Deficiency in LPN Staffing Levels
Penalty
Summary
The facility failed to meet the required nursing staff levels as per the regulation effective July 1, 2023, which mandates a minimum of one Licensed Practical Nurse (LPN) per 25 residents during the day, one LPN per 30 residents during the evening, and one LPN per 40 residents overnight. During a review of nursing staffing hours over a seven-day period, it was found that the facility did not ensure the minimum required number of LPNs for two out of 21 shifts. Specifically, on April 20, 2025, the day shift had 10.33 LPNs for a resident census of 328, which required 13.12 LPNs, and the night shift had 7.32 LPNs for the same resident census, which required 8.20 LPNs. This deficiency was confirmed through an interview with the Nursing Home Administrator on April 29, 2025.
Plan Of Correction
Facility will ensure that we will abide by the DOH guidelines for LPN staffing ratios. Staffing directors will be educated to ensure that we are abiding by DOH guidelines for LPN staffing ratios. NHA/designee will audit 3X weekly X4 weeks and then monthly X2 months to ensure that facility is abiding with DOH LPN staffing ratios. Results will be reviewed during the facilities monthly QAPI Meeting X3 months to determine the need for further review.