(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 a review of the facility's staffing worksheet, provided by the facility for the time period of 7/3/26, through 7/7/26, and staff interviews, it was determined that the facility failed to provide a daily minimum of 3.2 direct care hours (PPD) per resident for four of five days (7/3/26, 7/4/26, 7/5/26, and 7/6/26) as required.
Findings include:
A review of the facility's staffing worksheet, provided by the facility for the time period of 7/3/26, through 7/7/26, revealed the following
Date Census Minimum Hours Actual hours Minimum PPD Actual PPD
7/3/26 99 316.80 314.50 3.20 3.18
7/4/26 98 313.60 309.75 3.20 3.15
7/5/26 97 310.40 299.50 3.20 3.09
7/6/26 99 316.80 276.75 3.20 2.80
During an interview on 7/9/26, at 9:31 am the Nursing Home Administrator confirmed that the facility failed to provide a daily minimum PPD of 3.2 hours per resident for four of five days as required.
| | Plan of Correction - To be completed: 08/25/2026
1. The facility cannot correct that minimum PPD of 3.20 was not met on7/3-7/7/26 . There were no ill effects to residents.
2. The facility will maintain a minimum PPD of 3.20. Daily staffing meetings with a 7-day projection have been implemented to identify coverage needs in advance. Overtime and agency staff will be utilized and addressed in accordance with the facility attendance policy.
3. The Scheduler, DON and nursing administration will be re-educated by the Nursing Home Administrator/designee on the direct care PPD requirements.
4. The Nursing Home Administrator/designee will audit PPD daily for four weeks and then monthly for three months to ensure required state minimum PPD is met. Results will be submitted to the QAPI committee for review and recommendations.
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