Failure to Meet Minimum Direct Care Hours
Penalty
Summary
The facility failed to provide the required minimum hours of direct resident care per day as mandated by regulation. Specifically, a review of nursing schedules for the period between July 14 and August 3, 2025, showed that on three separate days, the facility provided less than the required 3.20 hours of direct care per resident. The actual hours provided were 3.19, 3.16, and 3.13 on the respective days. This deficiency was confirmed through staff interviews, including with the Nursing Home Administrator, who acknowledged that the facility did not meet the required daily hours of direct resident care on the identified dates.
Plan Of Correction
1.) The facility is unable to correct the cited three of 21 days that it failed to provide 3.20 hours of direct resident care for each resident. There were no concerns noted due to the direct care hours. 2.) Education will be provided to the Scheduler and Registered Nurse staff on providing 3.20 hours of direct care per resident. The facility has a labor management meeting to discuss staffing levels and needs. The facility can utilize agency and nursing management to assist with maintaining the 3.20 staffing hours per resident. 3.) Director of Nursing or designee will audit the daily hours of direct resident care for each resident daily times 5 days, weekly times 3 weeks, and monthly times 2 months. 4.) Results of the audit will be reviewed at the Quality Assurance Performance Improvement meeting.