(1) Effective July 1, 2023, 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 2.87 hours of direct resident care for each resident.
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Observations:
Based on review of facility staffing records, it was determined that the facility failed to ensure the total number of general nursing care hours provided in each 24-hour period be a minimum of 3.20 hours per patient day (PPD) for the two weeks reviewed (Weeks of January 10, 2026, and January 17, 2026).
Findings include:
Review of the staffing records revealed the following dates were below 3.20 hours PPD:
January 11, 2026- 3.15
January 15, 2026- 3.17
January 16, 2026- 3.12
January 17, 2026- 3.08
January 18, 2026- 2.84
The above information was conveyed to the Director of Nursing on January 29, 2026, at 2:00 p.m.
| | Plan of Correction - To be completed: 02/23/2026
1. There were no identified residents affected by the deficiency.
2. Facility Nursing Home Administrator, Director of Nursing, Staffing Coordinator, and Registered Nurses will be re-educated on the general nursing care hours in a 24 hour period of a minimum of 3.2 hours per patient day (PPD) staffing requirement and will also be re-educated on calculating PPD and adjusting staffing to attain the 3.2 PPD.
3. Staffing meetings will be held 5 days/week to review PPD from the previous day and projected PPD for the current day, as well as the upcoming week to ensure appropriate staffing levels. If projected staffing levels are below the 3.2 minimum, the facility will reach to current staff and staffing agencies to meet the minimum requirement. The facility will continue to recruit staff.
4. The Director of Nursing or designee will conduct an audit of PPD's weekly x 4 weeks to ensure the facility meets the minimum 3.2 PPD. Results of audits will be reported to the Quality Assurance Performance Improvement Committee during regular meetings.
5. Date of Compliance: 2/23/2026
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