual NA hours falling below the required hours (for example, on 4/25/26 and 4/26/26, 29.91 and 31.38 actual hours were provided versus 44.25 required). On the evening shift, the facility failed to provide at least one NA per 11 residents on four days, again with census counts of 58–59 residents and actual NA hours (30.50–38.16) below the required 39.55–40.23 hours. On the night shift, the facility failed to provide at least one NA per 15 residents on one day, with 27.00 actual hours versus 29.50 required for 59 residents. During an interview, the Director of Nursing confirmed that the facility did not provide the required number of NAs on the identified shifts.
Plan Of Correction
The Facility submits this plan of correction under the procedures established by the Department of Health in order to comply with the department's directive to change conditions which the department alleges are deficient under date and/or federal long term care regulations. This plan of correction should not be construed as either a waiver or the facility right to appeal or challenge the accuracy of severity of the alleged deficiencies or an admission of past or ongoing violation of state or federal regulatory requirements. 5520CNA The Nursing schedule is created to ensure CNA staffing ratios reflects the current census per shift. Each shifts CNA staffing is adjusted based on census. When additional staff is needed to meet ratios, shifts are posted on our staffing portal, bonuses are offered, phone calls and text messages are sent to staff. The facility will utilize agency to assist with open shifts when needed. The facility attendance policy is followed for staff and disciplines occur per policy. Attendance is tracked on a calendar and reviewed weekly. The facility holds a monthly retention committee meeting and ads are posted on Indeed for open positions. Interviews are conducted immediately. We have a dedicated recruiter to assist with recruiting and hiring new nursing staff. The Administrator or designee will educate the Nursing Admin, HR, the scheduler and RN Supervisors on the staffing ratios and PPD and how to adjust. A staffing meeting will occur daily to review ratios with the NHA, DON, HR and scheduler. Daily recruiting calls with the NHA, HR, and recruiter occur to update the status of new applicants and interviews. The 3 week DOH Staffing Calculator Tool will be updated daily to monitor hours. The Audits will be taken to QAPI for review.
Failure to Maintain Minimum Nurse Aide Day-Shift Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide staffing ratios on the day shift, specifically the requirement of at least one nurse aide per 10 residents. Review of facility staffing data for selected weeks showed that on two dates in late December 2025, the day-shift nurse aide staffing levels did not meet this mandated ratio. The deficiency was identified through review of staffing records for the weeks of early September 2025, late December 2025, and late March 2026, which revealed that on December 29 and December 31, 2025, the number of nurse aides scheduled on the day shift was insufficient for the resident census. During an interview on April 31, 2026, the Nursing Home Administrator confirmed that the nurse aide staffing ratios were not met on those days. No specific residents, medical histories, or clinical conditions were described in the report in relation to this staffing deficiency.
Plan Of Correction
1) Staff was educated on calling off in a timely manner and following all attendance policy and procedure in regards to clocking in and out. 2) Staffing reviewed on each workday to ensure vacant nurse aide shifts are filled to meet the ratio requirements, and the hours set which have been determined by census, and the ratio requirement are accurate, and all efforts are made to replace, fill, and or meet all necessary requirements. 3) Education provided to management staff to ensure that all ratios for nursing aide staffing are adhered to in order to meet the regulated needs based on census. All processes will be reviewed with the management team in regard to utilizing the staffing call list as well as the agency platforms to acquire replacement staff if needed. 4) NHA and or designee to review staffing daily to ensure ratio requirement is met for two weeks from 5/1/26 until 5/30/26. Ongoing monthly reviews will be conducted to ensure all staffing minimums are met. All findings will be reported to the QAPI committee for continued review and revision.
Failure to Maintain Required NA-to-Resident Staffing Ratios Across Multiple Shifts
Penalty
Summary
The deficiency involves the facility’s failure to meet state-mandated NA-to-resident staffing ratios on multiple dates across day, evening, and night shifts. Review of census and staffing data for March 8–14, March 22–28, and April 5–11, 2026, showed that the number of NA hours actually worked fell below the minimum required based on the resident census. For example, on March 8, 2026, with a census of 105 residents requiring 10.50 NAs on the day shift, only 8.10 NAs were scheduled and provided care. On March 9, 2026, the same census of 105 residents required 10.30 NAs on the day shift, but only 6.88 NAs were provided. Similar shortfalls occurred on numerous other day shifts. On March 12, 2026, a census of 105 residents required 10.50 NAs, but 7.03 NAs were provided; on March 13, 2026, 10.50 NAs were required and 6.89 were provided; on March 14, 2026, 10.50 NAs were required and 8.16 were provided. On March 22, 2026, a census of 101 residents required 10.10 NAs, but 8.15 were provided; on March 24, 2026, a census of 102 residents required 10.20 NAs, but 9.07 were provided; on March 25, 2026, a census of 103 residents required 10.30 NAs, but 8.60 were provided; on March 27, 2026, a census of 106 residents required 10.60 NAs, but 8.65 were provided. In April, on April 5, 2026, a census of 108 residents required 10.80 NAs, but 9.81 were provided; on April 6, 2026, the same census required 10.80 NAs, but 7.04 were provided; on April 7, 2026, 10.80 NAs were required and 9.05 were provided; and on April 9, 2026, a census of 109 residents required 10.90 NAs, but 8.70 were provided. The facility also failed to meet required NA staffing ratios on several evening and night shifts. On the evening shift, with a census of 105 residents on March 8, 13, and 14, 2026, 9.55 NAs were required each evening, but only 8.81, 8.21, and 8.62 NAs, respectively, were provided. On March 28, 2026, with a census of 107 residents requiring 9.73 NAs on the evening shift, only 9.31 NAs were provided. On the night shift, on March 11, 2026, a census of 104 residents required 6.93 NAs, but 6.13 were provided; on March 14, 2026, a census of 105 residents required 7.00 NAs, but 6.09 were provided; on March 22, 2026, a census of 101 residents required 6.73 NAs, but 6.68 were provided; and on March 27, 2026, a census of 106 residents required 7.07 NAs, but 6.42 were provided. The surveyors also determined there were no additional excess higher-level staff available to compensate for these NA staffing deficiencies, and the Administrator confirmed on interview that the required NA-to-resident ratios were not met on the identified dates.
Plan Of Correction
1. Actions taken for the situation identified: The facility cannot retroactively address the incidents. No residents were adversely affected. 2. How the facility will act to protect residents in similar situations: The facility will schedule, monitor and manage the nursing staff ratios to meet the requirements 3. System changes and measures to be taken: The Nursing Home Administrator has reviewed the required ratios with the Director of Nursing and other staff responsible for nursing staff scheduling. Daily staffing meetings are being held two times daily to review the scheduled staffing hours per patient day and ratios for the current and upcoming day(s) to ensure that the facility meets the requirements. 4. Monitoring mechanisms to assure compliance: The Nursing Home Administrator/designee will conduct audits of the nursing staff ratios to determine compliance weekly for four (4) weeks then monthly for two (2) months. Noted areas of non-compliance will be addressed upon discovery. Audit results will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings, and further action plans and audits will continue until substantial compliance is achieved. Ongoing self-monitoring will help to ensure facility continues to meet quality standards. 5. Date Corrective Action will be completed: Substantial compliance is expected by 5/11/2026
Failure to Maintain Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet required nurse aide (NA) to resident staffing ratios on three of twenty-one reviewed shifts, as identified through a review of weekly staffing records and staff interviews. State regulations effective July 1, 2024, require a minimum of 1 NA per 10 residents on the day shift, 1 NA per 11 residents on the evening shift, and 1 NA per 15 residents on the night shift. For a census of 28 residents, the facility was required to staff 2.8 NAs on the day shift and 2.55 NAs on the evening shift. On one evening shift, the facility staffed 2.13 NAs instead of the required 2.55, and on a separate day shift, the facility staffed 2.53 NAs instead of the required 2.8. On another evening shift, the facility again staffed 2.13 NAs instead of 2.55. The records also showed that there were no additional higher-level staff available on those dates to compensate for the NA shortfalls. In an interview, the Nursing Home Administrator confirmed that the facility did not meet the required NA-to-resident ratios on the identified dates. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency is based solely on staffing levels compared to regulatory requirements for the facility’s census.
Plan Of Correction
1.) There were no ill effects suffered by the residents due to the facility's failure to meet the ratio for residents to CNAS for 3 shifts. 2.A facility wide audit was completed to ensure ratios were met. CNA sign on bonuses and wages are competitive with surrounding areas. The facility uses bonuses for employees to pick up shifts. 3.DON and Corporate HR were re-educated on staffing ratios and ensure the facility is actively recruiting to fill any open positions. The DON will review census and staffing ratios to ensure ratios are being met. 4.The DON or designee will conduct an audit of nursing care ratios weekly x 4 weeks then monthly x2 months to ensure ratios are being met. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.
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