Failure to Meet LPN Staffing Requirements Overnight
Penalty
Summary
The facility failed to meet the regulatory requirement of having a minimum of one licensed practical nurse (LPN) per 40 residents during the overnight shift. This deficiency was identified during a review of nursing staffing hours and confirmed through staff interviews. Specifically, on April 13, 2025, the facility had a resident census of 17 but did not have any LPNs scheduled for the night shift, thereby not meeting the required LPN-to-resident ratio. This finding was confirmed in an interview with the Nursing Home Administrator and the Director of Nursing on April 16, 2025.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. At the time of the finding, the LPN ratios for the current working schedule were reviewed, and no issues were noted. 2. The Director of Nursing and/or designee will educate the RNs and LPNs on the LPN ratios and the importance of monitoring staffing as the day and/or shift progress as well as the ability to substitute an RN for an LPN; the designated RN charge nurse may take on an assignment and be counted in ratios. A facility such as Cole Place with a census of 59 or under may substitute an LPN for an RN on the overnight shift only if an RN is on call and located within a 30-minute drive of the facility. 3. The Director of Nursing and/or designee will audit the current working schedule, and the deployment sheets prior to the day and after the day is complete to ensure compliance. 4. Audits will be completed 3 times per week for 1 month, and weekly thereafter for 1 month or until substantial compliance is achieved. Results will be reviewed at the QAPI meeting.