Observations:
Based on review of nursing time schedules and staff interview, it was determined that the facility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per 40 residents on the night shift on three of seven days (2/11/26, 2/16/26 and 2/17/26).
Findings include:
Review of facility census data and nursing time schedules from 2/11/26 through 2/17/26, revealed the following LPN staffing shortage:
Night shift:CensusActual hoursHours required
2/11/26498.009.80
2/16/26468.009.20
2/17/26488.009.60
During an interview on 2/19/26 at 1:45 p.m. the Nursing Home Administrator confirmed the facility failed to provide the minimum of LPN's on the above days as required.
| | Plan of Correction - To be completed: 03/24/2026
Plan of Correction:
5530 - 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.
1. All residents received care in accordance with their plan of care and attending physician orders.
2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. Facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff.
3. LNHA, DON, and Staffing coordinator have been educated on Nursing Ratios.
4. To monitor and maintain ongoing compliance the DON or designee will audit staffing weekly x4 weeks then monthly for two months.
Results will be taken to the QAPI for review and revision as needed.
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