(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 three of 21 days reviewed.
Findings include:
A review of nursing care hours provided by the facility from June 18, 2026, through July 8, 2026, revealed that the facility failed to meet the minimum hours per patient day for the following days:
June 22, 2026, with 3.10 hours per resident day.
June 27, 2026, with 3.13 hours per resident day.
July 3, 2026, with 3.19 hours per resident day.
Interview with the Nursing Home Administrator and Director of Nursing on July 9, 2026, at 5:00 PM confirmed that the facility did not meet regulatory daily hours PPD as evidenced above.
| | Plan of Correction - To be completed: 08/04/2026
Unable to retroactively correct
NHA/designee will provide education to the scheduler and RN staff regarding current staffing requirements, including PPD and ratios.
Scheduler/designee DON/designee will conduct an audit weekly x4 weeks, then monthly x 2 months, of facility staffing data to ensure compliance. The results of these audits will be reported to the QA steering committee, and the committee will determine the need for future audits.
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