(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 meet the Licensed Practical Nurse (LPN) ratios of one LPN per 25 residents on the day shift for two of 14 days reviewed (4/5/25 and 4/6/25); and failed to meet the ratio of one LPN per 40 residents on the overnight shift for one of 14 days reviewed (4/8/25).
Findings include:
Review of nursing staffing documents for the time periods from 4/5/25 through 4/11/25, and 4/23/25 through 4/29/25, revealed the following LPN staffing shortages for the day shift:
4/5/25 facility census of 54 residents, 1.67 LPNs worked and 2.16 were required.
4/6/25 facility census of 53 residents, 1.81 LPNs worked and 2.12 were required.
Review of nursing staffing documents for the time periods from 4/5/25 through 4/11/25, and 4/23/25 through 4/29/25, revealed the following LPN staffing shortages for the overnight shift:
4/8/25 facility census of 52 residents, 1.19 LPNs worked and 1.30 were required.
During an interview on 5/2/25, at 11:30 a.m. the Nursing Home Administrator confirmed that the facility failed to meet the minimum LPN ratio requirements on the above shifts and dates.
| | Plan of Correction - To be completed: 07/02/2025
1. The Nursing Home administrator "In serviced" members of the management team (Director of Nursing, Scheduler, Nursing Supervisors) on the current ratios guiding staffing recruitment and in specific LPN (Licensed Practical Nurse) ratios per shift.
2. Audits of the daily staffing sheets will be conducted by the DON (Director of Nursing) or designee daily to ensure that the minimum LPN ratios are met.
3. A "nightshift LPN" position has been requested for the facility to ensure overnight hour needs are met.
4. All LPN's will now be a part of a weekend rotation where they will all take part in covering nursing needs every Saturday and Sunday.
5. In the event of an LPN call off, The DON, Registered Nurse Manager/Supervisor, and Nurse Scheduler will work together to find suitable replacement staff for the call offs.
6. All measures from above will be reviewed at the facility's quarterly QAPI (Quality Assurance and Performance Improvement) meetings for three quarters.
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