Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to provide the required minimum of 3.2 hours of direct nursing care per resident per day for eight out of twenty-one days reviewed. Specifically, on several dates in April, May, and July 2025, the total nursing care hours per patient day fell below the mandated threshold, with recorded hours ranging from 2.91 to 3.12 per resident per day. This deficiency was confirmed through a review of nursing staff care hours and interviews with the Nursing Home Administrator and Director of Nursing, who acknowledged that the facility did not meet the required staffing levels on the identified days. No additional information regarding the medical history or condition of specific residents was provided in the report.
Plan Of Correction
There is no evidence of any ill effect on any residents within the community due to lack of adherence to the PPD requirement for staff on the eight dates indicated. Daily compliance to the PPDs is presented by the Human Resource representative during the morning leadership meeting for discussion and recommendations to ensure we are compliant with the required nursing care hours. Identified concerns are highlighted and discussed with management for planning purposes. Upon identification of continued staffing needs, immediate mass texts are sent to all current staff including full-time, part-time, and PRN. In addition, needs are posted on agency sites and one-on-one conversations are held with staff to ensure staff needs are met. If continued needs exist, the group will touch base again mid-day to ensure corrective actions have been taken. Additional days are also reviewed for verification of the facility's adherence. An audit of the DOH Staffing Hour Calculator Report will be reviewed daily for two weeks and weekly for one month at the morning meeting for presentation and discussion of any variances with the established compliance requirements and actions taken to attempt to eliminate any variances. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions. 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