Non-Compliance with LPN to Resident Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios as mandated by the regulation effective July 1, 2023. Specifically, the facility did not maintain the minimum ratio of one LPN per 25 residents during the day shift on March 15, 16, 29, and 30, 2025. Additionally, the facility did not meet the required ratio of one LPN per 30 residents during the evening shift on March 16, 29, and 30, 2025. These deficiencies were identified based on a review of nursing time schedules over a 21-day period from March 14 through April 3, 2025, indicating non-compliance on four of those days.
Plan Of Correction
1. LPN ratios for the dates noted in the survey cannot be corrected as this is a past event. 2. Calculation of shift LPN ratios will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. Facility has attended LPN schools to recruit new staff and introduced an employee referral program, as well as calling area LPNs to consider joining facility staff. Presentation to local LPN school graduates scheduled for 4/28/25, and they graduate in May. Entered collaboration with local Penn State campus to introduce graduating nurses to our facility onsite. Agency staff are being utilized in an effort to reach daily shift ratios. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate LPN ratios as needed. 4. LPN ratios will be audited by scheduler and DON daily for 4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results will be reported to QAPI committee. 5. Date of correction is 06/11/2025.