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F0725
D

Inadequate Night Shift Staffing Led to Delayed Resident Care

Los Angeles, California Survey Completed on 05-09-2025

Penalty

No penalty information released
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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 adequate nursing staff during the night shift on two consecutive days, resulting in a resident not receiving timely assistance with personal hygiene needs. The resident, who was admitted with muscle weakness, difficulty walking, and a high risk for falls, was dependent on staff for toileting and other activities of daily living. On the nights in question, only two CNAs were present to care for 48 residents after two scheduled CNAs called in sick and were not replaced. As a result, the resident had to wait for hours after activating the call bell before receiving help to change her pull-ups, leading to distress and dissatisfaction. The resident reported feeling annoyed and angry due to the long wait times for assistance. The facility's staffing policy requires sufficient numbers of staff to meet residents' needs according to their care plans, but this was not met on the nights in question. The Director of Staff Development acknowledged that the reduced staffing negatively affected the quality of care and contributed to staff burnout. The deficiency directly impacted the resident's psychosocial and physical well-being, as timely care was not provided.

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