(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 11 shifts out of 63 shifts 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, 1:30 on the evening shift, and 1:40 on the night shift based on the facility's census.
July 14, 2026-3.00 LPNs on the evening shift, versus the required 3.03, for a census of 91.
July 17, 2026-2.75 LPNs on the evening shift, versus the required 3.03, for a census of 91.
July 19, 2026-3.00 LPNs on the day shift, versus the required 3.64, for a census of 91.
July 19, 2026-3.00 LPNs on the evening shift, versus the required 3.03, for a census of 91.
July 23, 2026-3.50 LPNs on the day shift, versus the required 3.56, for a census of 89.
July 26, 2026-2.00 LPNs on the night shift, versus the required 2.25, for a census of 90.
July 30, 2026-3.00 LPNs on the evening shift, versus the required 3.03, for a census of 91.
August 1, 2026-3.50 LPNs on the day shift, versus the required 3.64, for a census of 91.
August 1, 2026-2.75 LPNs on the evening shift, versus the required 3.03, for a census of 91.
August 2, 2026-3.19 LPNs on the day shift, versus the required 3.64, for a census of 91.
August 2, 2026-2.88 LPNs on the evening shift, versus the required 3.03, for a census of 91.
On the above dates mentioned, no additional excess higher-level staff were available to compensate for this deficiency.
The findings regarding the facility's failure to consistently provide minimum licensed practical nurse (LPN) staff were reviewed with the Nursing Home Administrator, on August 4, 2026, at 1:30 PM.
| | Plan of Correction - To be completed: 09/04/2026
LPN 5530
The facility will provide a staffing ratio of one Licensed Practical Nurse per twenty-five residents on day shift, one Licensed Practical Nurse to thirty residents on evening shift, and one Licensed Practical Nurse per forty residents on overnight shift.
All facility residents have the potential to be affected by this practice.
The facility has implemented staff incentives for current and new staff as well as reinforcing the facility's call-off policy to deter unnecessary call-offs. We will be using Indeed for advertisements of open positions and participating in career fairs as they are available. The Administrator/designee will educate staff on incentives and call off policy.
The Administrator/designee will audit nursing schedules during weekday daily meetings to ensure LPN ratios are maintained.
The results of the audits will be reviewed in the quality improvement meeting each month. The QI Committee will determine if continued auditing is necessary based on three consecutive months of compliance. Monitoring will be ongoing based on the QI committee's recommendations.
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