Repeated Failure to Correct Ongoing Staffing Deficiencies
Penalty
Summary
The deficiency involves the facility’s failure to make a good faith effort to correct ongoing deficient practices related to sufficient staffing over a three-year period. Review of the state agency’s public website showed multiple surveys ending on 07/29/2025, 04/24/2025, 01/30/2025, and 06/18/2025, each resulting in a deficiency cited for staffing while the facility reported a census of 82 residents. Quality Assurance and Performance Improvement (QAPI) meeting notes dated 12/15/2025 identified assuring appropriate staffing as an active area of the QAPI action plan, indicating that staffing concerns were formally recognized within the facility’s quality program. In an interview on 01/14/2026, the Administrator stated the facility had been aware of the need for more staff since before he assumed the role in November and acknowledged that the staffing issues were a repeat facility failure, though he could not explain why the failure persisted due to his limited tenure. He also reported that QAPI meeting notes from before December were unavailable, but that facility leadership had known about staffing issues for some time. No specific residents, clinical conditions, or direct resident care events are described in the report; the deficiency centers on repeated staffing violations and the facility’s failure over multiple survey cycles to effectively address and correct these known staffing problems through its QAPI and QAA processes.
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