Failure to Maintain Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient qualified nursing staff at all times to meet the needs of residents, as required by their own facility assessment and federal regulations. The Facility Assessment Tool, reviewed in May 2024, established minimum staffing levels for LPNs/RNs and CNAs for each shift, but multiple reviews of actual daily schedules revealed that the facility consistently scheduled fewer staff than required, particularly on weekends. Payroll-Based Journal (PBJ) data for Quarter 1 of 2025 triggered a one-star staffing rating, excessively low weekend staffing, and multiple days with no RN hours. Specific dates were identified where both nurse and CNA staffing fell below the facility's stated minimums, with some shifts missing as many as half the required staff. Residents reported significant delays in receiving care, including long waits for assistance with call lights, showers, and bathroom needs. During interviews, several residents stated they had not received showers for weeks, with one resident reporting a 12-week gap. At a resident group meeting, the majority of attendees indicated they often waited over 25 minutes for assistance. Staff interviews corroborated these concerns, with CNAs and nurses describing frequent short-staffing, inability to complete showers or care tasks, and the need for staff to work double shifts or stay late due to lack of coverage. Staff also reported that posted schedules did not accurately reflect the number of staff actually present in the building. Facility leadership, including the scheduler, DON, and administrator, acknowledged ongoing staffing issues and efforts to recruit or use agency staff. The medical director confirmed the facility was understaffed and overworked, noting frequent turnover in nursing leadership. The deficiency was further supported by direct observations from surveyors and multiple staff and resident interviews, all indicating that the facility did not maintain adequate staffing to meet residents' needs as outlined in their own assessment and regulatory requirements.