Failure to Meet Minimum LPN Staffing Requirements
Penalty
Summary
Facility administrative staff failed to meet required minimum staffing levels for licensed practical nurses (LPNs) on several occasions. Specifically, on one day during the reviewed period, the facility did not provide at least one LPN per 25 residents during the day shift, and on two separate nights, did not provide at least one LPN per 40 residents during the night shift. Review of nursing time schedules and census data confirmed these staffing shortages, and the Director of Nursing acknowledged that there were no additional higher-level staff present to compensate for the deficiency on those shifts. No information was provided regarding the involvement or condition of specific residents during the times of the staffing shortages.
Plan Of Correction
The Center continues to have retention and recruitment activities in place, which met on 7/16/2025. Nursing leadership did all things reasonably possible to meet the required ratios through bonuses, a day off on another day, split shifts, etc. All unscheduled staff were contacted, and supplemental staffing was contacted to send replacement staff. Ancillary staff were available and assisted in various tasks such as call bell attendant, delivery and removal of meal trays, delivery of water, bed making, and performance of other tasks within their scope of practice. Our Human Resource Clerk is scheduled to attend the Career Link job fair and meet with the organizer on 7/21/25. The facility will continue to ensure the schedule reflects the required staffing ratios and address call-offs. An off-shift scheduler was hired to perform scheduling duties after hours to maintain ratio. Staff and supplemental staffing have been reminded of the importance of them reporting to work as assigned. A weekend Manager program has been implemented, which will add extra monitoring on the weekends. No residents were affected. To monitor and maintain ongoing compliance, the DON/designee will audit 5 staffing sheets x 4 weeks to ensure LPN night shift ratios are being met. Audit results will be reviewed with the QAPI Committee meeting monthly to determine the need for further audits.