Staffing and Care Hours Deficiency
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) during various shifts, as confirmed by the Director of Nursing (DON) during an interview. Specifically, the facility did not provide the minimum number of LPNs per residents during the day, evening, and night shifts. Additionally, the facility did not meet the mandated 3.2 hours of direct resident care per resident in a 24-hour period on 17 out of 21 days, as evidenced by a review of nursing schedules and census information. The Patient Per Day (PPD) hours fell below the required threshold on multiple dates, with the lowest being 2.21 hours on one occasion. These deficiencies were acknowledged by the DON, indicating a consistent shortfall in providing adequate nursing care over the specified period.
Plan Of Correction
1. The facility cannot correct that the minimum number of general nursing hours to each resident in a 24-hour period were not met on 17 of 21 days (12/29, 12/30, and 12/31/24, 1/1, 1/3, 1/4/25, 1/5, 1/6, 1/7, 1/8, 1/9, 1/10, 1/11, 1/12, 1/14, 1/16, and 1/18/25). 2. The facility will ensure that general nursing hours are met every shift. 3. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5640 and ensuring general nursing hours to each resident are met each shift. Daily shift staffing hours will be reviewed at daily staffing meetings. The Nursing Supervisors will review shift staffing on the weekends. If the facility projects to not meet general nursing hours to each resident on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist. 4. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure general nursing hours for each resident are being met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.
Penalty
The facility did not provide the state-required minimum of 3.20 hours of direct nursing care per resident per day (PPD) on multiple reviewed days. Staffing documents and nursing schedules showed that on several days the calculated PPD fell below 3.20, with values ranging from 2.88 to 3.19 hours of direct care per resident. In an interview, the DON acknowledged that the minimum required PPD hours of direct care were not met on those days.
Surveyors determined that the facility did not consistently meet the required minimum of 3.2 hours of direct general nursing care per patient day (PPD) on several reviewed days. Staffing records for selected weeks showed that on four days the total nursing hours fell below the mandated 3.2 PPD threshold. In an interview, the NHA acknowledged that the required PPD staffing ratios were not achieved on those days.
Surveyors determined that the facility did not consistently provide the required minimum of 3.2 hours of direct nursing care per resident in multiple 24-hour periods. Review of facility staffing schedules over several weeks showed that, on numerous days, the calculated direct care hours per resident fell below the regulatory threshold. The NHA confirmed during interview that the required daily direct care hours were not met on those days.
Facility staff did not provide the required minimum of 3.2 hours of direct nursing care per resident per day on 16 out of 21 days, as confirmed by review of schedules and census data and acknowledged by the NHA.
A review of nursing schedules showed that the facility did not provide the required minimum of 3.2 hours of direct nursing care per resident on three days within a 21-day period, with care hours falling below the mandated threshold on each of those days.
The facility did not provide the required minimum of 3.2 hours of direct nursing care per resident per day on two reviewed days, as confirmed by staffing records and the Nursing Home Administrator.
Failure to Meet Minimum Direct Nursing Care Hours (PPD) on Multiple Days
Penalty
Summary
The facility failed to meet the state-required minimum of 3.20 hours of direct nursing care per resident per day (PPD) on multiple days within the review period. Review of staffing documents and nursing staff schedules for 4/20/26 through 4/28/26 showed that on five of the nine days reviewed, the total general nursing care hours, when calculated per resident, fell below the required 3.20 PPD. Specifically, the PPD levels were 3.14 on 4/24/26, 2.94 on 4/25/26, 2.88 on 4/26/26, 2.97 on 4/27/26, and 3.19 on 4/28/26. During an interview, the DON confirmed that the facility did not provide the minimum required PPD hours of direct care on these dates as required by regulation. No additional resident-specific clinical details, medical histories, or conditions at the time of the deficiency are provided in the report.
Plan Of Correction
The Nursing schedule is created to ensure staffing PPD reflects the current census per shift. Each shifts staffing is adjusted based on census. When additional staff is needed to meet ratios, shifts are posted on our staffing portal, bonuses are offered, phone calls and text messages are sent to staff. The facility will utilize agency to assist with open shifts. The facility attendance policy is followed for staff and disciplines occur per policy. Attendance is tracked on a calendar and reviewed weekly. The facility holds a monthly retention committee meeting and ads are posted on Indeed for open positions. Interviews are conducted immediately. We have a dedicated recruiter to assisting us with recruiting and hiring new nursing staff. The Administrator or designee will educate the Nursing Admin, HR, the scheduler and RN Supervisors on the staffing ratios and PPD and how to adjust. A staffing meeting will occur daily to review ratios with the NHA, DON, HR and scheduler. Daily recruiting calls with the NHA, HR, and recruiter occur to update the status of new applicants and interviews. The 3 week DOH Staffing Calculator Tool will be updated daily to monitor hours. The Audits will be taken to QAPI for review.
Failure to Maintain Required 3.2 Nursing Hours Per Patient Day
Penalty
Summary
The facility failed to meet the state requirement that, effective July 1, 2024, each resident receive a minimum of 3.2 hours of direct general nursing care per patient day (PPD) over each 24-hour period. Review of staffing for the weeks of September 7, 2025, and December 28, 2025, showed that on four of twenty-one reviewed days the total nursing hours fell below this minimum. Specifically, the facility provided 3.15 PPD on September 13, 2025; 2.99 PPD on December 29, 2025; 3.03 PPD on December 31, 2025; and 3.14 PPD on January 3, 2026. During an interview on April 31, 2026, at 2:15 p.m., the Nursing Home Administrator confirmed that the required 3.2 PPD staffing ratios were not met on these dates. No additional resident-specific clinical details, medical histories, or conditions at the time of the deficiency were provided in the report.
Plan Of Correction
1) Staff was educated on calling off in a timely manner and following all attendance policy and procedure in regard to clocking in and out. 2) Staffing reviewed daily to ensure vacant shifts are filled to meet the PPD requirements which have been determined by census, and all efforts are made to replace, fill, and or meet all necessary PPD requirements. 3) Education provided to management staff to ensure that all hours, ratios, and ppd are adhered to in order to meet the regulated needs based on census. All processes will be reviewed with the management team in regard to utilizing the staffing call list as well as the agency platforms to acquire replacement staff if needed. 4) NHA and or designee to review staffing daily to ensure PPD requirement is met for two weeks from 5/1/26 until 5/30/26. Ongoing monthly reviews will be conducted to ensure all staffing minimums are met. All findings will be reported to the QAPI committee for continued review and revision.
Failure to Meet Minimum Daily Direct Nursing Care Hours
Penalty
Summary
The facility failed to meet the state-required minimum of 3.2 hours of direct nursing care per resident per 24-hour period on 12 of 21 reviewed days. Review of nursing time schedules for March 8 through 14, March 22 through 28, and April 5 through 11, 2026, showed that on multiple specific dates the total direct care hours per resident fell below 3.2, with documented levels of 2.58, 3.00, 2.98, 2.80, 2.74, 3.01, 2.91, 3.15, 3.08, 2.89, 3.15, and 3.02 hours depending on the day. These figures were derived from staffing information furnished by the facility and reflected the total general nursing care hours provided across the entire facility for each 24-hour period reviewed. In an interview on April 20, 2026, at 8:52 a.m., the Nursing Home Administrator confirmed that the facility did not meet the required daily direct resident care hours on the identified days.
Plan Of Correction
1. Actions taken for the situation identified: The facility cannot retroactively address the incidents. No residents were adversely affected. 2. How the facility will act to protect residents in similar situations: The facility will schedule, monitor and manage the nursing direct care hours to meet the requirements 3. System changes and measures to be taken: The Nursing Home Administrator has reviewed the required hours per patient day requirements with the Director of Nursing and other staff responsible for nursing staff scheduling. Daily staffing meetings are being held to review the staffing hour per patient day and ratios for the current and upcoming day(s) to ensure that the facility meets the requirements. 4. Monitoring mechanisms to assure compliance: The Nursing Home Administrator/designee will conduct audits of the nursing staff direct care hours to determine compliance weekly for four (4) weeks then monthly for two (2) months. Noted areas of non-compliance will be addressed upon discovery. Audit results will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings, and further action plans and audits will continue until substantial compliance is achieved. From that point forward, ongoing self-monitoring will help to ensure facility continues to meet quality standards. 5. Date Corrective Action will be completed: Substantial compliance is expected by 05/11/2026
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
Facility administrative staff failed to provide the minimum required 3.2 hours of direct general nursing care per resident per day on 16 out of 21 days, as evidenced by a review of nursing time schedules and census data. On multiple dates, the provided nursing care per patient day (PPD) fell below the regulatory minimum, with values ranging from 2.77 to 3.18 hours for census counts between 153 and 165 residents. This deficiency was confirmed by the Nursing Home Administrator during an interview, acknowledging that the facility did not meet the mandated nursing care hours on the specified days. No specific information about individual residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
NHA will educate DON/Scheduler on minimum staffing hours/regulations on new staffing guidelines effective July 1, 2024. Facility has advertised for open nursing care positions. Interviews will be conducted as applicants apply. Open interviews have been scheduled for every Thursday in January 2026, 10 am to 2 pm. Scheduler will meet daily with NHA/DON/Designee to review staffing schedule for a period of 2 weeks to ensure the facility is providing the minimum general nursing hours to each resident. Scheduler will calculate HPPD throughout the day to ensure the facility has sufficient staff. Results of these audits will be reviewed in the Quality Improvement Committee for recommendations as needed.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per 24-hour period. A review of nursing schedules over a 21-day period revealed that on three specific days, the total nursing care hours fell below the mandated minimum. Specifically, on November 30, 2025, only 3.11 care hours per resident were provided; on December 6, 2025, 3.12 care hours per resident were provided; and on December 13, 2025, 3.09 care hours per resident were provided. This deficiency was identified through a review of the facility's nursing time schedules and affected the overall care provided to residents during those days.
Plan Of Correction
1,2) HPPD will be reviewed for the last 7 days to evaluate if the state minimum PPD of 3.2 is met. 3) Nursing admin and scheduler will be re-educated on new July 1 nurse staffing and PPD requirements. 4) Weekly audit of HPPD will be conducted for 60 days by NHA/designee to ensure minimal HPPD is met. Tracking and trends to be submitted to the QAPI committee.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.2 hours of direct general nursing care per resident per day for two out of twenty-one days reviewed. Specifically, on two dates, the provided nursing care hours were 3.16 and 3.14 per patient day, which is below the regulatory standard. This was confirmed through a review of facility nursing staffing documents covering several periods and was acknowledged by the Nursing Home Administrator during an interview. No additional details about specific residents or their conditions were provided in the report.
Plan Of Correction
No residents were found to be negatively affected by the deficient practice of regulation. In an effort to maintain compliance with the regulation, the facility shall utilize the following process: 1. In an attempt to achieve general nursing care hours of at least a minimum of 3.2 hours of direct resident care hours per resident in a 24-hour period, the facility has created a daily assignment grid for the Scheduler to complete daily that designates the required amount of direct care staff in relation to Resident census. The assignment grids will be reviewed during Labor Meetings to be held no less than weekly. This review will be the responsibility of the Director of Nursing or designee. 2. When a call-off is received, the Supervisor will make every effort to replace hours fully. 3. The facility will continue with recruitment efforts and will continue to enforce the attendance policy. 4. The facility shall complete a monitor of staffing PPD's on a daily basis utilizing the DOH staffing calculation tool until such time it is determined by the Quality Assurance Committee that the facility is maintaining compliance. This shall be the responsibility of the Director of Nursing or designee. 5. The scheduler and RN Supervisors will be re-educated on the regulatory guidelines for the minimum number of general nursing care hours of 3.2 hours of direct resident care hours per resident in a 24-hour period. This will be the responsibility of the Director of Nursing.
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