Deficiency in Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident in a 24-hour period. This deficiency was identified during a review of nursing schedules for the week of January 10 through January 16, 2025. Specifically, on January 11, 2025, the facility provided only 3.17 hours of care per resident, falling short of the mandated minimum. This shortfall was confirmed by the Director of Nursing during an interview conducted on January 17, 2025.
Plan Of Correction
The facility staffs the facility to at least meet the required staffing ratios of NAs, including the use of agency staff if necessary. When there are staff call outs, the facility attempts to call other staff in and notify agency staff as well. The facility continues to focus on recruitment and retention activities. Valley Manor will hold staffing meetings throughout the week to monitor state staffing ppd compliance. NHA or designee will educate DON/ADON/ and Nursing Supervisors on state staffing ppd regulation. To monitor the corrective action and ensure that it does not recur, the DON will audit PPD weekly X4; bi-weekly X 2 and monthly X 1. The results will be reviewed at the QAPI meeting.