LPN Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required minimum staffing ratios for Licensed Practical Nurses (LPNs) on both the day and night shifts over several days in March 2025. Specifically, the facility did not maintain the mandated ratio of one LPN per 25 residents during the day shift on seven occasions and one LPN per 40 residents during the night shift on three occasions. The staffing document review revealed that on these days, the number of LPNs present was insufficient for the number of residents, with shortfalls ranging from a fraction to over one LPN less than required. The deficiency was confirmed through an email exchange with the Nursing Home Administrator, who acknowledged the failure to meet the staffing requirements. The report details specific instances where the LPN staffing levels fell short, such as on March 9, 2025, when there were only 2.94 LPNs for 112 residents, whereas 4.48 LPNs were required. This pattern of inadequate staffing was consistent across the identified dates, indicating a systemic issue in maintaining the necessary LPN-to-resident ratios as per the regulation effective July 1, 2023.
Plan Of Correction
1. Facility cannot retroactively correct staffing deficiencies. 2. All residents are at risk for staffing levels that fail to meet minimum ratio requirements. 3. Facility utilizes recruiting services to fulfill staffing needs. Facility is currently re-evaluating LPN rates for hiring and has recently increased agency LPN rates. Recent re-education was provided to licensed nursing staff regarding staffing requirements and ratios. Bonuses continue to be offered to assist with filling open positions. Administrative nurses will also assist as needed to meet minimum ratio requirements. 4. NHA/DON will monitor daily staffing needs to ensure adequate licensed staffing is met. Audits will be reviewed at QAPI for ongoing compliance and quality assurance.