Facility Fails to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the state-mandated minimum of 3.2 hours of direct nursing care per resident per day on 11 out of 21 days. This deficiency was identified through a review of nursing schedules and census information for the periods of 3/1/25-3/7/25 and 4/8/25-4/21/25. On specific dates, the facility's nursing care hours per resident fell below the required threshold, with the lowest being 2.54 hours on 3/6/25. The Nursing Home Administrator confirmed this shortfall during an interview on 4/23/25.
Plan Of Correction
There were no adverse effects to the residents of our facility as a result of decreased HPPD on 3/1, 3/2, 3/3, 3/4, 3/5, 3/6, 3/7, 4/12, 4/16, 4/18, and 4/20/2025. The Director of Nursing, HR and Scheduler will be re-educated on the state requirement for HPPD by the Nursing Home Administrator or Designee. Staffing meetings will be held 3 days a week to review HPPD from the previous day and the projected HPPD, as well as the upcoming week to ensure appropriate staffing levels. If projected staffing levels are below the minimum of 3.2 HPPD, then the facility will reach out to current staff and staffing agencies to enlist staff to meet the minimum requirement. The facility will continue to recruit staff through all platforms. Audits of HPPD will be completed 5 days a week x4 by the NHA/designee to ensure HPPD meets the state minimums. Results of the audits will be submitted to the QAPI committee monthly for review and recommendations.