(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 nursing schedules and staffing information furnished by the facility it was determined that the facility failed to ensure a minimum of one licensed practical nurse per 25 residents on the day shift for four of 12 days reviewed from September 18, 2025 through September 29, 2025 and failed to ensure a minimum of one licensed practical nurse per 40 residents for night shift for two of 12 days reviewed from September 18, 2025 through September 29, 2025.
Findings include:
Review of facility census data indicated that on September 18, 2025, the facility census was 102, which required 4.08 licensed practical nurses during the day shift. Review of the nursing time schedules revealed 4.13 licensed practical nurses provided care on the day shift.
Review of facility census data indicated that on September 19, 2025, the facility census was 102, which required 4.08 licensed practical nurses during the day shift. Review of the nursing time schedules revealed 3.97 licensed practical nurses provided care on the day shift.
Review of facility census data indicated that on September 21, 2025, the facility census was 100, which required 2.50 licensed practical nurses during the night shift. Review of the nursing time schedules revealed 2.00 licensed practical nurses provided care on the night shift.
Review of facility census data indicated that on September 23, 2025, the facility census was 101, which required 2.53 licensed practical nurses during the night shift. Review of the nursing time schedules revealed 2.00 licensed practical nurses provided care on the night shift.
Review of facility census data indicated that on September 27, 2025, the facility census was 101, which required 4.04 licensed practical nurses during the day shift. Review of the nursing time schedules revealed 4.06 licensed practical nurses provided care on the day shift.
Review of facility census data indicated that on September 28, 2025, the facility census was 102, which required 4.08 licensed practical nurses during the day shift. Review of the nursing time schedules revealed 4.00 licensed practical nurses provided care on the day shift.
No additional excess higher-level staff were available to compensate for these deficiencies.
Interview with the Director of Nursing on October 23, 2025 at 10:29 a.m. confirmed that the facility did not meet the required licensed practical nurse-to-resident staffing ratios for the days listed above.
| | Plan of Correction - To be completed: 11/30/2025
The submission of this plan of correction does not constitute admission or agreement on the part of the provider with the deficiencies or conclusions contained in the Statement of Deficiencies. This plan of correction is prepared and executed solely to respond to the allegation of non-compliance cited during the survey ended on 9/30/2025.
1. Actions taken for the situation identified:
The facility cannot retroactively address the incidents. No residents were adversely affected.
2. How the facility will act to protect residents in similar situations:
The facility will schedule, monitor and manage the nursing staff ratios to meet the requirements
3. System changes and measures to be taken:
The Nursing Home Administrator has reviewed the required ratios with the Director of Nursing and other staff responsible for nursing staff scheduling. Daily staffing meetings are being held to review the scheduled hours per patient day and ratios for the current and upcoming day(s) to ensure that the facility meets the requirements.
4. Monitoring mechanisms to assure compliance:
The Nursing Home Administrator/designee will conduct audits of the nursing staff ratios to determine compliance weekly for four (4) weeks then monthly for two (2) months. Noted areas of non-compliance will be addressed upon discovery. Audit results will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings, and further action plans and audits will continue until substantial compliance is achieved. Ongoing self-monitoring will help to ensure facility continues to meet quality standards.
5. Date Corrective Action will be completed:
Substantial compliance is expected by November 30, 2025.
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