(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 nursing time schedules, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for five of 21 days reviewed.
Findings include:
Review of nursing schedules for 21 days from March 31 through April 20, 2024, revealed the following:
The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on night shift (11:00 p.m. to 7:00 a.m.) on April 4, 5, 6, 19 and 20, 2024.
In an interview on April 22, 2024, at 12:45 p.m., the Director of Nursing stated that the facility failed to meet the minimum LPN to resident ratios for the days listed above.
| | Plan of Correction - To be completed: 04/26/2024
Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted solely because of requirements under state and federal laws.
1 Director of Nursing provided re-education of DOH staffing requirements to scheduler, on-call nursing team, charge nurses and managers on duty 4/26/24.
2. Facility will use staffing agency to meet requirements as needed.
3. Director of Nursing to meet weekly with scheduler to review and ensure schedule is filled to meet compliance requirements.
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