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 one of six reviewed days. Specifically, staffing documents and nursing schedules showed that on 6/29/25, the provided direct care hours were only 2.90 per patient daily (PPD), which is below the required threshold. This deficiency was confirmed by the Nursing Home Administrator during an interview, who acknowledged that the facility did not provide the minimum required hours of direct care on the identified date. No additional details regarding the residents' medical history or condition at the time of the deficiency were provided in the report.
Plan Of Correction
The facility cannot retroactively correct cited deficiencies. The facility will continue to maintain the required ratios and implement a contingency plan if needed by calling in off-duty staff, calling sister facilities, or utilizing bonuses as needed to ensure sufficient nursing staff. Additionally, the facility will continue to maintain efforts to recruit and retain staff to meet care needs and ensure residents are receiving appropriate care and services. The regional staff educated NHA/DON on ensuring sufficient nursing staff to meet residents' needs and ensure that the facility is holding daily staffing meetings. The RDO educated NHA/DON on ensuring sufficient nursing staff and ensuring a minimum of 3.20 PPD. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 5x weekly x4, then monthly x2, to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.