Failure to Maintain Adequate Nursing Staff Levels
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, as evidenced by multiple confidential resident and family interviews, staff interviews, clinical record reviews, and facility policy review. Residents with intact cognition reported long call light response times, insufficient assistance during meals, and delays in receiving care such as wound dressing changes and transfers to bed. Family members expressed concerns about residents not being changed properly at night, insufficient staff to assist with feeding, and fear of retaliation for reporting concerns. Staff interviews confirmed that staffing levels were often below the facility's own assessment requirements, with only two CNAs and one nurse per floor on about half of the shifts, and at least one instance where the DON worked the floor overnight due to staffing shortages. A review of time card data on selected dates showed the required number of CNAs was not met on several shifts. Resident Council notes documented ongoing issues with call light response times exceeding 15 minutes and unmade beds. The facility's own assessment indicated a need for at least five CNAs on day and evening shifts and four or more on overnight shifts, which was not consistently achieved. These findings collectively demonstrate that the facility did not maintain sufficient nursing staff to meet the care needs of its residents as required.