(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 a review of nurse staffing and staff interview, it was determined the facility failed to ensure the minimum licensed practical nurse ratio to resident ratio was provided on each shift for 8 shifts out of 42 reviewed.
Findings include:
A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:25 on the day shift and 1:40 on the night shift based on the facility's census.
September 19, 2025- 2.50 LPNs on the night shift, versus the required 2.60, for a census of 104.
September 20. 2025- 4.00 LPNs on the day shift, versus the required 4.16, for a census of 104.
September 20, 2025- 2.50 LPNs on the night shift, versus the required 2.58, for a census of 103.
September 21, 2025- 4.00 LPNs on the day shift, versus the required 4.12, for a census of 103.
September 21, 2025- 2.50 LPNs on the night shift, versus the required 2.60, for a census of 104.
September 22, 2025- 2.50 LPNs on the night shift, versus the required 2.60, for a census of 104.
September 23, 2025- 2.00 LPNs on the night shift, versus the required 2.63, for a census of 105.
September 24, 2025- 4.13 LPNs on the day shift, versus the required 4.20, for a census of 105.
On the above date mentioned, no additional excess higher-level staff were available to compensate for this deficiency.
An interview with the Nursing Home Administrator, on October 23, 2025, at 12:30 PM, reviewed the findings of the above deficiency.
| | Plan of Correction - To be completed: 12/09/2025
5530 Nursing Services
1. The facility is unable to correct LPN staffing ratio on September 19-20-21-22-23-24, 2025.
2. No other dates were identified during the survey.
3. To prevent this from reoccurring, the DON/designee completed education with the
Nursing supervisors and the scheduler to maintain LPN ratio with current census. If call offs occur, the supervisor needs to call staff and post on agency sites for the open shift.
NHA, DON, HR and/or Scheduler will meet daily during the week to review staffing needs, call offs ,ppd & ratios.
4. To monitor and maintain ongoing compliance, the DON/designee will audit the schedule weekly x4 , biweekly x 4 and monthly x 2 to ensure the LPN ratio has been met. Results will be reviewed at the QAPI meeting.
5. 12/9/2025
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