(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 review of the facility nursing staffing documents and staff interview, it was determined that the facility failed to meet the minimum of one Licensed Practical Nurse (LPN) per 40 residents for the overnight shift for six of 21 days reviewed (5/20/26, 5/21/26, 5/26/26, 6/04/26, 6/06/26, and 6/07/26).
Findings include:
Review of facility nursing staffing documents for the time period from 5/19/26, through 6/08/26, revealed the following LPN staffing shortages for the overnight shift where the LPN ratios were not met:
5/20/26census of 390.68 LPNs worked and 1.00 were required
5/21/26census of 400.59 LPNs worked and 1.00 were required
5/26/26census of 431.00 LPNs worked and 1.08 were required
6/04/26census of 430.87 LPNs worked and 1.08 were required
6/06/26census of 421.00 LPNs worked and 1.05 were required
6/07/26census of 410.40 LPNs worked and 1.03 were required
During a telephone interview on 6/10/26, at 9:50 a.m. the Assistant Nursing Home Administrator confirmed that the facility did not meet the minimum LPN ratios for the above days and shift.
| | Plan of Correction - To be completed: 07/12/2026
1) No residents were found to be affected by failing to meet the required LPN ratio
2) All residents will be visually monitored by the RN supervisor or designee each shift to ensure the residents are receiving quality care.
3) Education and in-servicing will be provided to the scheduler, RNs and LPNs by the administrator on the state required staffing levels for licensed practical nurses. The scheduler will be responsible, daily, to ensure that the facility has enough staff to meet the state staffing ratios. In the event that the scheduler is not in the facility, the Director of Nursing and/or RN Supervisor, designee, will review the schedule, and, if needed, make necessary changes to meet staffing ratios. The facility will continue to advertise and hires LPNs. When call offs occur, mandation of current staff will occur, per facility policy, admin nursing will be called, and agency staff will be utilized.
4) The bi-weekly schedule and the Day Sheets will be monitored by the Nursing Home Administrator, Director of Nursing, and/or designee daily, to ensure staffing is in place to meet the state ratios. If it is found that staffing is inadequate, calls will be made to on-call employees, agency staff, and those not on the schedule to pick up shifts
5) Facility will continue to hire new LPNs as needed to fill vacant shifts.
6) Information of results of staffing ratios and progress will be reviewed at the quarterly Quality Assurance Process Improvement Meetings.
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