Facility Fails to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently meet the required minimum of 3.2 hours of direct nursing care per resident per day, as mandated by state regulation effective July 1, 2024. A review of the facility's staffing levels revealed multiple instances in December 2024 where the nursing care hours fell short of the required minimum. Specifically, on December 14, 15, 19, 20, 23, 24, 25, 27, 28, and 31, the facility provided between 2.82 and 3.19 hours of direct care per resident, which is below the mandated threshold. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 2, 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. 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. 5. Date of compliance will be January 21, 2025.