Failure to Maintain Adequate Nursing and CNA Staffing per Facility Assessment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own facility assessment for direct care staffing and to ensure adequate nursing staff on all shifts. The facility assessment specified that day and evening shifts should each have 2 nurses and 4 CNAs, and night shift should have 1 nurse and 2 CNAs. Review of assignment sheets and actual working schedules from 12/20/2025 to 1/19/2026 showed that, out of 31 days, only 2 days were staffed according to these requirements. On the survey date, three CNAs were assigned to the floor while one CNA was assigned to 1:1 supervision, effectively reducing floor coverage. Staff interviews confirmed that on morning shifts there should be two nurses, but sometimes there is only one, and that CNA staffing fluctuates between two, three, or four CNAs, with staff describing it as a struggle when only two CNAs are available. During observations on the survey date, one resident was seen lying horizontally on his bed with his upper torso hanging off the bed and his head touching the floor mat. At 10:55 AM, the resident remained in this position until a CNA was called by the surveyor to observe and then repositioned the resident. The DON reported that staffing had been a concern recently due to staff illness and a limited pool of staff to call in for coverage, and also stated that the facility had not used agency staff for many years. The DON further explained that typical day-shift staffing should be two nurses and four CNAs, but this had been difficult to maintain, particularly because one resident required 1:1 supervision, which pulled a CNA from general floor duties, and that sometimes there was only one nurse on day shift.
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