Failure to Maintain Required LPN-to-Resident Staffing Ratios on Multiple Shifts
Penalty
Summary
The facility failed to meet state-required LPN-to-resident staffing ratios on multiple shifts, as identified through review of weekly staffing records and staff interviews. On four of twenty-one shifts reviewed, the number of LPNs scheduled and working did not meet the minimum required ratios of 1:25 on the day shift, 1:30 on the evening shift, and 1:40 on the night shift based on the facility’s census. Specifically, on April 8, 2026, the day shift had 1.02 LPNs instead of the required 1.08 for a census of 27 residents. On April 10, 2026, the day shift had 1.03 LPNs instead of the required 1.12 for a census of 28 residents, and the night shift had 0.00 LPNs instead of the required 1.00 for the same census. On April 12, 2026, the day shift had 1.00 LPN instead of the required 1.12 for a census of 28 residents. On these dates, there were no additional higher-level staff available to compensate for the LPN shortfall. In an interview on April 14, 2026, at 2:00 PM, the nursing home administrator confirmed that the facility had not met the required LPN-to-resident ratios on the identified dates. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency is based solely on staffing levels relative to the resident census and regulatory requirements.
Plan Of Correction
1.) There were no ill effects suffered by the residents due to the facility's failure to meet the ratio for residents to LPNs for 4 shifts. 2.A facility wide audit was completed to ensure ratios were met. LPN sign on bonuses and wages are competitive with surrounding areas. The facility uses bonuses for employees to pick up shifts. 3.DON and Corporate HR were re-educated on staffing ratios and ensure the facility is actively recruiting to fill any open positions. The DON will review census and staffing ratios to ensure ratios are being met. 4.The DON or designee will conduct an audit of nursing care ratios weekly x 4 weeks then monthly x2 months to ensure ratios are being met. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.
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