Deficiency in Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.20 hours of direct nursing care per resident per 24-hour period for five out of seven days reviewed. Specifically, on January 6, 7, 9, 11, and 12, 2025, the facility provided less than the mandated hours, with recorded hours being 2.74, 2.83, 2.85, 3.18, and 2.94 respectively. This deficiency was identified through a review of staffing documents and confirmed during an electronic mail correspondence with the Nursing Home Administrator, who acknowledged the expectation for the facility to be staffed according to State Regulations.
Plan Of Correction
1. Facility cannot retroactively correct this concern. 2. Current residents are at risk of being affected by staffing levels. Will review resident council meeting minutes for staffing related concerns. 3. Will continue to offer bonuses when PPD is below minimum and attempt to mandate staff when call outs and absences occur. Agency rates for aides were recently increased to assist with staffing challenges. 4. NHA/designee will monitor staffing ratios and PPD daily to ensure appropriate levels are being met. Audits will be reviewed at QAPI to ensure compliance and quality care.