Failure to Meet LPN to Resident Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on three separate occasions. On February 2, 2025, during the day shift from 7:00 a.m. to 3:00 p.m., the facility did not have the mandated one LPN per 25 residents. Additionally, on the same day during the evening shift from 3:00 p.m. to 11:00 p.m., the facility did not meet the required one LPN per 30 residents. Furthermore, on December 22, 2024, during the night shift from 11:00 p.m. to 7:00 a.m., the facility failed to maintain the minimum ratio of one LPN per 40 residents. These deficiencies were identified through a review of nursing schedules over a 21-day period.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.