Observations:
Based on a review of facility nursing time schedules from 7/27/26 through 8/2/26 and staff interview, it was determined that the facility failed to maintain 3.20 hours of general nursing care (PPD) to each resident in a 24-hour period on the following days:
7/28/26= 3.16 PPD.
7/29/26= 3.12 PPD.
7/31/26= 2.82 PPD.
8/01/26= 2.99 PPD.
8/02/26= 2.90 PPD.
During an interview on 8/4/26 at 3:25 p.m., the Director of Nursing confirmed that the facility failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on the above days as required.
| | Plan of Correction - To be completed: 09/15/2026
The Center continues to have retention and recruitment activities in place, which met on 08.13.2026. Nursing leadership did all things reasonably possible to meet the required PPD through bonuses, day off on another day, split shifts. We call /text unscheduled staff were contacted, and supplemental staffing were contacted to send replacement staff. Ancillary staff were available and assisted in various tasks such as call bell attendant, delivery and removal of meal trays, delivery of water, bed making and performance of other tasks within their scope of practice. The facility will continue to ensure the schedule reflects the required staffing PPD and address call offs. Human Resources continues to place ads online on Apploi which is linked to multiple job application sites. Labor Management Meetings are held daily Monday-Friday to review staffing needs and initiatives of the week to recruit and retain staff. An off-shift scheduler continues to perform scheduling duties after hours to maintain PPD. Nursing supervisors will be educated to make phone calls to replace call offs and no shows. To monitor and maintain ongoing compliance, the DON/designee will audit 5 staffing sheets x 4 Weeks to ensure PPD is being met. Audit results will be reviewed with QAPI Committee meeting monthly to determine the need for further audits.
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