(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 staffing document review and staff interview, it was determined that the facility failed to ensure a required minimum of one licensed practical nurse (LPN) per 40 residents on the night shift for three of seven days reviewed (August 9, 10, and 15, 2026).
Findings Include:
Review of facility provided staffing information for August 9, 2026, on night shift, revealed a census of 92 residents. Further review revealed an LPN ratio of 2.13; therefore, the facility did not meet the required minimum LPN ratio of 2.30.
Review of facility provided staffing information for August 10, 2026, on night shift, revealed a census of 92 residents. Further review revealed an LPN ratio of 2.00; therefore, the facility did not meet the required minimum LPN ratio of 2.30.
Review of facility provided staffing information for August 15, 2026, on night shift, revealed a census of 92 residents. Further review revealed an LPN ratio of 2.13; therefore, the facility did not meet the required minimum LPN ratio of 2.30.
During a staff interview with the Nursing Home Administrator and the Director of Nursing (DON) on August 19, 2026, at 2:35 PM, the DON confirmed that the LPN ratio did not meet on those shifts.
| | Plan of Correction - To be completed: 09/15/2026
Facility leadership immediately reviewed current staffing schedules for all overnight shifts.
Additional licensed nursing staff were assigned to the 11 PM to 7 AM shift to ensure compliance with required staffing levels.
Agency and per diem nursing resources were activated to fill identified vacancies.
The staffing coordinator verified that all upcoming schedules met minimum staffing requirements.
The Administrator, Director of Nursing, and Staffing Coordinator will review staffing schedules.
A staffing contingency plan has been implemented that includes the use of overtime, per diem staff, agency personnel, and on-call nursing staff when vacancies occur.
Nursing management staff will receive re-education regarding regulatory staffing requirements and facility staffing policies.
Daily staffing reports will be reviewed to identify and address potential shortages before the start of the shift.
The DON or designee will conduct weekly audits of overnight staffing schedules for four weeks, then monthly for 1 month.
Audit results will be presented at the Quality Assurance and Performance Improvement (QAPI) meeting.
Any identified staffing variances will be addressed immediately through corrective action.
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