Facility Fails to Meet LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on 14 out of 42 reviewed shifts. The deficiency was identified through a review of the facility's weekly staffing records, which showed that on multiple dates, the number of LPNs on duty was below the required minimum for the facility's census. For instance, on November 28, 2024, there were only 2.19 LPNs on the evening shift, whereas 2.53 were required for a census of 76 residents. Similarly, on December 1, 2024, the evening shift had 2.16 LPNs instead of the required 2.53 for the same census. The deficiency was further confirmed through an interview with the Nursing Home Administrator on December 30, 2024, who acknowledged that the facility did not meet the required LPN to resident ratios on the specified dates. Additionally, there were no higher-level staff available to compensate for the shortage of LPNs during these shifts. This lack of adequate staffing was consistent across several dates in November and December 2024, affecting both day and night shifts.
Plan Of Correction
Facility cannot retroactively correct past LPN to resident ratios. The facility is focusing on retention of existing LPNs and recruitment of new LPNs, through efforts of the Human Resources Manager and Nursing Administration. An employer team has been established to assist the facility in recruitment and marketing for recruitment. LPN rates have been increased per new union contract with Embassy Healthcare, LLC. The scheduler has been educated regarding the LPN ratio regulatory requirements. Calculation of the daily LPN ratios will be completed and reviewed for accuracy by the scheduler/designee. Daily ratios will be audited weekly for 4 weeks, then monthly for 3 months. Audits will be reviewed at QAPI for compliance.