Failure to Maintain Adequate Nurse and CNA Staffing per Facility Assessment and Policy
Penalty
Summary
The facility failed to provide adequate nursing staff each day to meet resident needs as outlined in its own facility assessment and staffing policy. The Scheduling Coordinator reported she creates schedules only for CNAs and that the DON schedules the nurses. She stated that for day and evening shifts the facility should have 5 CNAs on the 4th floor, 5 CNAs on the 3rd floor, and 4 CNAs on the 2nd floor, and 3 CNAs per floor on night shift, and that the facility does not use agency staff. She also stated she staffs according to a budget, was told she could staff 15 CNAs for morning and evening and 9 CNAs for night shift, and was unaware of the facility’s staffing budget details or minimum staffing requirements. The DON stated he is responsible for nurse staffing, does not use agency staff, and always ensures 2 nurses per floor per shift, staffing a total of 18 nurses per day and 37 CNAs per day, and reported he was not aware of low nurse staffing on weekends or responsible for PBJ submissions. Review of nursing staff time punch reports for nurses and CNAs from 07/01/2025 to 09/30/2025 for weekend shifts showed that on all 26 weekend days reviewed, the facility did not meet the stated minimum requirements of 18 nurses and 37 CNAs per day as described by the Scheduling Coordinator, DON, and facility assessment. A CMS PBJ report for the same fiscal quarter documented that the facility triggered for excessively low weekend staffing. The facility assessment documented staffing of two nurses per shift per floor, five CNAs on morning shift, five CNAs on evening shift, and three CNAs on night shift for each of the three floors, equating to approximately 39 CNAs per day, but elsewhere in the same assessment it documented staffing for only 13 CNAs per day, which contradicted both the other portion of the assessment and the statements from the Scheduling Coordinator and DON. The facility’s written staffing policy stated it would provide adequate staff to meet resident needs and specified 3.8 hours of nursing and personal care per day for residents needing skilled care and 2.5 hours per day for residents needing intermediate care.
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