Failure to Meet LPN to Resident Ratio
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratio on one of the fourteen days reviewed. Specifically, on January 18, 2025, during the day shift from 7:00 a.m. to 3:00 p.m., the facility did not have the mandated minimum of one LPN per 25 residents. This deficiency was confirmed during an interview with the Nursing Home Administrator (NHA) on February 4, 2025, at 1:45 p.m., who acknowledged the shortfall in meeting the staffing requirements on the specified day.
Plan Of Correction
1. The facility failed to maintain LPN ratio on January 18th, 2025. 2. The facility will need to maintain a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight. Calculation of shift ratios will be completed and reviewed daily for accuracy by the scheduler or designee. 3. The scheduler and nursing supervisors will be educated on these ratios. For staff call offs, every effort will be made to replace the call off using resources available including communicating with staff to replace the vacancy. Staffing patterns are projected at least one week in advance to enable ongoing efforts to fill any vacant shifts. 4. Daily audits will be conducted for 1 month. Audits will be conducted by the scheduler or designee. Results of audits will be reviewed by the QAPI committee. 5. Date certain is 4-4-25.