Deficiency in Meeting Required Nursing Care Hours
Penalty
Summary
The facility failed to meet the required staffing minimum of 3.20 hours of direct nursing care per resident on three specific days: November 25, 27, and 29, 2024. On November 25, the facility had a census of 73 residents and provided 231.00 direct nursing staff hours, resulting in 3.16 hours of care per resident. On November 27, with a census of 72 residents, 226.00 direct nursing staff hours were provided, equating to 3.14 hours of care per resident. On November 29, again with a census of 72 residents, 228.00 direct nursing staff hours were provided, resulting in 3.17 hours of care per resident. These findings were confirmed by the Nursing Home Administrator during a review of staffing calculations, nursing staff schedules, and staff punch reports on February 4, 2025.
Plan Of Correction
1. Facility to ensure that HPPD requirements are maintained in accordance with regulatory requirements. 2. Staffing Coordinator or designee will conduct an audit of HPPD from 2/22/25-2/28/25 to verify HPPD in accordance with regulation and if discrepancies are identified regulatory requirements will be reviewed by the Nursing Home Administrator and Staffing Coordinator. 3. Nursing Home Administrator or designee will reeducate Staffing Coordinator on the HPPD regulatory requirements by 3/4/25. 4. Staffing Coordinator or designee will conduct audits 2 days per week x 4 weeks and then 2 days per month x 2 months to ensure that HPPD are consistent with regulatory requirements. The results of these audits will be forwarded to Quality Assurance Process Improvement team for review and recommendations.