LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) as per the regulation effective July 1, 2023. Specifically, the facility did not provide the minimum of one LPN per 25 residents during the day shift on February 8, 2025, and one LPN per 40 residents during the night shift on five separate days: February 3, 4, 6, 8, and 9, 2025. A review of the facility's census data and nursing time schedules revealed that on these dates, the actual LPN hours were below the required hours. For instance, on February 8, 2025, during the day shift, the facility had 31.14 actual LPN hours against the required 32.64 hours for a census of 102 residents. Similarly, on the night shift of February 3, 2025, the facility provided only 15.60 actual LPN hours against the required 21.40 hours for a census of 107 residents. This deficiency was confirmed by the Assistant Director of Nursing during an interview on February 11, 2025.
Plan Of Correction
The facility cannot correct that LPN staffing ratios were not met on 2/3/25, 2/4/25, 2/6/25, 2/8/25, 2/9/25. The facility will ensure that LPN staffing ratios are met every shift. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5530 and ensuring LPN staffing ratios are met each shift. Daily staffing ratios will be reviewed at daily staffing meetings. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure LPN staffing ratios are being met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.