Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the state-required minimum of 3.20 hours of direct resident care per patient daily (PPD) on four out of five days, from March 12 to March 15, 2025. A review of staffing documents and nursing staff schedules revealed that on March 12, the facility provided 3.17 PPD, on March 13, 2.70 PPD, and on both March 14 and 15, 3.02 PPD. This deficiency was confirmed during an interview with the Nursing Home Administrator on March 19, 2025, who acknowledged the failure to meet the required staffing levels on the specified dates.
Plan Of Correction
The facility cannot retroactively correct cited deficiencies. The facility will continue to maintain the required ratios and implement a contingency plan if needed by calling in off duty staff, calling sister facilities, or utilizing bonuses as needed to ensure sufficient nursing staff. Additionally, the facility will continue to maintain efforts to recruit and retain staff to meet care needs and ensure residents are receiving appropriate care and services. The regional staff educated NHA/DON on ensuring sufficient nursing staff to meet residents' needs and ensure that the facility is holding daily staffing meetings. The RDO educated NHA/DON on ensuring sufficient nursing staff and ensuring a minimum of 3.20 PPD. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 5x weekly for 4 weeks, then monthly for 2 months to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.