Failure to Meet Minimum LPN Staffing Requirements
Penalty
Summary
The facility failed to meet the required minimum staffing levels for licensed practical nurses (LPNs) as mandated by regulation. Specifically, on two days during the reviewed period, the facility did not provide at least one LPN per 25 residents on the day shift, and on two separate days, did not provide at least one LPN per 40 residents on the night shift. This was determined through a review of the facility's census data and nursing time schedules, which showed that the actual LPN hours worked were less than the required hours for the number of residents present. The Nursing Home Administrator confirmed during an interview that the minimum LPN staffing requirements were not met on these days. No information was provided regarding the specific residents affected, their medical history, or their condition at the time of the deficiency.
Plan Of Correction
Date of POC Updated to reflect reason for previous rejection: 1. The facility cannot correct that the LPN staffing ratio was not met on one LPN per 25 residents on the morning shift on two of five days (9/27/25 and 9/28/25) and one LPN per 40 residents on the night shift on two of five days (9/25/25, and 9/30/25). There were no adverse effects to residents on the identified dates. 2. The facility will ensure that staffing ratios are met every shift. 3. A Daily staffing meeting with scheduler will be held by administration to monitor staffing ratios. 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. --- Date of POC Updated to reflect reason for previous rejection: 1. The facility cannot correct that the LPN staffing ratio was not met on one LPN per 25 residents on the morning shift on two of five days (9/27/25 and 9/28/25) and one LPN per 40 residents on the night shift on two of five days (9/25/25, and 9/30/25). There were no adverse effects to residents on the identified dates. 2. The facility will ensure that staffing ratios are met every shift. 3. A Daily staffing meeting with scheduler will be held by administration to monitor staffing ratios. 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. 4. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure staffing ratios are met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.