LPN Staffing Deficiency
Summary
The facility failed to meet the required LPN-to-resident staffing ratios as mandated by regulations effective July 1, 2023. The regulation requires a minimum of one LPN per 25 residents during the day, one LPN per 30 residents during the evening, and one LPN per 40 residents overnight. However, the facility did not comply with these staffing requirements on multiple occasions during the review period from January 5 through January 29, 2025. Specifically, the facility was deficient in providing the required number of LPNs during the day shift for four out of 14 days, during the evening shift for 10 out of 21 days, and during the overnight shift for 13 out of 21 days. For instance, on January 8, 2025, the facility had a census of 157 residents, necessitating 6.28 LPNs during the day shift, but only 6.19 LPNs were available. Similarly, on January 6, 2025, the facility required 3.90 LPNs for the overnight shift with a census of 156 residents, but only 2.03 LPNs were present. The deficiency was confirmed through a review of nursing schedules, staffing information, and staff interviews. The Nursing Home Administrator acknowledged the failure to meet the required staffing ratios during an interview on January 30, 2025. No additional higher-level staff were available to compensate for the staffing shortfall, further exacerbating the deficiency.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. The facility cannot retroactively correct past staffing issues. To prevent a future occurrence, the scheduler will be reeducated on staffing licensed practical nurses to include expectations of Hours Per Patient Day and ratios by the director of nursing/designee. The facility will hold staffing meetings 5 days per week, consisting of the Nursing Home Administrator, Director of Nursing, Human Resources and scheduler to review ratio compliance for upcoming schedules. During staffing meetings, discussion will be held on efforts to fill open slots to meet ratio by contacting external agencies for staff and asking in-house staff to cover additional shifts. To monitor and maintain ongoing compliance, the Director of Nursing/designee will monitor licensed practical nurse hours 5 days a week and ongoing to ensure compliance. Ad hoc education will be provided as needed. Results of audits will be forwarded to the facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Penalty
Administrative staff did not ensure required LPN coverage on certain day and evening shifts, as shown by a comparison of nursing time schedules and census data. On one day shift, the number of LPN hours worked was below what was required for the number of residents present, and on one evening shift, LPN hours were again below the mandated minimum. The DON confirmed that minimum LPN staffing requirements were not met on these shifts.
Surveyors determined that the facility did not maintain the required minimum of one LPN per 25 residents on several day shifts during multiple reviewed weeks. Review of staffing records showed that on multiple identified days, the number of LPNs scheduled on day shift was insufficient for the resident census. In an interview, the NHA acknowledged that the required LPN staffing ratios were not met on those days.
Surveyors found that the facility did not maintain required LPN-to-resident staffing ratios on multiple day, evening, and night shifts. Review of census data and nursing schedules showed that the number of LPNs providing care on several day shifts was slightly below the minimum required based on the census, and at least one evening and one night shift were also understaffed. There were no additional higher-level staff available to offset these LPN shortfalls, and the Administrator confirmed that required LPN staffing ratios were not met on the identified shifts.
The facility did not maintain the required LPN-to-resident staffing ratios on several shifts, as shown by a review of weekly staffing records and staff interviews. On four of twenty-one shifts reviewed, the number of LPNs on duty was below the mandated minimum based on the census, including day shifts where LPN coverage was slightly under the required level and a night shift with no LPN coverage at all. No additional higher-level nursing staff were present to offset these shortages, and the administrator acknowledged that required LPN-to-resident ratios were not met on the identified shifts.
The facility did not meet the required minimum LPN-to-resident ratios on several day and evening shifts, as shown by a review of nursing schedules. On multiple occasions, there were not enough LPNs scheduled to meet the mandated ratios for the number of residents present.
The facility did not provide the required minimum number of LPNs on several day and night shifts, as shown by a review of staffing schedules and census data. The Nursing Home Administrator confirmed that LPN staffing levels fell below regulatory requirements on these occasions.
Failure to Meet Minimum LPN Staffing Requirements on Day and Evening Shifts
Penalty
Summary
Facility administrative staff failed to meet state-required minimum LPN staffing levels on specified day and evening shifts, as identified through review of nursing time schedules and census data. For the day shift on 4/25/26, with a census of 59 residents, the facility provided 15.92 hours of LPN coverage instead of the required 18.88 hours, resulting in an LPN staffing shortage. For the evening shift on 4/20/26, with a census of 62 residents, the facility provided 14.57 hours of LPN coverage instead of the required 16.53 hours, again resulting in an LPN staffing shortage. During an interview on 4/30/26 at 3:00 p.m., the Director of Nursing confirmed that the facility did not provide the minimum number of LPNs required by regulation on these identified shifts.
Plan Of Correction
Formatted text (without <text> tags or quotes): The Nursing schedule is created to ensure LPN staffing ratios reflects the current census per shift. Each shifts LPN staffing is adjusted based on census. When additional staff is needed to meet ratios, shifts are posted on our staffing portal, bonuses are offered, phone calls and text messages are sent to staff. The facility will utilize agency to assist with open shifts when needed. The facility attendance policy is followed for staff and disciplines occur per policy. Attendance is tracked on a calendar and reviewed weekly. The facility holds a monthly retention committee meeting and ads are posted on Indeed for open positions. Interviews are conducted immediately. We have a dedicated recruiter to assist with recruiting and hiring new nursing staff. The Administrator or designee will educate the Nursing Admin, HR, the scheduler and RN Supervisors on the staffing rations and PPD and how to adjust. A staffing meeting will occur daily to review ratios with the NHA, DON, HR and scheduler. Completion Date: 06/15/2026 Status: APPROVED Date: 05/15/2026 Daily recruiting calls with the NHA, HR, and recruiter occur to update the status of new applicants and interviews. The 3 week DOH Staffing Calculator Tool will be updated daily to monitor hours. The Audits will be taken to QAPI for review.
Failure to Maintain Required LPN Day-Shift Staffing Ratios
Penalty
Summary
The facility failed to meet state-required LPN staffing ratios on multiple day shifts across three reviewed weeks. Review of staffing data for the weeks of September 7, 2025, December 28, 2025, and April 27, 2026, showed that the minimum requirement of one LPN per 25 residents on day shift was not met on September 7, 2025, September 13, 2025, December 28, 2025, December 29, 2025, December 31, 2025, April 25, 2026, and April 26, 2026. These findings were based solely on the facility’s own staffing records, which demonstrated insufficient LPN coverage relative to the resident census on those dates. During an interview on April 31, 2026, at 2:15 p.m., the Nursing Home Administrator confirmed that the facility did not meet the required LPN staffing ratios on the identified days. No additional resident-specific clinical information, medical histories, or conditions were documented in relation to these staffing shortfalls in the report.
Plan Of Correction
1) Staff was educated on calling off in a timely manner and following all attendance policy and procedure in regards to clocking in and out. 2) Staffing reviewed daily to ensure vacant shifts are filled to meet the ratio requirements, and the hours set which have been determined by census and the ratio requirement are accurate and all efforts are made to replace, fill, and or meet all necessary requirements. 3) Education provided to management staff to ensure that all hours, ratios, and ppd are adhered to in order to meet the regulated needs based on census. All processes will be reviewed with the management team in regard to utilizing the staffing call list as well as the agency platforms to acquire replacement staff if needed. 4) NHA and or designee to review staffing daily to ensure LPN ratio requirement is met for two weeks from 5/1/26 until 5/30/26. Ongoing monthly reviews will be conducted to ensure all staffing LPN minimum hours are met. All findings will be reported to the QAPI committee for continued review and revision.
Failure to Maintain Required LPN-to-Resident Staffing Ratios Across Multiple Shifts
Penalty
Summary
The facility failed to meet state-required LPN-to-resident staffing ratios on multiple shifts over specified dates. Review of census data and nursing time schedules showed that on several day shifts, the number of LPNs scheduled and providing care was below the minimum requirement based on the facility’s census. On March 8, 2026, with a census of 105 residents requiring 4.20 LPNs on the day shift, only 1.80 LPNs provided care. On March 9 and March 12, 2026, with a census of 103 residents requiring 4.12 LPNs on each day shift, only 4.00 LPNs provided care on each of those days. On March 14, 2026, with a census of 105 residents requiring 4.20 LPNs on the day shift, 4.03 LPNs provided care. On April 6, 2026, with a census of 108 residents requiring 4.32 LPNs on the day shift, 4.00 LPNs provided care, and on April 9, 2026, with a census of 108 residents requiring 4.36 LPNs on the day shift, 4.06 LPNs provided care. The facility also failed to meet minimum LPN staffing ratios on at least one evening and one night shift. On an evening shift on March 8, 2026, with a census of 105 residents requiring 3.50 LPNs, only 3.44 LPNs provided care. On a night shift on March 13, 2026, with a census of 105 residents requiring 2.63 LPNs, only 2.06 LPNs provided care. The review further determined that there were no additional excess higher-level staff available to compensate for these LPN staffing shortfalls. In an interview on April 20, 2026, the Administrator confirmed that the facility did not meet the required LPN-to-resident staffing ratios for the identified days and shifts.
Plan Of Correction
1. Actions taken for the situation identified: The facility cannot retroactively address the incidents. No residents were adversely affected. 2. How the facility will act to protect residents in similar situations: The facility will schedule, monitor and manage the nursing staff ratios to meet the requirements 3. System changes and measures to be taken: The Nursing Home Administrator has reviewed the required ratios with the Director of Nursing and other staff responsible for nursing staff scheduling. Daily staffing meetings are being held to review the scheduled hours per patient day and ratios for the current and upcoming day(s) to ensure that the facility meets the requirements. 4. Monitoring mechanisms to assure compliance: The Nursing Home Administrator/designee will conduct audits of the nursing staff ratios to determine compliance weekly for four (4) weeks then monthly for two (2) months. Noted areas of non-compliance will be addressed upon discovery. Audit results will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings, and further action plans and audits will continue until substantial compliance is achieved. Ongoing self-monitoring will help to ensure facility continues to meet quality standards. 5. Date Corrective Action will be completed: Substantial compliance is expected by 5/11/2026
Failure to Maintain Required LPN-to-Resident Staffing Ratios on Multiple Shifts
Penalty
Summary
The facility failed to meet state-required LPN-to-resident staffing ratios on multiple shifts, as identified through review of weekly staffing records and staff interviews. On four of twenty-one shifts reviewed, the number of LPNs scheduled and working did not meet the minimum required ratios 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. Specifically, on April 8, 2026, the day shift had 1.02 LPNs instead of the required 1.08 for a census of 27 residents. On April 10, 2026, the day shift had 1.03 LPNs instead of the required 1.12 for a census of 28 residents, and the night shift had 0.00 LPNs instead of the required 1.00 for the same census. On April 12, 2026, the day shift had 1.00 LPN instead of the required 1.12 for a census of 28 residents. On these dates, there were no additional higher-level staff available to compensate for the LPN shortfall. In an interview on April 14, 2026, at 2:00 PM, the nursing home administrator confirmed that the facility had not met the required LPN-to-resident ratios on the identified dates. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency is based solely on staffing levels relative to the resident census and regulatory requirements.
Plan Of Correction
1.) There were no ill effects suffered by the residents due to the facility's failure to meet the ratio for residents to LPNs for 4 shifts. 2.A facility wide audit was completed to ensure ratios were met. LPN sign on bonuses and wages are competitive with surrounding areas. The facility uses bonuses for employees to pick up shifts. 3.DON and Corporate HR were re-educated on staffing ratios and ensure the facility is actively recruiting to fill any open positions. The DON will review census and staffing ratios to ensure ratios are being met. 4.The DON or designee will conduct an audit of nursing care ratios weekly x 4 weeks then monthly x2 months to ensure ratios are being met. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.
Failure to Meet Minimum LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum LPN-to-resident ratios on five out of twenty-one days reviewed, as evidenced by nursing time schedules. Specifically, on two days, the day shift did not have at least one LPN per 25 residents, and on three separate days, the evening shift did not have at least one LPN per 30 residents. These deficiencies were identified through a review of staffing schedules covering the period from late November to mid-December 2025. No information about specific residents, their medical histories, or their conditions at the time of the deficiency is provided in the report.
Plan Of Correction
1,2) LPN staffing ratios will be reviewed for the last 7 days to evaluate if LPN ratios are met. 3) Nursing admin and scheduler will be re-educated on new July 1 nurse staffing and PPD requirements. 4) Weekly audit of LPN ratios will be conducted for 60 days by NHA/designee to ensure LPN ratios are met. Tracking and trends to be submitted to the QAPI committee.
Failure to Meet Minimum LPN Staffing Requirements
Penalty
Summary
The facility failed to meet the required minimum staffing levels for licensed practical nurses (LPNs) as mandated by regulation. Specifically, on two days during the reviewed period, the facility did not provide at least one LPN per 25 residents on the day shift, and on two separate days, did not provide at least one LPN per 40 residents on the night shift. This was determined through a review of the facility's census data and nursing time schedules, which showed that the actual LPN hours worked were less than the required hours for the number of residents present. The Nursing Home Administrator confirmed during an interview that the minimum LPN staffing requirements were not met on these days. No information was provided regarding the specific residents affected, their medical history, or their condition at the time of the deficiency.
Plan Of Correction
Date of POC Updated to reflect reason for previous rejection: 1. The facility cannot correct that the LPN staffing ratio was not met on one LPN per 25 residents on the morning shift on two of five days (9/27/25 and 9/28/25) and one LPN per 40 residents on the night shift on two of five days (9/25/25, and 9/30/25). There were no adverse effects to residents on the identified dates. 2. The facility will ensure that staffing ratios are met every shift. 3. A Daily staffing meeting with scheduler will be held by administration to monitor staffing ratios. Staffing ratios will be reviewed at Standup and Stand down. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects not to meet staffing ratios on a shift, nursing administration/designee will be responsible to call off duty personnel or call extra support staff. --- Date of POC Updated to reflect reason for previous rejection: 1. The facility cannot correct that the LPN staffing ratio was not met on one LPN per 25 residents on the morning shift on two of five days (9/27/25 and 9/28/25) and one LPN per 40 residents on the night shift on two of five days (9/25/25, and 9/30/25). There were no adverse effects to residents on the identified dates. 2. The facility will ensure that staffing ratios are met every shift. 3. A Daily staffing meeting with scheduler will be held by administration to monitor staffing ratios. Staffing ratios will be reviewed at Standup and Stand down. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects not to meet staffing ratios on a shift, nursing administration/designee will be responsible to call off duty personnel or call extra support staff. 4. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure staffing ratios are met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
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