Failure to Maintain Sufficient Nursing Staff on All Shifts
Penalty
Summary
The facility failed to provide a sufficient number of nursing staff on all shifts, as required by its own policies and state regulations. Record reviews showed that the facility's staffing levels frequently did not meet the ratios outlined in its Facility Assessment, with nurse and nursing assistant (NA) coverage falling short on multiple days and shifts. For example, there were instances where the nurse-to-resident ratio was as high as 1 nurse for every 91 residents, and NA-to-resident ratios were also higher than the facility's stated standards. The facility's own Director of Nursing confirmed that staffing was insufficient on certain shifts during the reviewed period. Residents and staff interviews corroborated the staffing shortages. Multiple residents reported having to wait long periods for their call lights to be answered, sometimes over an hour, and attributed these delays to short staffing and high staff turnover. Staff members also described frequent call-ins and being left to care for large numbers of residents, particularly during the night shift and on weekends. Nursing assistants reported being responsible for entire wings by themselves and having to wait for assistance with residents requiring more complex care, such as Hoyer lift transfers. A review of grievances filed in 2025 revealed 18 complaints related to long call light response times, further supporting the finding of inadequate staffing. The combination of documented staffing levels, resident and staff interviews, and grievance records demonstrated that the facility did not consistently provide enough nursing staff to meet the needs of all residents, as required by policy and regulation.