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 for eight out of the 21 days reviewed. This deficiency was identified through a review of nursing staffing hours and staff interviews. Specifically, the facility did not meet the required hours on several dates, including October 13 and 14, 2024, December 29 to 31, 2024, and January 2 to 4, 2025. The hours per resident per day on these dates ranged from 2.74 to 3.19, falling short of the mandated 3.2 hours. This information was confirmed during an interview with the Nursing Home Administrator on March 7, 2025.
Plan Of Correction
1. Nursing Staff PPD care hours will be reviewed daily for the current day and for the remainder of the week during morning meeting for compliance with the state regulation of the nursing hours guidance for a staff PPD of 3.2. 2. The facility will continue to actively hire and advertise open positions to meet current regulations. 3. The facility will continue to use per diem staff to fill open shifts and ask current RN's, LPN's and CNA's to fill open shifts. 4. DON and or designee will review PPD staffing hour weekly for four works then monthly three months and bring audits to the monthly QA meeting for review.