(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 nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift, per 30 residents during the evening shift, and per 40 residents during the night shift on three of 21 days (9/23/25, 10/5/25, and 10/10/25).
Findings include:
Review of the facility census data, nursing time schedules, and deployment sheets revealed the following LPN staffing shortages:
On 9/23/25, census 108, evening shift needed 3.60 LPNs, the facility provided 3.44.
On 9/23/25, census 108, night shift needed 2.70, the facility provided 2.28.
On 9/5/25, census 108, night shift needed 2.70, the facility provided 2.17.
During an interview on 11/4/25, at 11:00 a.m. the Director of Nursing confirmed that the facility failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift, per 30 residents during the evening shift, and per 40 residents during the night shift three of 21 days.
| | Plan of Correction - To be completed: 11/21/2025
1. The Facility will continue to take measures to adequately provide staff to ensure the needs of residents are met.
2. The Facility will continue to take measures to adequately provide staff to meet the required licensed practical nurse to resident ratios on dayshift, evening shift, and night shift.
3. The Director of Nursing/designee will provide re-education on minimum staffing ratios to RN Supervisors, HR, and Scheduling who are responsible to monitor staffing and staffing ratios.
4. The Director of Nursing/designee will audit the daily schedules to monitor the minimum number of staff to resident ratios are being met. If ratios are not met the Director of Nursing/designee will make attempts to meet the number of staff to resident ratios. These audits will be conducted daily for 14 days and then weekly X 3 weeks. Audit results will be reviewed in Quality Assurance Performance Improvement Committee x 2 months.
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