(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, it was determined that the facility failed to provide a minimum of 3.2 hours of direct care for each resident for 15 of 21 days reviewed.
Findings include:
Review of nursing schedules for 21 days from February 4, 2026, through February 24, 2026, revealed the following total nursing care hours below minimum requirements:
Friday, February 6, 2026: 3.08 care hours per resident. Saturday, February 7, 2026: 3.04 care hours per resident. Sunday, February 8, 2026: 2.69 care hours per resident. Monday, February 9, 2026: 3.19 care hours per resident. Thursday, February 12, 2026: 3.12 care hours per resident. Saturday, February 14, 2026: 3.14 care hours per resident. Sunday, February 15, 2026: 2.82 care hours per resident. Monday, February 16, 2026: 2.99 care hours per resident. Tuesday, February 17, 2026: 3.10 care hours per resident. Thursday, February 19, 2026: 3.08 care hours per resident. Friday, February 20, 2026: 2.79 care hours per resident. Saturday, February 21, 2026: 3.06 care hours per resident. Sunday, February 22, 2026: 2.82 care hours per resident. Monday, February 23, 2026: 2.68 care hours per resident. Tuesday, February 24, 2026: 3.10 care hours per resident.
| | Plan of Correction - To be completed: 04/08/2026
1. Nursing hours noted in the survey cannot be corrected as this is a past event. 2. Calculation of daily PPD will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. Facility continues to utilize various recruitment initiatives including social media, job postings, job and career fairs and pre-scheduled events at nursing schools and colleges to attract new candidates. Also, facility has initiatives to encourage staff retention. Agency contracts are in place in an effort to reach daily PPD requirements. The scheduler will look ahead for a minimum of 1 week to determine projected PPD to allow more time to achieve PPD hours requirements. 4. PPD hours will be audited by scheduler and DON daily for 4 weeks, then 3 days per week x 2 months, or until substantial compliance is achieved. Results will be reviewed at QAPI meeting. 5. Date of compliance is 04/08/2026.
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