(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 facility nursing staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one Licensed Practical Nurse (LPN) per 25 residents on day shift for nine of 21 days (6/1/26, 6/7/26, 6/8/26, 6/9/26, 6/14/26, 6/16/26, 6/18/26, 6/19/26, and 6/20/26); and failed to ensure one LPN per 40 residents on the overnight shift for four of 21 days reviewed (6/6/26, 6/7/26, 6/12/26, and 6/18/26).
Findings include:
Review of facility nursing staffing documents for the time period from 6/1/26, through 6/21/26, revealed the following LPN staffing shortages for the day shift where the LPN ratio was not met:
6/1/26 census of 77 residents 3.00 LPNs worked and 3.08 were required
6/7/26 census of 81 residents 3.00 LPNs worked and 3.24 were required
6/8/26 census of 80 residents 3.09 LPNs worked and 3.20 were required
6/9/26 census of 81 residents 3.00 LPNs worked and 3.24 were required
6/14/26 census of 82 residents 3.00 LPNs worked and 3.28 were required
6/16/26 census of 83 residents 3.06 LPNs worked and 3.32 were required
6/18/26 census of 83 residents 3.13 LPNs worked and 3.32 were required
6/19/26 census of 83 residents 3.09 LPNs worked and 3.32 were required
6/20/26 census of 83 residents 3.13 LPNs worked and 3.32 were required
Review of facility nursing staffing documents for the time period from 6/1/26, through 6/21/26, revealed the following LPN staffing shortages for the overnight shift where the LPN ratio was not met:
6/6/26 census of 80 residents 1.88 LPNs worked and 2.00 were required
6/7/26 census of 81 residents 1.94 LPNs worked and 2.03 were required
6/12/26 census of 81 residents 1.19 LPNs worked and 2.03 were required
6/18/26 census of 83 residents 1.88 LPNs worked and 2.08 were required
During an interview on 7/7/26, at 1:42 p.m. the Nursing Home Administrator confirmed that the facility did not meet the minimum LPN ratios for the above days and shifts.
| | Plan of Correction - To be completed: 07/27/2026
P5530
The facility is unable to fix the deficient licensed practical nurse ratios retroactively. There were no negative outcomes to residents or impact on care.
The facility will provide staff to ensure the needs of residents are met.
The facility will produce daily schedule to meet the required licensed practical nurse to resident ratios on all shifts.
The Director of Nursing or designee will provide education on minimum licensed practical nurse staffing ratios to Registered Nurse Supervisors and Human Resources/Scheduling who are responsible to maintain adequate staffing and licensed practical nurse staffing ratios.
Director of Nursing or designee will educate HR/ Scheduler and RN supervisors of protocols for replacing staff related to call offs including mandating staff, extending current shifts to cover call offs, when replacement staff are unable to be found.
The Director of Nursing or designee will meet 5 days per week x4 weeks to audit daily deployment sheet for accuracy to ensure daily schedule meets licensed practical nurse ratio.
The Director of Nursing or designee will audit the hours worked to ensure that the minimum number of licensed practical nurse staff to resident ratios have been met using the Department of Health staffing grid x4 weeks
The Director of Nursing or designee will audit weekly that protocols were followed when a call off occurred. This includes asking staff to stay, posting need, posting need with agencies, offering bonus, mandating when needed.
The facility has ads posted on Indeed, a website used by job seekers. Bonus structure was recently changed. New scheduling system was implemented 12/14/2025.
The results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.
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