Failure to Meet LPN to Resident Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on four shifts out of 21 reviewed. Specifically, on March 27 and March 29, 2025, the day shift staffing was below the required 1 LPN per 25 residents, with 3.22 and 3.06 LPNs respectively, instead of the required 3.28 for a census of 82. On March 28, 2025, the evening shift had 2.69 LPNs instead of the required 2.73 for a 1:30 ratio, and the night shift had 1.88 LPNs instead of the required 2.05 for a 1:40 ratio. No additional higher-level staff were available to compensate for these deficiencies. The Nursing Home Administrator confirmed the facility's failure to meet the required LPN to resident ratios on these dates during an interview on April 1, 2025.
Plan Of Correction
Facility cannot retroactively correct this deficiency. New scheduling system in place to assist with replacing call offs and filling open shifts via automatic blasts to staff. New scheduling system also has the ability to post open shifts to all staff including agency. Agency call offs are attempted to be replaced by the agency with additional bonus as needed. Recruitment of nursing staff will continue via facility website, Indeed, recruiting group, social media websites, local newspaper, job fairs, open house and off site recruiters. Agency utilized for open shifts. Retention efforts made with any resignation. Agency rates are reviewed weekly to ensure marketable and adjustments made as necessary. Text Blast for all open shifts. Facility recruiters have purchased list of nursing and aide staff to reach out to for recruitment. New onsite HR Director hired with extensive retention and recruitment experience. LPN call outs are the issue with fulfilling this need consistently, so all efforts are made to replace this hole when it occurs. Calculation of daily PPD and shift ratios will be completed and reviewed daily for accuracy by the scheduler/back up scheduler, DON/ADON and NHA. All efforts will be made to meet PPD and staffing ratios. If call offs occur, all efforts will be made to attempt to fill that position. Daily PPD and ratios will be audited weekly x4, then monthly x2. Results to QA for review and recommendations.