F0725

E

Failure to Adjust Staffing for High-Acuity Resident and Sub-Acute Unit Needs

Fresno, California Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure sufficient nursing staff and appropriate staffing adjustments to meet all residents’ needs, particularly in the sub-acute unit and in relation to a high-acuity resident. The facility did not adjust staffing levels or care approaches despite longstanding knowledge that one resident required extensive staff time due to chronic behavioral issues and specific care preferences, such as lengthy nighttime bed baths and refusal to use the shower room. Care plans and staff interviews documented that this resident frequently raised her voice, verbally abused staff, used racial slurs, threw items, made false accusations, and demanded significant attention, including bed baths on shower days and hair washing at the sink. Multiple residents and staff reported that CNAs often spent one to three hours in this resident’s room, which reduced the time available to respond to other residents’ needs.

The facility also reduced PM shift CNA staffing on the sub-acute unit from two CNAs to one without conducting or documenting an assessment of resident acuity or monitoring the impact of this change. The administrator stated the reduction was based on a census decrease from 23 to 17 residents and a determination that CNA hours had previously exceeded requirements while nursing hours were slightly below required levels. However, the unit manager and CNAs reported that most residents on the sub-acute unit required two-person assistance for care, and that the single CNA on PM shift struggled to meet all residents’ needs. Although the administrator stated an additional LVN was scheduled on PM shifts solely to assist with ADLs and documentation and not assigned direct nursing responsibilities, the LVN interviewed reported assisting with both CNA-type care and nursing duties, including toileting, charting, and assessments.

These staffing decisions and lack of acuity-based adjustment led to specific delays in care for multiple residents. One ventilator-dependent resident with Guillain-Barré syndrome, chronic respiratory failure, tracheostomy, major depressive disorder, and anxiety, who was completely dependent for all ADLs and cognitively intact, reported waiting approximately three hours on two separate evenings for a CNA to respond to his call light and change a soiled brief. He stated that the CNA apologized and explained she had been busy with other residents. Another resident reported that nighttime bed baths for the high-acuity resident often caused her own bedtime to be delayed from her preferred 8:30 p.m. to around 10:00 p.m. A third resident stated she had to wait 20 to 30 minutes on the commode for assistance to get off because CNAs were occupied with the high-acuity resident, and she reported raising this issue multiple times in resident council. Resident council minutes documented complaints that another peer resident was taking too much CNA time and playing the TV too loudly. Staff, including the MDS coordinator, medical records director, and social services director, acknowledged hearing repeated complaints that other residents’ needs were not being met because of the time staff spent with the high-acuity resident, yet no documented staffing adjustment or systematic follow-up was made in response.