Deficiency in Minimum Nursing 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 on two specific days. On January 15, 2025, with a census of 146 residents, the facility provided only 3.10 hours per resident. On January 16, 2025, with a census of 150 residents, the facility provided only 2.64 hours per resident. This deficiency was confirmed during an interview with the Nursing Home Administrator on February 5, 2025, who acknowledged the shortfall in nursing hours on these two days.
Plan Of Correction
DON will educate Administrator and Staffing Coordinator on the PPD state requirements. Staffing meetings will be held 5 days per week to review ratios from the prior day(s) and the projected staffing to the upcoming week to ensure appropriate staffing levels are planned. Identified staffing needs will be offered to existing staff and contracted agencies, as needed, by the Administrator/designee. The facility will continue to recruit staff through use of company platforms and recruiter representatives. Audits of PPD requirements will be completed by the NHA/designee to ensure that the facility meets daily hours requirements. Audits will be completed by the administrator during the staffing meetings.