Failure 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 two out of twenty-one days reviewed. Specifically, staffing documents and nurse schedules showed that on 5/30/25 and 6/30/25, the provided hours of care were 3.15 and 3.14 PPD, respectively, which is below the required threshold. During interviews, a resident reported that nurse aides were responsible for more residents than expected, indicating issues with understaffing on the affected days. These findings were confirmed and communicated to the Nursing Home Administrator and Director of Nursing during the exit interview.
Plan Of Correction
P 5640 1. NHA or designee to educate staffing coordinator, DON, ADON, Unit Managers, and Nursing Supervisors on the state-required minimum staffing levels of 3.2 hours per patient day. 2. NHA or designee will conduct daily staffing meetings five times per week for the next two months to ensure the state minimum number of general nursing care hours are met. 3. NHA or designee will review staffing sheets once per week for the next two months to ensure adequate nursing coverage is scheduled to meet the minimum number of general nursing care hours. 4. Facility recruitment/retention efforts include utilizing job postings on the company's career website, Indeed, and LinkedIn. The company offers competitive wages, benefits within 30 days of employment, tuition reimbursement program, etc. Facility administration holds weekly retention events with activities and food and also has a quarterly employee recognition program. 5. Results of findings will be reviewed during Monthly QAPI for recommendations and until compliance is met. I Certify This Document to be a True and Correct Statement of Deficiencies and Approved Facility Plan of Correction for the Above-Identified Facility Survey