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 per day. This deficiency was identified through a review of the facility's staffing levels and confirmed by staff interviews. Specifically, on five out of the seven days reviewed, the facility's nursing care hours fell below the required minimum. On March 27, 2025, the facility provided 3.09 hours, on March 28, 2025, 2.74 hours, on March 29, 2025, 2.80 hours, on March 30, 2025, 2.85 hours, and on March 31, 2025, 3.05 hours of direct care per resident. An interview with the Nursing Home Administrator confirmed the facility's failure to consistently meet the required nursing care hours.
Plan Of Correction
Facility cannot retroactively correct this deficiency. New scheduling system in place to assist with replacing call offs and filling open shifts via automatic blasts to staff. New scheduling system also has the ability to post open shifts to all staff including agency. Agency call offs are attempted to be replaced by the agency with additional bonus as needed. Recruitment of nursing staff will continue via facility website, Indeed, recruiting group, social media websites, local newspaper, job fairs, open house and off site recruiters. Agency utilized for open shifts. Retention efforts made with any resignation. Agency rates are reviewed weekly to ensure marketable and adjustments made as necessary. Text Blast for all open shifts. Facility recruiters have purchased list of nursing and aide staff to reach out to for recruitment. New onsite HR Director hired with extensive retention and recruitment experience. Calculation of daily PPD and shift ratios will be completed and reviewed daily for accuracy by the scheduler/back up scheduler, DON/ADON and NHA. All efforts will be made to meet PPD and staffing ratios. If call offs occur, all efforts will be made to attempt to fill that position. Daily PPD and ratios will be audited weekly x4, then monthly x2. Results to QA for review and recommendations.