Deficiency in Direct Resident Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.20 hours of direct resident care per resident for two out of five days reviewed. Specifically, on April 5, 2025, the facility provided only 2.99 hours of direct care per resident, and on April 6, 2025, it provided 2.83 hours. This deficiency was identified through a review of nursing schedules and confirmed during an interview with the Nursing Home Administrator on April 7, 2025.
Plan Of Correction
1. The hours of direct care staffing noted in the survey findings cannot be corrected as this is a past event. 2. Calculation of direct care staffing will be completed and reviewed daily for accuracy by the scheduler or designee. The facility has developed internal incentives to retain and attract staff and meet shift ratio requirements. Administrator will re-educate Director of Nursing and Scheduler regarding direct care staffing regulations. 3. Facility scheduler, Director of Nursing, Human Resources and Administrator have a daily staffing meeting (5 days per week) to review schedules including compliance with ratios. For staff call offs, every effort will be made to replace the call off using resources available including communicating with staff to replace the vacancy. Staffing patterns are projected at least one week in advance to enable ongoing efforts to fill any vacant shifts. The facility will take admissions when staffing is appropriate. 4. Direct care staffing will be monitored daily by Scheduler and/or Director of Nursing or designee. Audits of ratios will be completed by Director of nursing or designee daily for 4 weeks then 3 days per week x 2 months or until substantial compliance is achieved. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee.