Failure to Maintain Adequate Weekend Nursing Staff
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of every resident on weekends during the period from October 1, 2024, to December 31, 2024. Payroll Based Journal (PBJ) data for the first quarter of 2025 revealed that on twelve separate weekend dates, the ratio of nursing hours per resident fell below 1.0. Interviews with residents confirmed that staffing was insufficient, particularly on weekends and overnight shifts, resulting in delayed responses to call lights and assistance. One resident, who was cognitively intact, reported that it could take hours for staff to respond on weekends, and her spouse, who required two staff members to be moved with a lift, experienced longer wait times for assistance due to staff shortages. Another resident also reported that service could be improved on weekends, specifically noting a lack of sufficient staff. The Business Office Assistant confirmed that PBJ data is directly uploaded from the payroll system and acknowledged that there have been times when the facility was understaffed. The deficiency was substantiated by both resident interviews and PBJ staffing calculations, which demonstrated repeated instances of low staffing levels on weekends during the specified period.