Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period. This deficiency was identified through a review of the facility's nursing staffing sheets for specific weeks in August 2024, December 2024, and January 2025. On sixteen out of twenty-one sampled days, the facility's staffing hours fell below the required threshold, with recorded hours ranging from 2.08 to 3.09 hours per resident. The facility administration confirmed during an interview on January 31, 2025, that they did not meet the nursing hour requirements on these days.
Plan Of Correction
The facility is currently staffed at or above state minimum requirements. Step 2 The facility will partner with agencies to ensure the state minimum requirement of 3.2 hours of direct resident care is met, allowing for better management of last-minute callouts and unexpected staffing events. Step 3 The staff coordinator and other administrative staff involved in coordinating staffing educated on federal and state CNA staffing requirements. Step 4 The NHA or designee will audit staffing levels weekly x4 and monthly x2. Results will be reviewed during the monthly QAPI meeting.