Failure to Provide Sufficient Direct Care Staff
Penalty
Summary
The facility failed to provide sufficient direct care staff to meet the needs of all residents, as evidenced by multiple observations, interviews, and record reviews. On one occasion, no CNA was assigned to residents in rooms on the east and northeast unit, affecting thirteen residents. Staff assignments changed multiple times during the morning, and staff who were not scheduled for direct care, such as a restorative aide and a dialysis transporter, were reassigned to cover care duties. Staff reported frequent assignment changes, lack of clear assignments at the start of shifts, and high resident-to-CNA ratios, with some CNAs responsible for 17 or more residents. The staff scheduler confirmed that staffing is based on census and budget, but could not explain the lack of coverage or frequent assignment changes. Several residents reported not receiving showers or complete bed baths since admission or return from the hospital, with some stating they had to wait extended periods for assistance with toileting and hygiene. One resident was observed with a brown substance under their fingernails and a pile of dirty linens in their room, and both the resident and their family member reported long wait times for staff response and no improvement after concerns were raised. Other residents described similar experiences, including waiting up to an hour for call lights to be answered and attempting to perform self-care due to lack of staff assistance. Resident assessments indicated that those affected required substantial to total assistance with bathing, toileting, and personal hygiene. Staff interviews corroborated the residents' accounts, with CNAs stating that high resident assignments made it impossible to complete all required care tasks, including showers, incontinence care, and timely response to call lights. The lack of consistent and adequate staffing directly resulted in unmet care needs for multiple residents across different units.