Deficiency Due to Insufficient Nursing Staff Coverage
Penalty
Summary
The facility failed to ensure adequate nursing staff to meet the needs of residents, as evidenced by multiple resident interviews and review of staffing records. Residents reported long wait times for assistance, particularly on weekends and during certain shifts, with one resident stating she waited 30-45 minutes for help and experienced incontinence as a result. Several residents expressed frustration about insufficient staff coverage, especially on weekends and second shift, and noted that call lights were not answered promptly. Review of the facility's PBJ (Payroll-Based Journal) staffing data for the first quarter of 2025 revealed low weekend staffing. The facility's policy states that sufficient numbers of licensed nurses and CNAs are to be available 24/7, but interviews with staff and review of schedules indicated frequent call-ins and difficulty filling open positions, particularly on weekends. The facility attempted to address call-ins by offering bonuses and asking staff to stay over, but gaps in coverage persisted. The Human Resources staff confirmed that agency staff were not used and that new hires often did not remain after orientation, further contributing to staffing shortages. Staffing levels discussed included a requirement for 4 CNAs and 2 nurses on day and afternoon shifts, and 1-2 CNAs and 2 nurses on night shift, depending on census. Despite these requirements, both residents and staff reported that actual staffing often fell short, especially on weekends. The facility's inability to consistently provide sufficient nursing staff resulted in unmet resident care needs, including missed showers and delayed responses to call lights, leading to resident dissatisfaction and compromised care.