Insufficient Nursing Staff Across Multiple Units
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents across nine of ten units, as evidenced by staff and resident interviews, direct observations, and census counts. On multiple units, there were only two nurse aides present for nearly 50 residents, and in some cases, aides were pulled from one unit to another, leaving units understaffed. Staff members, including unit managers and agency nurses, confirmed that staffing was inadequate, with administrative staff and supervisors often stepping in to cover shifts or pass medications. There were also instances where nurse aides reported being the only aide on the floor after certain times, and some units started shifts with only one or one and a half aides for dozens of residents. Residents reported delays in receiving medications, and staff described frequent occurrences of working without a nurse present on the unit, requiring nurses from other floors or office staff to administer medications. Agency staff turnover and restrictions on agency use further contributed to staffing challenges. The Director of Nursing and Nursing Home Administrator acknowledged ongoing staffing difficulties, confirming that the facility did not have enough nursing staff to provide necessary care and services to maintain residents' highest practicable well-being.