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 patient day (PPD) for seven out of the 21 days reviewed. This deficiency was identified through a review of nursing care hours from March 30, 2025, to April 29, 2025. Specific dates where the facility did not meet the required hours include April 20, 23, 25, 26, 27, 28, and 29, 2025, with PPD ranging from 2.76 to 3.15. An interview with the Nursing Home Administrator and Director of Nursing on April 30, 2025, confirmed the facility's failure to meet the required nursing care hours.
Plan Of Correction
The facility cannot retroactively correct past PPD staffing levels. The facility will continue to take measures to adequately provide nursing staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff. These measures include continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign-on bonuses. The Director of Nursing/designee will educate PPD staffing levels to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios. The Director of Nursing/designee will audit the daily schedules 5x week x 6 weeks to ensure that the minimum PPD staffing levels have been scheduled. The results of the audits will be reviewed at the facility's QAPI meeting for recommendations.