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 resident care per resident in a 24-hour period. On January 7, 8, and 9, 2024, the facility's staffing levels were insufficient, providing only 2.75, 2.82, and 2.87 direct care nursing hours per resident, respectively. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 9, 2025, who acknowledged the facility's failure to consistently meet the required nursing care hours.
Plan Of Correction
The facility cannot retroactively correct the nursing hours. Calculation of daily PPD will be completed and reviewed for accuracy by the scheduler/designee. The NHA/designee and Human Resources/designee will continue recruitment efforts including but not limited to job postings, working with facility recruiter, sending needs out to agencies, and continuing to be a clinical site for nursing assistant classes. The facility focuses on retention of existing clinical staff and recruitment of new clinical staff through the efforts of the retention events and staffing meetings. Bi-Weekly staffing meetings will be held to address good faith efforts towards meeting nursing hours. Daily PPD will be audited weekly x4, then monthly x2. The audits will be presented to monthly QAPI x 2 months.