Failure to Meet Minimum LPN Staffing Requirements
Penalty
Summary
The facility failed to meet the required minimum staffing levels for LPNs on multiple shifts over several days. Specifically, the facility did not provide at least one LPN per 25 residents during the day shift on four out of five days, one LPN per 30 residents during the evening shift on two out of five days, and one LPN per 40 residents during the night shift on three out of five days. Review of the facility's census data and nursing time schedules confirmed that the actual LPN hours worked were consistently below the required hours for each shift on the identified days. The Director of Nursing confirmed during an interview that the facility did not meet the minimum LPN staffing requirements on these occasions.
Plan Of Correction
1. The facility cannot correct that the LPN staffing ratio was not met on day shift on four of five days (7/4/25 through 7/7/25), one LPN per 30 residents on the evening shift on two of five days (7/5/25 and 7/6/25), and one LPN per 40 residents on the night shift on three of five days (7/4/25 through 7/6/25). There were no adverse effects to residents on the identified date. 2. The facility will ensure that staffing ratios are met every shift. 3. Nursing administration and the scheduler will be re-educated by the Nursing Home Administrator/designee on ensuring staffing ratios are met each shift. Daily shift staffing ratios will be reviewed at Standup and Stand down. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects not to meet staffing ratios on a shift, nursing administration/designee will be responsible to call off-duty personnel or call extra support staff to assist. 4. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations. I Certify This Document to be a True and Correct Statement of Deficiencies and Approved Facility Plan of Correction for the Above-Identified Facility Survey