(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 nurse staffing data and staff interviews, it was determined that the facility failed to provide a minimum of 3.2 hours of direct resident care for each resident for one of ne week reviewed (04/01/2026-04/07/2026).
Findings Include:
A review of facility census data, nursing schedules, and staff punch reports over a period of one week (04/01/2026-04/07/2026) revealed the facility failed to provide 3.2 hours of direct resident care for each resident on the following days:
-April 4, 2026, with a census of 195 residents, Minimum PPD of 3.2 which equals to total of 624 hours. Actual provided a PPD of 3.15 with 614.25 total direct care hours.
- April 5, 2026, with a census of 192 residents, Minimum PPD of 3.2 which equals to total of 614.4 hours. Actual provided a PPD of 3.20 with 613.50 total direct care hours.
- April 6, 2026, with a census of 194 residents, Minimum PPD of 3.2 which equals to total of 620.80 hours. Actual provided a PPD of 3.13 with 607.00 total direct care hours.
Interview with the Director of Nursing, Employee E2, and Nursing Home Administrator, Employee E1 on April 16, 2026, at 2:20 p.m. confirmed minimum hours of direct resident care were not met.
| | Plan of Correction - To be completed: 05/25/2026
The provider submits the following plan of correction in good faith and to comply with Federal regulation. This plan is not admission of wrong doing nor does it reflect agreement with the facts and conclusion stated in the statement deficiencies.
Regional nurse will educate the administrator and director of nursing about P5640 that states 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 3.2hours of direct resident care for each resident
Director of nursing will educate staffing coordinator and shift supervisors about P5640 to ensure that a minimum 3.2 hours of direct care is met daily
The director of nursing will use the staffing calculator tool to complete audit of daily staffing ppd weekly x 4 weeks, then monthly x 3 months
Report of audits will be presented at the monthly QAPI until substantial compliance is achieved
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