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. This deficiency was identified during a review of the facility's weekly staffing records, which showed that on two specific days, March 28 and March 30, 2025, the facility provided only 3.14 and 3.02 hours of direct care nursing per resident, respectively. This shortfall in nursing hours was confirmed during an interview with the Nursing Home Administrator on April 2, 2025, indicating a failure to consistently meet the mandated staffing levels for resident care.
Plan Of Correction
1. The facility cannot retroactively correct staffing PPD. 2. NHA/designee will conduct an initial audit of the past two weeks scheduled to determine if PPD are in compliance. 3. NHA/designee will re-educate the scheduler on the proper PPD. The facility will hold labor meetings Monday-Friday to verify PPD is made. 4. NHA/designee will conduct random audits of facility PPD weekly for four weeks, then monthly for two months thereafter to verify proper PPD hours. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.