LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required LPN-to-resident staffing ratios on specific days, as evidenced by a review of nursing schedules and staffing information. On March 31, 2025, the facility had a census of 57 residents, necessitating 2.28 LPNs during the day shift, but only 2.07 LPNs were scheduled. Similarly, the night shift required 1.43 LPNs, but only 1.07 LPNs were present. On April 3, 2025, with a census of 62 residents, the evening shift required 2.07 LPNs, but only 2.00 LPNs were scheduled. In all instances, there were no additional higher-level staff available to compensate for the staffing shortfall. The Director of Nursing confirmed during an interview on April 10, 2025, that the facility did not meet the required LPN-to-resident staffing ratios for the specified days. This deficiency was identified through a comprehensive review of the facility's census data and nursing time schedules, which highlighted the shortfall in staffing levels necessary to comply with the regulations effective July 1, 2023.
Plan Of Correction
Unable to retroactively correct staffing ratios for Licensed Practical Nurses (LPNs) on dates noted. Residents who receive nursing care services have the potential to be affected. Recruitment and retention activities: 1. Generous Sign on Bonus 2. Flexible Scheduling 3. Benefits Package for full-time employees 4. Competitive Wages 5. "Kudos" employee recognition program 6. Referral bonus 7. Agency Contracts 8. Administrative Coverage 9. Attend Job Fair Monitoring will be captured through auditing staff schedules. Audit will be conducted daily for 12 weeks. The audits will be conducted by the Staffing Coordinator or designee. Results of the audits will be presented for review at the 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.