Failure to Maintain Adequate CNA Coverage During Lunch Breaks
Penalty
Summary
The facility failed to provide sufficient nursing staff coverage to meet residents' needs and ensure their safety when multiple Certified Nursing Assistants (CNAs) took extended lunch breaks without adequate coverage. On several occasions, including April 15, 16, and 27, 2025, documentation and timecard reviews showed that groups of CNAs clocked out for lunch simultaneously, leaving entire hallways or large portions of the facility without CNA coverage for periods ranging from 16 to 30 minutes. During these times, the remaining staff were insufficient to safely care for the number of residents present, with as few as two CNAs and one Restorative Nursing Assistant left to care for up to 96 residents. Interviews with the Director of Staff Development (DSD) confirmed that the facility's practice was to stagger CNA lunch breaks to maintain coverage, but this was not consistently followed. The DSD acknowledged that the number of staff left on the floor during these periods was not adequate to ensure resident safety or meet their needs. Payroll and schedule reviews corroborated that CNAs took extended or simultaneous breaks, and in at least one instance, a CNA attempted to adjust their timecard after taking a longer break. The facility's job description for CNAs emphasized the importance of providing care in a manner conducive to safety and comfort, which was not maintained during these uncovered periods.