Failure to Meet Minimum Direct Care Hours
Summary
The facility failed to provide the required minimum hours of direct resident care per day as mandated by regulation. Specifically, a review of nursing schedules for the period between July 14 and August 3, 2025, showed that on three separate days, the facility provided less than the required 3.20 hours of direct care per resident. The actual hours provided were 3.19, 3.16, and 3.13 on the respective days. This deficiency was confirmed through staff interviews, including with the Nursing Home Administrator, who acknowledged that the facility did not meet the required daily hours of direct resident care on the identified dates.
Plan Of Correction
1.) The facility is unable to correct the cited three of 21 days that it failed to provide 3.20 hours of direct resident care for each resident. There were no concerns noted due to the direct care hours. 2.) Education will be provided to the Scheduler and Registered Nurse staff on providing 3.20 hours of direct care per resident. The facility has a labor management meeting to discuss staffing levels and needs. The facility can utilize agency and nursing management to assist with maintaining the 3.20 staffing hours per resident. 3.) Director of Nursing or designee will audit the daily hours of direct resident care for each resident daily times 5 days, weekly times 3 weeks, and monthly times 2 months. 4.) Results of the audit will be reviewed at the Quality Assurance Performance Improvement meeting.
Penalty
The facility did not meet the required 3.20 hours of direct resident care per resident on two days, providing only 2.99 and 2.83 hours on those days. This was confirmed through nursing schedules and an interview with the Nursing Home Administrator.
The facility did not meet the required minimum of 2.87 hours of direct resident care per resident in a 24-hour period. On two occasions, the facility provided less than the mandated hours, with 2.74 and 2.68 hours of care per resident. This was confirmed by the Nursing Home Administrator.
The facility did not meet the required minimum of 2.87 hours of direct nursing care per resident on two consecutive days. With a census of 94 and 93 residents, the facility provided only 2.53 and 2.33 hours of care per resident, respectively. This was confirmed through a review of nursing schedules and punch reports, and acknowledged by the Nursing Home Administrator.
The facility did not meet the required minimum nursing care hours for residents on two days, providing 3.13 and 3.07 direct care nursing hours per resident instead of the mandated 3.20 hours. This was confirmed by the NHA.
The facility did not meet the required 2.87 hours of direct nursing care per resident per day on three occasions, providing only 2.56 and 2.55 hours instead. This was confirmed by the DON during an interview.
The facility did not meet the required 3.20 hours of direct resident care per resident for eight days within a 21-day period. Nursing schedules showed that the facility provided less than the required hours on several days, with the lowest being 3.00 hours. This was confirmed by the Nursing Home Administrator.
Deficiency in Direct Resident Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.20 hours of direct resident care per resident for two out of five days reviewed. Specifically, on April 5, 2025, the facility provided only 2.99 hours of direct care per resident, and on April 6, 2025, it provided 2.83 hours. This deficiency was identified through a review of nursing schedules and confirmed during an interview with the Nursing Home Administrator on April 7, 2025.
Plan Of Correction
1. The hours of direct care staffing noted in the survey findings cannot be corrected as this is a past event. 2. Calculation of direct care staffing will be completed and reviewed daily for accuracy by the scheduler or designee. The facility has developed internal incentives to retain and attract staff and meet shift ratio requirements. Administrator will re-educate Director of Nursing and Scheduler regarding direct care staffing regulations. 3. Facility scheduler, Director of Nursing, Human Resources and Administrator have a daily staffing meeting (5 days per week) to review schedules including compliance with ratios. For staff call offs, every effort will be made to replace the call off using resources available including communicating with staff to replace the vacancy. Staffing patterns are projected at least one week in advance to enable ongoing efforts to fill any vacant shifts. The facility will take admissions when staffing is appropriate. 4. Direct care staffing will be monitored daily by Scheduler and/or Director of Nursing or designee. Audits of ratios will be completed by Director of nursing or designee daily for 4 weeks then 3 days per week x 2 months or until substantial compliance is achieved. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 2.87 hours of direct resident care per resident in a 24-hour period, as mandated by the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, §211.12 Nursing Services, effective July 1, 2023. On February 5, 2025, the facility provided only 2.74 hours of direct care nursing per resident, and on February 9, 2025, it provided 2.68 hours per resident. This deficiency was confirmed during an interview with the Nursing Home Administrator on February 12, 2025, who acknowledged the facility's failure to consistently provide the minimum required nursing care hours to each resident daily.
Plan Of Correction
1. Facility cannot retroactively correct past nursing hours. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilizing agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary nursing hours. Nursing scheduler was educated on this new process. 4. NHA will audit nursing hours weekly for 4 weeks and then monthly for 2 months to ensure CNA nursing hours are met. 5. Audits will be submitted to QAPI for review.
Deficiency in Direct Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 2.87 hours of direct nursing care per resident on two consecutive days, June 29 and 30, 2024. On June 29, with a census of 94 residents, only 237.50 direct nursing staff hours were provided, resulting in 2.53 hours of care per resident. On June 30, with a census of 93 residents, 217.00 direct nursing staff hours were provided, equating to 2.33 hours of care per resident. These deficiencies were confirmed through a review of nursing time schedules, punch reports, and staff interviews, and were acknowledged by the Nursing Home Administrator during a review session on February 11, 2024.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly x4 weeks then monthly for two months. 5. Results will be taken to the QAPI for review and revision as needed.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum general nursing care hours for residents on two specific days. On January 18, 2025, the facility provided 3.13 direct care nursing hours per resident, and on January 22, 2025, it provided 3.07 direct care nursing hours per resident. These figures were below the mandated minimum of 3.20 hours of general nursing care per resident. This deficiency was confirmed during an interview with the Nursing Home Administrator (NHA) on February 4, 2025.
Plan Of Correction
1. The facility failed to maintain a minimum of 3.2 hours of direct resident care for each resident on multiple days and shifts. 2. Facility will need to maintain a PPD of 3.2 hours. Calculation of the PPD will be completed and reviewed daily for accuracy by the scheduler or designee. 3. The scheduler and nursing supervisor will be educated on the daily PPD. For staff call offs, every effort will be made to replace the call off using resources available including communicating with staff to replace the vacancy. Staffing patterns are projected at least one week in advance to enable ongoing efforts to fill any vacant shifts. 4. Daily audits will be conducted for 1 month. Audits will be conducted by the scheduler or designee. Results of audits will be reviewed by the QAPI committee. 5. Date certain is 4-4-25.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 2.87 hours of direct nursing care per resident per day. This deficiency was identified during a review of the facility's staffing levels, which revealed that on three specific dates, the facility provided only 2.56 and 2.55 hours of direct care nursing per resident. These dates were December 21, 24, and 25, 2024. An interview with the Director of Nursing confirmed the facility's failure to consistently meet the required nursing care hours on these days.
Plan Of Correction
1. Facility cannot retroactively correct past nursing hours. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilizing agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary nursing hours. Nursing scheduler was educated on this new process. 4. NHA will audit nursing hours weekly for 4 weeks and then monthly for 2 months to ensure CNA Nursing hours are met. 5. Audits will be submitted to QAPI for review.
Deficiency in Required Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.20 hours of direct resident care per resident for eight out of 21 days reviewed. Specifically, the nursing time schedules from November 13 through December 3, 2024, showed that the facility provided less than the required hours on several days. On November 16, 2024, the facility provided 3.10 hours, on November 23, 2024, 3.13 hours, on November 24, 2024, 3.11 hours, on November 27, 2024, 3.19 hours, on November 28, 2024, 3.00 hours, on November 29, 2024, 3.05 hours, on December 1, 2024, 3.16 hours, and on December 2, 2024, 3.17 hours of direct care per resident. This deficiency was confirmed during an interview with the Nursing Home Administrator on December 5, 2024, at 9:24 a.m.
Plan Of Correction
Administrator, Director of Nursing, Scheduler, and Human Resources will have a morning and afternoon staffing meeting 5 days per week to go over the current day's Per Patient Day hours and the upcoming day's PPD to ensure minimum number of direct care hours is met. If minimum number of hours is not met, facility will reach out to current staff and staffing agencies to obtain direct care staff and increase hours. PPD will be audited at quality assurance and performance improvement meeting x3 months.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
