Deficiency in LPN Staffing Levels
Penalty
Summary
The facility failed to meet the required minimum staffing levels for Licensed Practical Nurses (LPNs) during the day shift. Specifically, on March 19, 2025, the facility had 5.00 LPNs scheduled for a resident census of 158, which required 6.32 LPNs to comply with the regulation of one LPN per 25 residents. This deficiency was confirmed through a review of nursing staff care hours and an interview with the Nursing Home Administrator on March 20, 2025, at 11:00 a.m., who acknowledged that the staffing levels did not meet the required minimums.
Plan Of Correction
1. Administrator, Director of Nursing, Staffing Coordinator and/or Designee will continue to recruit and advertise to satisfy the staffing regulation to ensure that quality of care is provided to the residents. This will be done by rounding, observation, auditing, communication with residents and families through daily interaction, care conferences and resident council. 2. Staffing for the facility was reviewed to ensure that the center is meeting and adhering to ensure that the facility had adequate resident to LPN ratio to meet the regulatory requirement: minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening and 1 LPN per 40 residents overnight. 3. Education regarding the LPN ratio of a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening and 1 LPN per 40 residents overnight was provided to the staffing coordinator, HR, nursing administration to ensure that the center is in compliance. 4. A weekly audit of nurse aide ratio staffing will be conducted by the NHA/designee to ensure that the facility meets regulatory requirements. The findings of the audits will be brought to the Quality 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.