Deficiency in 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 day. A review of nursing schedules from March 14 through April 3, 2025, revealed that on 16 out of 21 days, the facility did not meet this minimum standard. Specific days with deficiencies included March 14, 15, 16, 17, 18, 22, 23, 24, 26, 28, 29, 30, 31, and April 1, 2, and 3, 2025. On these days, the care hours per resident ranged from 2.52 to 3.16, falling short of the required 3.2 hours.
Plan Of Correction
Nursing hours noted in the survey cannot be corrected as this is a past event. Calculation of daily PPD will be completed and reviewed daily for accuracy by the scheduler. The facility has developed internal incentives to retain and attract new staff. Two nurse aide classes have been already scheduled and are being recruited with the first class starting 4/28/25. LPN school recruitment efforts continue with a presentation scheduled on 4/24/25 for nurses that graduate in May. Developed collaboration with local Penn State campus to introduce graduating nurses to long term care in our facility. Agency contracts are in place in an effort to reach daily PPD requirements. The scheduler will look ahead for a minimum of 1 week to determine projected PPD to allow more time to achieve PPD hours requirements. PPD hours will be audited by the scheduler and DON daily for 4 weeks, then 3 days per week x 2 months, or until substantial compliance is achieved. Results will be reviewed at QAPI meeting. Date of compliance is 06/11/2025.