Failure to Maintain Minimum CNA Staffing Levels
Penalty
Summary
The facility failed to provide sufficient nursing staff, specifically Certified Nurse Aides (CNAs), to meet the needs of residents on all shifts over a two-month period. Staffing schedules for July and August 2025 showed that the facility did not meet its own minimum staffing requirements for CNAs on any day or evening shift and was below the minimum on most night shifts. The facility's staffing policy and assessment required a minimum of 11 CNAs for day and evening shifts and 6 for night shifts, but these levels were not achieved. Observations revealed unsupervised residents, foul odors, and strong smells of urine in resident areas, indicating lapses in care and supervision due to inadequate staffing. Interviews with residents and staff confirmed the impact of insufficient staffing. Residents reported long wait times for call bells, cold meals, irregular showers, and delays in receiving medications. CNAs described being unable to complete assigned tasks, such as getting residents out of bed, providing showers, and supervising common areas. They also reported difficulty in feeding residents and performing necessary transfers, especially when staffing dropped to three or fewer CNAs per shift. Registered Nurses (RNs) indicated that they were unable to complete medication passes and assessments on time due to the need to assist CNAs with basic care tasks. Facility leadership, including the Staffing Coordinator, DON, and Administrator, acknowledged ongoing staffing challenges and difficulties in recruitment and retention. The Staffing Coordinator noted that agency staff were unreliable and that the facility often relied on staff working double shifts. The Administrator admitted to being unaware of the role of the Facility Assessment in determining staffing needs. The Corporate Administrator stated that the Facility Assessment was intended to guide staffing decisions, but it was not reviewed with the new administrator. These actions and inactions led to the facility's failure to ensure adequate staffing to maintain the well-being of each resident.