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F0725
F

Insufficient Staffing Resulting in Delayed Resident Care

Woodburn, Oregon Survey Completed on 04-28-2025

Penalty

Fine: $84,475
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient nursing staff to meet the care needs of residents across all three halls reviewed, resulting in delayed and unmet care needs. Direct Care Staff Daily Reports showed that the facility did not meet state minimum CNA staffing requirements on multiple dates over two separate periods. The facility assessment indicated ongoing analysis of staffing needs, but records and interviews revealed persistent shortages. Residents requiring assistance with mechanical lifts, two-person ADL support, and eating were affected, and several residents exhibited behaviors that required additional attention. Staff interviews confirmed that high acuity and inadequate staffing made it difficult to complete all required tasks, with CNAs reporting being overworked and unable to respond promptly to resident needs. Observations and interviews documented numerous instances of prolonged call-light response times, with some residents waiting over an hour for assistance. In one case, a call-light was obstructed from view, further delaying response. Family members and residents reported frequent long wait times, particularly in the evenings, and staff were observed to be visibly stressed and hurried. The scheduling coordinator acknowledged reliance on census-based staffing, use of agency and PRN staff, and efforts to fill shifts when staff called off, but the administrator confirmed ongoing staffing shortages and long call-light wait times.

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