Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.2 hours of direct nursing care per resident per day for two out of four days reviewed. Specifically, staffing records and nursing schedules showed that on June 21, 2025, only 3.01 hours of direct care per resident were provided, and on June 22, 2025, only 3.17 hours were provided. This shortfall was confirmed by the Nursing Home Administrator during an interview, who acknowledged that the facility did not meet the required minimum for those days. No additional information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
P 5640 1. Facility is unable to retroactively correct the minimal direct care hours for June 21 & 22, 2025. 2. Nursing Home Administrator will have a daily staffing meeting with the Director of Nursing and facility Nursing Scheduler to review daily staffing schedules to ensure compliance with staffing regulations, discuss potential barriers to meeting required staffing ratios, and identify strategies to meet staffing ratios including but not limited to recruitment efforts, bonus structure, use of agency, and overtime hours. 3. Nursing Home Administrator/designee will educate the Director of Nursing and facility Nursing Scheduler on P5640 and the importance of ensuring compliance with a minimum of 3.2 hours of direct resident care as mandated by state laws regarding mandated minimum staffing requirements. 4. Nursing Home Administrator will audit daily nursing staffing ratios to ensure the facility is in compliance with mandated state laws regarding a minimum of 3.2 hours of direct resident care hours. These audits will be conducted weekly for 4 weeks and monthly for 2 months. Results of these audits will be reviewed by the Quality Assurance Performance Improvement committee.