Failure to Ensure Sufficient Staffing According to Facility Assessment
Penalty
Summary
The facility failed to ensure sufficient staffing as required by its own facility assessment and policy, particularly during night shifts in July 2024 and January 2025. The facility assessment identified a resident population with complex needs, including mental, cardiac, respiratory, skin, cancer, musculoskeletal, and gastrointestinal disorders. Specific acuity factors included residents requiring oxygen, updraft treatments, behavioral health interventions, injections, ostomy care, hospice, respite care, and parenteral nutrition. The assessment also documented that a significant number of residents required assistance with activities of daily living such as dressing, bathing, transfers, eating, and toileting. The facility's own standards called for a CNA-to-resident ratio of 1:13 on night shifts, but staffing schedules for the months reviewed showed multiple instances where only two or three CNAs were scheduled for night shifts with resident censuses ranging from 40 to 47, which did not meet the assessed staffing needs. Interviews with staff, including LPNs, RNs, CNAs, the DON, and the Administrator, confirmed that staffing shortages were a known issue prior to the hiring of new leadership. Staff reported that these shortages resulted in residents being found soiled and still in bed at the start of shifts. The facility's policy on sufficient and competent staffing stated that staffing numbers and skill requirements should be based on resident needs as determined by care plans, resident assessments, and the facility assessment, but the documented schedules did not align with these requirements for the periods in question.