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F0725
F

Failure to Provide Sufficient Nursing Staff to Meet Resident Needs

Jefferson, Wisconsin Survey Completed on 04-14-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient nursing staff each day to meet the needs of all residents, as required by its own Facility Assessment. Interviews with residents revealed that they experienced significant delays in response to call lights, with some reporting wait times of up to an hour or more, particularly during busy periods such as mealtimes or when staff levels were low. One resident, who requires a Hoyer lift and assistance from two staff members for transfers, reported being the last to receive morning care and experiencing longer wait times when staffing was inadequate. Another resident, who is dependent on continuous oxygen, expressed concern about not receiving timely assistance, especially during dinner hours, and described the situation as distressing. Staff interviews corroborated these concerns, with multiple staff members indicating that staffing shortages were particularly acute on weekends due to frequent call-ins. Staff described being pulled in multiple directions, struggling to complete all required tasks and documentation within their shifts, and sometimes needing to stay late or finish charting the next day. One LPN noted that the staffing goal was not always met and suggested that having a dedicated admission nurse would alleviate some of the workload. The staff scheduler confirmed that staffing was based on the Facility Assessment and resident acuity, but also acknowledged that the number of staff scheduled did not always meet the identified requirements, and that medication technicians (MTs) were counted as CNAs on the schedule, despite not being listed in the Facility Assessment. A review of staffing schedules for the month of February showed that the facility was consistently short of the required number of licensed nurses and CNAs as outlined in the Facility Assessment. On numerous days, the facility was down by one or more licensed nurses and several CNAs, with the shortfalls ranging from half a CNA to as many as five and a half CNAs on certain days. These staffing deficits were confirmed by both the staff scheduler and facility leadership during interviews. The surveyor concluded that the facility did not provide staffing levels that met its own identified needs, as documented in the Facility Assessment, and that both residents and staff expressed ongoing concerns about inadequate staffing.

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