Failure to Meet Required Nursing Care Hours
Penalty
Summary
The facility failed to meet the required Per Patient Day (PPD) of 3.20 hours of direct resident care for each resident on four specific days between March 28 and April 6, 2025. A review of the facility's staffing data revealed that on March 29, 2025, the PPD was 3.19, on March 30, 2025, it was 2.83, on April 4, 2025, it was 2.96, and on April 6, 2025, it was 2.97. This deficiency was identified during a review of the facility's staffing data and was communicated to the Nursing Home Administrator during a telephone interview on April 14, 2025.
Plan Of Correction
1. All residents will receive care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler will review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from the internal staffing pool and contracted agency staff. The facility continues to coordinate staffing schedules and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All nursing leadership staff have been educated on Nursing staffing Ratios and HPPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.