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 nursing care per resident per day. A review of nursing time schedules from December 2 through 22, 2024, revealed that on six specific days, the facility did not meet this requirement. On December 8, 9, 10, 13, 14, and 15, 2024, the care hours per resident were 2.70, 2.92, 2.93, 3.07, 2.97, and 2.81, respectively. This deficiency was identified based on the analysis of the nursing time schedules, indicating a shortfall in the required nursing care hours for the residents on these days.
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. The 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 nursing staff to resident ratios weekly X4; bi-weekly X2 and monthly X1. The results will be reviewed at the QAPI meeting.