Insufficient CNA Staffing on Multiple Night Shifts
Penalty
Summary
The facility failed to provide a sufficient number of certified nurse assistants (CNAs) during four night shifts out of twenty-seven reviewed, as evidenced by staffing records and interviews. On the specified dates, the number of CNAs scheduled did not meet the minimum regulatory requirement of one CNA per twenty residents, given the facility's census of over 170 residents. Staffing records showed only seven CNAs present during these shifts, which was below the facility's own staffing plan and regulatory standards. Interviews with staff confirmed that the schedule is based on census and that shortages occasionally occur, with attempts made to fill gaps using agency staff or by having the staffing coordinator work as a CNA when needed. A resident reported delays in receiving assistance with personal care and water, citing a specific incident where it took several hours to receive water after requesting it at night. Staff interviews corroborated that while the facility generally maintains adequate staffing, there have been instances of CNA shortages. The staffing coordinator confirmed reliance on agency staff and efforts to ensure coverage, but acknowledged that there were shifts with fewer than the planned number of CNAs. These findings were supported by a review of daily schedule and punch reports for the relevant period.