Insufficient Staffing Leads to Delayed Care and Resident Complaints
Penalty
Summary
The facility was found to have insufficient nursing staff to provide timely and appropriate care to its residents, as evidenced by multiple complaints from residents, family members, and staff. Residents reported issues such as delayed response to call lights, inadequate assistance with activities of daily living (ADLs), and a lack of dignity in care. Specific instances included a resident who was not shaved despite requests, another who was left in a soiled brief for an extended period, and a resident who experienced long wait times for assistance, impacting their ability to engage in desired activities. Staff interviews revealed that the facility's staffing levels were inadequate to meet the needs of residents, particularly those with high acuity levels. Nurses and certified nursing assistants (CNAs) were often responsible for a large number of residents, leading to delays in care and medication administration. The facility's staffing coordinator confirmed that staffing was based on census rather than acuity, which contributed to the challenges faced by staff in providing timely care. The report also highlighted issues with the facility's call system, which was not functioning effectively, further exacerbating the delays in care. Additionally, the facility's staffing practices were criticized for not adequately addressing the needs of residents with high acuity or behavioral issues. The lack of a unit manager on certain floors further compounded the staffing challenges, leaving nurses to manage both care and administrative tasks, which affected the overall quality of care provided to residents.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.4.25 resident #75, 83, 23, 251, 254, 10, 29, 50, 68, 45, 27, 256, 62, 11, 46, 73, 55 and 85 were assessed by licensed nurse, no concerns identified. Resident #256 discharged on 4.8.25 and is no longer residing in the facility. Resident #250 discharged on 4.2.25 and is no longer residing in the facility. On 4.7.25 resident #73 discharged and is no longer residing in the facility. On 4.4.25 resident #75, 83, 23, 251, 10, 29, 50, 27, and 85 were provided nutritive, palatable meals, at appropriate temperature per their preference; no concerns identified. Resident #251 discharged on 4.9.25 and is no longer residing in the facility. Resident #27 discharged on 4.14.25 and is no longer residing in the facility. For resident #62 was completed on 4.9.25; resident #62 discharged on 4.10.25 and is no longer residing in facility. On 4.14.25 facility with external provider for dietary services to include management oversight, line staff and cooks. On 4.8.25 the facility ordered 6 Insulated food delivery carts which were shipped on 4.16.25, and have delivery date of 4.22.25. On 4.4.25 resident #72 was assessed by licensed nurse, provided hygiene assistance with nail care, grooming, shaving and shower; no other concerns identified. (**Need to know when he saw the barber to cut the hair) On 4.7.25 Administrator reviewed last 2 weeks of staffing to ensure appropriate staffing in place per current state/federal regulations; no concerns identified. On 4.14.25 facility with external consulting company for dietary services to include management oversight, line staff and cooks. On 4.8.25 the facility ordered 6 insulated food delivery carts which were shipped on 4.16.25, and have delivery date of 4.22.25. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On 4.7.25 Director of Nursing completed review of 24-hour report, to ensure sufficient staffing with emphasis on ensuring sufficient staffing to provide timely and appropriate care and services, timely call light response, care, ADL assistance and treating residents with dignity. On 4.11.25 the Director of Social Services completed a quality review of current residents to ensure that residents rights are honored with emphasis treating residents with dignity and respect, communicating in a language that residents can understand, providing shaving assistance to dependent residents, providing water temperatures for bathing/ hygiene at preferred temperatures, and timely response to call lights; any concerns identified were corrected. On 4.9.25 a quality review was completed by Registered Dietician on current residents to ensure provided with nutritive/palatable meal at appropriate temperature per their preference. Any issues identified were corrected. On 4.10.25 Director of Nursing completed an audit review of current residents. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On 4.17.25 Ad Hoc Resident Council meeting held to review survey results and plans being implemented for correction of alleged deficiencies identified. On 4.22.25 the Facility Assessment for The Luxe at Jupiter Rehabilitation Center was reviewed and updated by the Administrator and Facility Leadership team, including Medical Director. On 4.22.25 the Director of Nursing completed education with current staff on the components of F725 sufficient staffing with emphasis on ensuring sufficient staffing to provide timely and appropriate care and services, timely call light response, care, ADL assistance and treating residents with dignity by the Director of Nursing/designee. Newly hired staff will be educated on the components of F725 sufficient staffing with emphasis on ensuring sufficient staffing to provide timely and appropriate care and services, timely call light response, care, ADL assistance and treating residents with dignity by the Assistant Director of Nursing/Designee during orientation as part of the systematic change. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct audits of 5 residents twice a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure compliance with F725 sufficient staffing with emphasis on ensuring sufficient staffing to provide timely and appropriate care and services, timely call light response, care, ADL assistance and treating residents with dignity. The findings of these quality monitorings to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.