(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.
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Observations:
Based on review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure the total of nursing care hours provided in each 24-hour period was a minimum of 3.2 hours per patient day (PPD), effective July 1, 2024, for 6 of 21 days reviewed.
Findings include:
A review of nursing care hours provided by the facility from June 9, 2026, through June 15, 2026, and July 11, 2026, through July 24, 2026, revealed that the facility failed to meet the minimum hours per patient day for the following days:
June 12, 2026, with 3.09 hours per resident day.
June 14, 2026, with 2.87 hours per resident day.
June 15, 2026, with 2.86 hours per resident day.
July 15, 2026, with 3.18 hours per resident day.
July 19, 2026, with 3.12 hours per resident day.
July 22, 2026, with 3.12 hours per resident day.
Interview with the Nursing Home Administrator and Director of Nursing on July 24, 2026, at 1:18 PM confirmed that the facility did not meet regulatory daily hours PPD as evidenced above.
| | Plan of Correction - To be completed: 09/14/2026
1. While the facility cannot retroactively correct the citations.
2. Facility will conduct an audit consisting of the last two-week period of nursing staffing HPPDs.
3. The facility will maintain a staffing contingency plan to address call-offs, unexpected absences, increased resident acuity, and other circumstances that could result in staffing below the required HPPD. When staff call off or are otherwise unavailable, the facility will utilize available qualified staff, including on-call staff, agency staff when appropriate, overtime, or other approved staffing resources to maintain required coverage. The facility shall make reasonable attempts to acquire new staff, including offering competitive pay rates, shift differentials, partnering with local community schools, and offering employee benefits.
4. Administrator and Director of Nursing will discuss staffing in morning meeting and if admissions are to be limited that day due to staffing.
5. The NHA/Designee will educate the scheduler/designee on the requirements of meeting the minimum HPPD per the regulation.
6. The Scheduling Manager/ Designee will randomly audit the HPPD weekly x's 3 weeks to ensure HPD regulatory compliance. Any concerns/issues will be reviewed monthly at QAPI.
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