Observations:
Based on review of facility nursing staffing documents and staff interview, it was determined that the facility failed to ensure one Licensed Practical Nurse (LPN) per 30 residents on the afternoon shift for one of seven days (7/14/26) and one LPN per 40 residents on the overnight shift for five of seven days reviewed (7/08/26, 7/09/26, 7/11/26, 7/12/26, and 7/14/26).
Findings include:
Review of facility nursing staffing documents for the time period from 7/08/26, through 7/14/26, revealed the following LPN staffing shortage for the afternoon shift where the LPN ratio was not met:
7/14/26 census of 103 residents3.14 LPNs worked and 3.43 were required.
Review of facility nursing staffing documents for the time period from 7/08/26, through 7/14/26, revealed the following LPN staffing shortages for the overnight shift where the LPN ratio was not met:
7/08/26 census of 100 residents2.09 LPNs worked and 2.50 were required.
7/09/26 census of 100 residents 2.09 LPNs worked and 2.50 were required.
7/11/26 census of 100 residents 2.08 LPNs worked and 2.50 were required.
7/12/26 census of 100 residents 2.12 LPNs worked and 2.50 were required
7/14/26 census of 103 residents 2.37 LPNs worked and 2.58 were required.
During a telephone interview on 7/22/26, at 11:10 a.m. the Nursing Home Administrator confirmed that the facility did not meet the minimum LPN ratios for the above dates and shifts.
| | Plan of Correction - To be completed: 08/31/2026
1. The facility cannot correct that LPN staffing ratio was not met on evening shift (3pm to 11pm) for the following days (7/14/2026) The facility cannot correct that LPN staffing ratio was not met on overnight shift (11p to 7am) for the following days (7/8/26, 7/9/2026, 7/11/2026, 7/12/2026, and 7/14/2026). The facility cannot correct that LPN staffing ratio was not met on the dates listed above as there were no adverse effects and no interruption to resident care.
2.To limit the recurring staffing issues facility will attempt this following:
A. Create an employee retention program that includes competitive pay, benefits, recognition, and career development opportunities.
B. Conduct regular staffing analyses to identify trends, anticipate shortages, and adjust hiring accordingly.
C. Attempt to build a float pool or on-call workforce to provide coverage during absences, vacations, or increased demand.
D. Establish agreements with staffing agencies to provide temporary personnel when needed.
3.The Facility Scheduler, Director of Nursing, Assistant Director of Nursing, RN Supervisors, Cooperate Scheduler will be re-educated regarding the state ratios by the Nursing Home Administer/designee.
4.A daily staffing meeting will be held daily (which includes Nursing Home Administrator, Director of Nursing, Corporate Scheduler, Facility Scheduler, Cooperate Human Resources, Facility Human Resources, and Facility Recruiter) to review the schedule with ratios. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing ratios, the scheduler/or designee will call off duty facility staff and will utilize external staffing support resources. The facility is actively recruiting staff via Indeed.com (employment/hiring web site) for LPNs.
5.Nursing Home Administrator/designee will audit staffing daily for three weeks and monthly for three months to ensure staffing ratios are met.
6.Outcomes will be reviewed monthly at the Quality Assurance Performance Improvement Meeting.
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