LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required LPN-to-resident staffing ratios on multiple occasions. Specifically, during the day shift on two days, the facility did not provide the minimum of one LPN per 25 residents. On January 19 and February 8, 2025, the facility's census was 56, requiring 2.24 LPNs, but only 2.20 LPNs were available. This shortfall indicates a failure to comply with the staffing requirements set forth by the regulation effective July 1, 2023. Additionally, the facility did not meet the required staffing ratios on the night shift for nine days. For instance, on January 19, 2025, with a census of 54, the facility required 1.35 LPNs but only had 1.07 LPNs available. Similar deficiencies were noted on other nights, with the facility consistently providing fewer LPNs than required by the regulation. The Nursing Home Administrator confirmed these deficiencies, and there were no additional higher-level staff available to compensate for the shortfall.
Plan Of Correction
Unable to retroactively correct staffing ratios for Licensed Practical Nurses (LPNs) on dates noted. Residents who receive nursing care services have the potential to be affected. Recruitment and retention activities: 1. Generous Sign on Bonus 2. Flexible Scheduling 3. Benefits Package for full-time employees 4. Competitive Wages 5. "Kudos" employee recognition program 6. Referral bonus 7. Agency Contracts 8. Administrative Coverage Monitoring will be captured through auditing staff schedules. Audit will be conducted daily for 12 weeks. The audits will be conducted by the Staffing Coordinator or designee. Results of the audits will be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.