(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
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Observations:
Based on a review of nurse staffing and staff interview, it was determined the facility failed to ensure the minimum licensed practical nurse staff to resident ratio was provided on each shift for 2 shifts out of 21 reviewed.
Findings include:
A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:30 on the evening shift and 1:40 on the night shift based on the facility's census.
May 10, 2025 - 2.63 LPNs on the evening shift, versus the required 2.97 for a census of 89.
May 10, 2025 - 2.00 LPNs on the night shift, versus the required 2.23 for a census of 89.
On the above dates mentioned no additional excess higher-level staff were available to compensate this deficiency.
An interview with the Director of Nursing on May 16, 2025, at 1:50 PM, confirmed the facility had not met the required LPN to resident ratios on the above dates.
| | Plan of Correction - To be completed: 06/19/2025
Facility cannot retroactively correct this deficiency.
Recruitment of nursing staff will continue via facility websites, Indeed, social media websites, job fairs, off site recruiters and instant interviews from walk-in candidates. Agency staff may be utilized for open shifts if available.
Retention efforts will be made in earnest. Referral bonuses are offered to current employees. The facility is currently offering a significant sign-on bonus for all new nursing staff.
Labor meeting occurs daily and attended by NHA, DON, HRD, and scheduler. Agenda includes reviewing HPPD and ratios from the prior day, current day, and next day to ensure the ratio HPPD are met and sustained over time.
The Director of Nursing/designee will audit the ratio 1x/week for 4 weeks then monthly for 2 months.
All efforts will be made to meet LPN's ratios. If a call off occurs all efforts will be made to fill that position.
Labor meeting minutes will be submitted to the QAPI committee to include daily HPPD, ratios, and staff calloffs. Minutes will be submitted for 2 month to ensure deficient practice does not recur.
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