Observations:
Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for three of three days reviewed.
Findings include:
Review of nursing schedules for three days from November 16 through 18, 2025, revealed the following:
The facility failed to meet the minimum LPN to resident ratio of one LPN for 25 residents on the day shift (7:00 a.m. to 3:00 p.m.) on November 16, 17, and 18, 2025.
The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on the night shift (11:00 p.m. to 7:00 a.m.) on November 16, 17, and 18, 2025.
| | Plan of Correction - To be completed: 01/12/2026
Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.
1) The facility cannot retroactively correct the past LPN Ratios.
2) The facility will continue to make good faith effort to schedule staff to meet or exceed the mandated ratios of One LPN to 25 residents on day shift; one LPN to 30 residents on evening shift and one LPN to 40 residents on night shift. The facility will make all good-faith efforts to continue to utilize both internal and external resources to meet or exceed the staffing ratios. Community will continue to use developed Recruitment Plan which includes updating hiring advertisements on community websites, facebook and other media outlets. Community will increase submission of hiring needs and wages on social media posts. Administrator/HR personnel will continue to attend area job/career fairs. Community has contacted local Nursing schools to offer internship opportunities. Community has contracts with 5 outside nursing agencies to provide additional staffing. As of 11.26.25, Community has hired 2 additional LPNs to open positions.
3) To prevent this from reoccurring, the RDCS re-educated the NHA; DON and Scheduler on the updated staffing regulations in relation to the minimum ratio of one LPN to 25 residents on days, one LPN to 25 residents on evenings and one LPN to 40 residents on nights. The staffing will continue to be reviewed each day for the subsequent day(s) by the NHA and/or DON to ensure adequate staff to meet or exceed the minimum ratios. Needs are posted each week for internal staff to pick up extra shifts as well as posted with outside agencies.
4) To monitor and maintain ongoing compliance, the NHA/designee will continue to audit deployment sheets to ensure the facility staffing meets or exceeds the minimum LPN ratios. Audits will be completed daily. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
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