Failure to Maintain Sufficient Nursing Staff to Meet Resident Care Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on a 24-hour basis to meet residents’ needs in accordance with the facility assessment, which set a 3.0 PPD for direct nursing care. Multiple confidential staff interviews described frequent short staffing, with CNAs reporting they were often the only aide on a hall that included residents requiring two-person assistance. Staff stated they were unable to complete all assigned tasks, including showers and baths, and that residents sometimes remained dirty or were not gotten out of bed for mealtimes. Several CNAs reported that when they requested help from medication aides or management, they were told those staff were busy, and that nurse management was not assisting with direct care when staffing was short. The DON acknowledged that staff had reported needing more CNAs during staff meetings and stated that the goal was to have one CNA per hall, but also said it had not been reported that staff could not complete their tasks. The Administrator similarly stated it had not been reported that staff were unable to complete their tasks, asserted that staffing needs were being met, and indicated there was no staffing policy. Record review showed the facility assessment, last reviewed on 07/24/2025, required 3.0 PPD of direct nursing care, while facility hours for specific dates in February 2026 demonstrated that the total PPD worked did not reach 3.0 on several of those days. The Area Director of Operations reported he did not know how to generate facility hours for the full months requested, and the complete facility hours for January and February 2026 were not provided upon exit.
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