LPN Staffing Deficiency on Evening Shifts
Penalty
Summary
The facility failed to meet the regulatory requirement of having a minimum of one licensed practical nurse (LPN) per 30 residents during the evening shift. This deficiency was identified during a review of staffing data for the period from January 26, 2025, through February 4, 2025. Specifically, the facility did not meet the required staffing levels on the evening shifts of January 26, 2025, and February 1, 2025. This finding was confirmed with the Nursing Home Administrator during a telephone interview on February 6, 2025.
Plan Of Correction
1. The facility is unable to retroactively provide minimum LPN coverages to meet minimum required staffing ratios for 1/26/25 & 2/1/25. 2. A facility audit was completed to ensure LPN minimum staffing ratios were being met daily. The Recruitment Team is continuing efforts to recruit more LPNs and ensuring wages are competitive with surrounding area facilities. Agency staff are being utilized to assist with meeting minimum LPN staffing ratios while recruitment continues. 3. The Nursing Scheduler/Designee was re-educated on ensuring nursing care LPN minimum staffing ratios are met, and that the facility is actively recruiting LPNs. 4. The Administrator or designee will conduct an audit of the nursing care LPN ratios to ensure compliance weekly for 4 weeks, then monthly for 2 months. The results will be submitted to the QAPI Committee for review and analysis of the need for ongoing monitoring.