Failure to Meet Minimum Nursing Care Hours Requirement
Penalty
Summary
Facility administrative staff failed to provide the required minimum of 3.2 hours of direct general nursing care per resident in a 24-hour period on 13 out of 21 reviewed days. Review of nursing time schedules from 8/26/25 through 9/15/25 showed that on multiple dates, the provided nursing care hours per patient day (PPD) fell below the regulatory minimum, with PPDs ranging from 2.43 to 3.15. This deficiency was confirmed by the Director of Nursing during an interview, who acknowledged that the facility did not meet the mandated nursing care hours on the identified dates. 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
The facility cannot correct that the PPDs were not met on 8/29, 8/30, 9/5, 9/6, 9/7, 9/8, 9/9, 9/10, 9/12, 9/13, 9/14, and 9/15. There were no adverse effects to the residents on the identified date. 2. The facility will ensure that staffing ratios are met every shift. 3. Nursing administration and the nursing scheduler will be re-educated by the Nursing Home Administrator/designee on ensuring PPDs are met for the day. A daily staffing meeting will be held by administration to monitor PPD levels. Nursing supervisors will monitor on weekends. If the facility is projected to not meet PPD, the scheduler/or designee will call off-duty facility staff and will utilize external staffing support resources. 4. The Nursing Home Administrator/designee will audit staffing daily for three weeks and monthly for three months to ensure PPDs are met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.