Failure to Meet LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on two occasions, as evidenced by a review of nurse staffing records and staff interviews. On March 26, 2025, the night shift had only 2.0 LPNs instead of the required 2.10 for a census of 84 residents. Similarly, on March 29, 2025, the night shift had 2.0 LPNs instead of the required 2.13 for a census of 85 residents. No additional higher-level staff were available to compensate for this deficiency. The Nursing Home Administrator confirmed the failure to meet the required staffing ratios during an interview on April 1, 2025.
Plan Of Correction
The facility will provide a staffing ratio of one Licensed Practical Nurse per 25 residents on day shift, one Licensed Practical Nurse to 30 residents on evening shift, and one Licensed Practical Nurse per 40 residents on overnight shift. All facility residents have the potential to be affected by this practice. The facility has implemented staff incentives for current and new staff as well as reinforcing the facility call off policy to deter unnecessary call offs. We are also hiring additional PRN LPNs to help cover shifts when there are call offs or openings in the schedule. We will be using Indeed for advertisements of open positions, participating in career fairs as they are available, and giving sign on bonuses and/or referral bonuses to new hires and our staff. NHA or designee will educate staff on incentives and call off policy. Administrator/designee during weekday daily review of nursing schedules will audit to ensure License Practical Nurse ratios are maintained. The results of these audits will be discussed at the facility QAPI meeting monthly for further review and recommendations.