LPN Staffing Deficiency on Evening Shift
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratio on one occasion during the evening shift. Specifically, on December 25, 2024, the facility's staffing records showed that there were only 2.03 LPNs available, whereas the required number was 2.10 for a census of 63 residents. This deficiency was confirmed through interviews with both the Nursing Home Administrator and the Director of Nursing on March 13, 2025. No additional higher-level staff were available to compensate for this shortfall, leading to a failure in meeting the regulatory staffing requirements.
Plan Of Correction
The facility cannot retroactively correct past LPN ratios. The facility will continue to take measures to adequately provide LPN staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff with the required LPN to resident ratios. These measures include continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign-on bonuses. The Director of Nursing/designee will continue to educate minimum staffing ratios to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios. The Director of Nursing/designee will audit the daily schedules to ensure that the minimum number of nurse aide staff to resident ratios have been scheduled. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.