LPN Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on one of the 21 days reviewed. Specifically, on October 6, 2024, the facility did not have the mandated number of LPNs during both the day and night shifts. During the day shift, from 7:00 a.m. to 3:00 p.m., the facility did not maintain the minimum ratio of one LPN per 25 residents. Additionally, during the night shift, from 11:00 p.m. to 7:00 a.m., the facility failed to meet the required ratio of one LPN per 40 residents. This deficiency was identified through a review of nursing schedules covering the periods from October 1 to 7, 2024, January 1 to 7, 2025, and January 24 to 30, 2025.
Plan Of Correction
Director of Nursing will in-service Staffing Coordinator, ADON's, Nursing Supervisors and Unit Managers regarding minimum staffing to resident ratios on all shifts. Director of Nursing, Administrator, Associate Administrator, Staffing Coordinators, and ADON's will continue to review staffing daily to ensure facility meets staffing ratios. DON will report any shift that does not meet the minimum LPN requirements to the Administrator. Director of Nursing/Designee will continue to actively pursue applicants for nursing positions to assure staffing to resident ratios are met every shift. Staffing to resident ratios will be reviewed at QAPI meetings.