Failure to Maintain CNA Staffing Levels per Facility Assessment
Penalty
Summary
The deficiency involves the facility’s failure to administer operations in a manner that ensured adequate staffing in accordance with its own facility assessment and staffing policy. The facility assessment dated 11/15/25 specified that CNAs would be staffed at a ratio of one CNA to every 15 to 18 residents. The facility’s written staffing policy dated 11/05/25 stated that there shall be a sufficient number of trained staff members on duty to ensure each resident’s physical, social, and emotional health, care, and safety needs are met in accordance with their individualized care plans, and that staffing levels would be based on day-to-day resident needs, activity, and intensity of staff assistance. Surveyor review of census and overnight staffing records showed that on three consecutive nights the facility did not meet its stated CNA staffing ratios. With a census of 69 residents, only two CNAs were on duty, resulting in each CNA being responsible for 34.5 residents. On the following night, with a census of 70 residents, two CNAs were again assigned, resulting in each CNA being responsible for 35 residents. On the third night, with a census of 71 residents, two CNAs were assigned, resulting in each CNA being responsible for 35.5 residents. The Administrator confirmed the overnight census numbers, the number of CNAs assigned on those nights, and the calculated CNA-to-resident ratios. This failure affected all residents in the facility, with a reported census of 71 residents at the time of the survey.
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