Failure to Maintain Sufficient Nursing Staff per Facility Assessment
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on multiple units and shifts to meet residents’ needs as defined by its own facility assessment and nursing staffing plan. The facility assessment, last updated in March 2026, established specific par levels of RNs/LPNs and CNAs for each floor and shift in both the House Building and Skilled Nursing Facility (SNF) units, based on census and acuity. The Director of Nursing (DON) confirmed these par levels, including additional par levels for the SNF 12th floor and House Building 10th floor that were not yet reflected on the written par level sheet because residents had recently been removed from those units. Interviews with residents, resident representatives, the Resident Council, and staff indicated ongoing concerns about staffing adequacy in the facility. A review of actual staffing schedules for the lookback period from 12/15/2025 through 03/24/2026 showed repeated instances where the facility did not meet its established par levels for both nurses and CNAs, particularly on the day shift. On numerous dates in December 2025, multiple SNF floors were short at least one nurse and/or one CNA compared to the par levels, including days when several floors (such as the 3rd through 9th, 11th, and 13th SNF floors) were simultaneously short of one nurse, one CNA, or both. House Building floors, especially the 4th and 7th floors, were also documented as short of CNAs on several of these days. These shortfalls occurred across consecutive days, including holidays, and affected a wide range of units with varying bed capacities. The pattern of insufficient staffing continued into January and February 2026. On many day shifts in January, multiple SNF floors were short of one nurse, one CNA, or both, with some dates showing nearly all SNF floors below par nurse staffing and several also below par CNA staffing. House Building 3rd, 4th, 7th, and 8th floors were repeatedly short of CNAs on day shifts. In February, the schedules again documented that several SNF floors, particularly the 3rd, 5th, 6th, 7th, 8th, and 9th floors, were short of one nurse on multiple day shifts, and House Building floors were short of CNAs on several occasions. These documented staffing shortages, in combination with interview reports of staffing concerns, demonstrate that the facility did not consistently ensure sufficient nursing staff were available each day to provide nursing and related services necessary to assure resident safety and to help residents attain or maintain their highest practicable physical, mental, and psychosocial well-being. No specific individual resident medical histories or conditions are detailed in the report. The deficiency is based on the facility-wide failure to meet its own acuity-based staffing par levels across numerous units and dates, as evidenced by the staffing schedules and corroborated by interviews with residents, their representatives, the Resident Council, and staff.
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