(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 nursing time schedules and staff interview, it was determined that the facility failed to provide a minimum of 3.20 PPD (per patient daily) hours of direct care for each resident on five of six days (2/18/26 through 2/22/26).
Findings include:
Review of staffing documents and nursing staff schedules from 2/18/26 through 2/23/26, indicated that the State required PPD minimum hours of 3.20 was not met on the following days:
2/18/26= 3.12 PPD.
2/19/26= 3.07 PPD.
2/20/26= 3.03 PPD.
2/21/26= 3.15 PPD.
2/22/26= 3.08 PPD.
During an interview on 2/25/26, at 9:50 a.m. the Nursing Home Administrator confirmed that the facility failed to provide a minimum of 3.20 PPD hours of direct care on the above dates as required.
| | Plan of Correction - To be completed: 03/30/2026
A review of care delivery for the dates cited was completed by the Director of Nursing and Administrator. No negative resident outcomes were identified.
All residents have the potential to be affected. Daily staffing meetings with a 7-day staffing projection have been implemented to identify coverage needs in advance. Overtime and agency staff will be utilized as necessary to meet minimum staffing ratios. All call-offs will be reviewed and addressed in accordance with the facility Attendance Policy.
The Scheduler, DON, and Administrator will be educated on direct care ppd requirements effective July 1, 2024. Nursing staff will be re-educated on attendance expectations and the importance of reporting for scheduled shifts. The Attendance Policy will be consistently enforced, including progressive discipline for violations.
The DON or designee will audit all three shifts daily for 3 weeks, then weekly for 2 weeks, then monthly for 3 months to ensure nurse aide staffing meets ratio requirements. Results will be submitted to the QAPI Committee monthly, for review and/or recommendation by 03/30/2026 ongoing.
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