Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently provide the minimum required general nursing care hours of 3.2 hours per resident per day. A review of the facility's staffing levels revealed multiple instances where the nursing care hours fell short of this requirement. Specifically, on several dates in November and December 2024, the facility provided between 2.14 and 3.12 direct care nursing hours per resident, which is below the mandated minimum. This deficiency was confirmed during an interview with the Nursing Home Administrator on December 30, 2024.
Plan Of Correction
Facility cannot retroactively correct past nursing hours. The facility is focusing on retaining current nursing staff and recruitment using in-house recruitment resources and a company team to assist with recruitment, dedicated to only nursing applicants to correct nursing hours. The facility has contracted with 3 staffing agencies to augment facility employees for the nursing department. The facility is implementing staff incentives for current and new staff as well as reinforcing the facility call-off policy to deter unnecessary call-offs. NHA or designee will educate staff on incentives and the call-off policy. NHA/designee will audit nursing hours weekly for three weeks, then monthly for 3 months. Audits will be reviewed by QA monthly for 3 months to ensure compliance with POC.