Failure to Provide Sufficient Nursing Staff and 24-Hour Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents and to ensure a licensed nurse was in charge on each shift, as required by facility policy and federal regulations. Review of the facility's staffing policy indicated that licensed nurses and certified nursing assistants (CNAs) should be available 24 hours a day, with staffing levels determined by resident care needs. However, analysis of the CMS Payroll-Based Journal (PBJ) Staffing Data Report and employee timesheets for the second quarter of 2025 revealed that on eight separate days, the facility did not meet these requirements. Specifically, there were days when no Registered Nurse (RN) or Licensed Practical Nurse (LPN) was present for a full 24-hour period, and the per patient day (PPD) staffing hours were below expected levels. The facility also received a 1-star staffing rating and was unable to provide additional requested timesheet documentation for the identified dates. Interviews confirmed the deficiency, with the Director of Nursing (DON) acknowledging that a nurse should always be present in the facility. The census during the period in question ranged from 32 to 39 residents, and on the identified dates, the facility failed to provide the required 24 hours of nursing coverage. This lack of adequate staffing was directly observed through the review of timesheets and staffing data, and no additional information about specific residents' medical histories or conditions was provided in the report.