(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.
|
Observations:
Based on staffing documentation review and staff interview, it was determined that the facility failed to ensure a required minimum of one Licensed Practical Nurse (LPN) per 25 residents on day shift for two of five days reviewed (June 27-28, 2026).
Findings include:
Review of facility staffing ratio and resident census information for June 26 - 30, 2026, revealed the following LPN ratios, which did not meet the minimum LPN ratio required for the resident census on the following shifts:
June 27, 2026, day shift - 57 residents and 2.09 LPNs, which didn't meet the required ratio of 2.28.
June 28, 2026, day shift - 58 residents and 2.06 LPNs, which didn't meet the required ratio of 2.32.
The Nursing Home Administrator (NHA) was informed of the facility's continued non-compliance via email correspondence on July 1, 2026, at 1:13 PM.
The NHA acknowledged receipt of that information via email correspondence on July 1, 2026, at 1:14 PM.
| | Plan of Correction - To be completed: 07/13/2026
Preparation and submission of this plan does not constitute an admission of, or agreement with, it is required by State and Federal Law. It is executed and implemented as a means to continuously improve the quality of care to comply with state and federal requirements.
1. There were no negative resident outcomes effected by this deficient practice.
2. All residents have the potential to be affected by this deficient practice.
3. Nursing staffing coordinator will be educated to the LPN staffing ratios. Staff recruitment efforts continue. Shift bonuses will be offered to Licensed Practical Nurses. PRN staff will be contacted via call or text message in the event of a call off. Staffing agencies will be contacted. If necessary, staff mandation will occur.
4. The NHA or designee will meet 5 days per week to ensure schedule reflects the proper staff ratios and PPD. The NHA or designee will audit the staffing PPD to ensure proper staffing weekly x 4 weeks and then monthly x2 months. All findings will be corrected immediately and presented to the monthly QAPI committee.
|
|
