Failure to Meet Minimum Nursing Care Hours Requirement
Penalty
Summary
The facility failed to provide the required minimum of 3.2 hours of direct nursing care per resident per day, as mandated effective July 1, 2024. A review of nursing staff care hours for the period from July 11, 2025, through July 31, 2025, showed that on each of the 21 days reviewed, the facility did not meet this minimum standard. The reported hours per patient day (PPD) ranged from 2.41 to 3.05, consistently falling short of the regulatory requirement. This deficiency was confirmed through both a review of staffing records and an interview with the Administrator, who acknowledged the findings. The report does not mention any specific residents or their medical conditions, nor does it provide details about the impact on individual patients. The deficiency is solely based on the facility's failure to meet the mandated nursing care hours across the entire facility during the specified period.
Plan Of Correction
P5640 1. Findings of nursing staff care hours cannot be retroactively corrected. 2. Facility will provide a minimum of 3.2 hours nursing care hours per patient day. In order to recruit and retain staff, facility has an active nurse aide training course that runs continuously to hire and train new CNAs. Facility recently put up a recruitment billboard to attract nurses and CNAs. Facility also has active job ads and recruiters who work around the clock to interview and hire new staff. Facility continuously hosts staff morale events, staff spotlights, and monthly caught caring awards to retain current staff. Facility offers bonuses to current staff in an effort to get more staff scheduled per shift. 3. Scheduling manager will be educated on the requirement of providing a minimum of 3.2 nursing care hours per patient per day. Staffing team will meet daily Monday-Friday to review staffing needs and create plans to ensure adequate coverage. 4. Director of Nursing or Designee will conduct random audits to verify that facility is providing a minimum of 3.2 nursing care hours per patient per day weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at the QAPI meeting for review and recommendations.