Failure to Meet Minimum Direct Care Staffing Hours
Penalty
Summary
The facility failed to provide the required minimum of 3.2 hours of direct resident care per resident per day, as mandated by regulation effective July 1, 2024. Review of nursing schedules for selected weeks in June, July, and September 2025 showed that on 19 out of 21 days reviewed, the facility did not meet this staffing requirement. The direct care hours per resident ranged from 2.51 to 3.15 on these days, consistently falling short of the regulatory minimum. This deficiency was confirmed through both documentation review and an interview with the Nursing Home Administrator, who acknowledged that the required daily hours of direct resident care were not met on the specified days. No additional details about specific residents, their medical history, or their condition at the time of the deficiency were provided in the report.
Plan Of Correction
The facility attempts to staff to meet state required number of staff hours for a minimum of 3.2 hours of direct resident care per resident per day. The facility offers shift bonuses for pick-up shifts and for additional hours in case of call-offs. Registered nurses, licensed practical nurses, and nursing administration all assist to help fill in as needed. An active recruitment campaign is ongoing, which includes sign-on bonuses, shift differentials, and employee referral bonuses. Agency staff are contracted as available to fill in needed shifts. The Nursing Home Administrator and Director of Nursing meet daily to review staffing sheets to ensure proper staffing. Time and attendance are reviewed daily for ratios and staffing numbers. These calculations are recorded daily in labor tracking and submitted to the facility's management company ongoing.