Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the state-mandated minimum of 3.2 hours of direct nursing care per resident per day on six out of ten days reviewed. Specifically, staffing documents and nursing schedules from the period of 8/2/25 through 8/11/25 showed that on 8/3/25, 8/4/25, 8/5/25, 8/9/25, 8/10/25, and 8/11/25, the provided per patient daily (PPD) hours ranged from 2.82 to 3.19, all below the required threshold. These findings were based on a review of the facility's staffing records and were confirmed during an interview with the Nursing Home Administrator. No information was provided regarding the specific residents affected, their medical histories, or their conditions at the time of the deficiency. The deficiency was identified solely through documentation review and staff interview, with no additional details about the impact on resident care or outcomes included in the report.
Plan Of Correction
1. The facility will ensure state-required general nursing care hours in each 24 hr period will be a minimum of 3.2 hrs of direct resident care for each resident. The facility cannot correct that we did not meet the minimum PPD of 3.2 hrs on August 3, 4, 5, 9, 10 & 11, 2025. 2. The facility will ensure that the 3.2 state minimum direct resident care hours in each 24hr period is met. 3. The Nursing Home Administrator will re-educate the Director of Nursing, HR Director/Scheduler, and RN Supervisors on regulation P5640 ensuring a minimum of 3.2 direct resident care hrs are met in each 24hr period. Resident care hrs will be reviewed at our daily staffing meeting to ensure a minimum PPD of 3.2 is scheduled to be met. The RN Nursing Supervisors will continue to review direct resident care hrs on evenings and weekends. If the facility's projection to meet the state minimum falls below a 3.2 due to call offs, No Call No Shows, etc., the RN Supervisors will be responsible to ask currently working staff to pick up a shift, call off-duty personnel, and/or call extra support staff via staffing agencies to assist as necessary. 4. The HR Director/designee will audit staffing sheets daily for three months to ensure the minimum 3.2 hrs of direct resident care for each resident is met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits. 5. Date of compliance: 9-16-2025