Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently meet the required minimum of 3.2 hours of direct resident care per resident per day. On January 25, 2025, the facility provided only 3.02 hours, and on January 26, 2025, it provided 2.60 hours of direct care nursing per resident. This deficiency was identified through a review of the facility's staffing levels and was confirmed during an interview with the Nursing Home Administrator on January 30, 2025.
Plan Of Correction
1. Facility cannot retroactively correct the overall PPD. 2. Director of Nursing/Designee will conduct an initial audit of the next two weeks schedule to determine if the overall PPD is in compliance. 3. Director of Nursing/Designee will re-educate the scheduler on the proper staffing PPD. The facility will hold labor meetings Monday-Friday to verify PPD is met. Incentives put in place for staff to pick up shifts, not call out and assist with recruiting efforts. 4. Director of Nursing/Designee will conduct random audits of overall PPD then monthly for two months thereafter to verify proper PPD. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.