Observations:
Based on review of nursing schedules and staff interviews, it was determined that the facility failed to provide 3.20 hours of direct resident care for each resident for two of four days (24-hour periods) reviewed for April 24 through April 27, 2025.
Findings include:
Review of the nursing time schedules provided by the facility revealed that the facility provided 3.09 hours of direct care for each resident on April 26, and 3.00 hours of direct care for each resident on April 27, 2025.
Interview with the Nursing Home Administrator on April 29, 2025, at 10:47 a.m. confirmed that the facility did not meet the required daily hours of direct resident care for each resident on the days listed above.
| | Plan of Correction - To be completed: 05/19/2025
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This Plan of Correction (POC) does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. The Hours of direct care for March 29, 2025 and March 30, 2025 could not be corrected There were no other dates identified as issues at the time of the survey. To prevent a future occurrence, the Administrator/designee will educate nursing staff on the on the requirements of meeting the Hours of direct care per day. The facility will hold staffing meetings 5 days per week, consisting of the Nursing Home Administrator, Director of Nursing, Human Resources and scheduler to review ratio compliance for upcoming schedules. During staffing meeting discussion will be held on efforts to fill open slots to meet ratio by contacting external agencies for staff and asking in house staff to cover additional shifts. Holding admissions will be considered if warranted
To monitor and maintain ongoing compliance, the Administrator/designee will complete random audits of daily staffing sheets to ensure the Hours of direct care are met daily. Audits will be weekly x4 and then monthly x2. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendation
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