Failure to Provide Timely ADL Assistance Due to Inadequate Staffing
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs) for multiple residents who were dependent on staff for meal service, toileting, bathing, dressing, and getting out of bed. Direct observations revealed that several residents remained in bed for extended periods, were left in soiled briefs, and did not receive timely assistance with meals or personal hygiene. For example, one resident was observed lying in bed for hours with her upper torso slumped, surrounded by paper debris, and later found sitting in a wheelchair with an untouched breakfast tray out of reach. Another resident reported not being assisted out of bed or having his brief changed by the morning shift, remaining wet for several hours, and staff confirmed delays in care. Additional observations included residents left in urine-soaked briefs, missing scheduled baths, and having cold or untouched meals placed out of reach. Some residents expressed frustration about waiting for care, especially on weekends when staffing was lower. Staff interviews corroborated these findings, with CNAs and nurses reporting that low staffing levels made it impossible to provide timely care to all residents, particularly those requiring extensive assistance or mechanical lifts. Staff also described working without breaks and being unable to get all residents out of bed or fed in a timely manner. Facility records indicated that a significant proportion of residents required assistance with feeding and toileting, yet staffing levels were insufficient to meet these needs. Staff interviews and confidential employee statements highlighted issues such as unreported call-offs, reduced CNA hours, and lack of management support during low staffing periods. The facility's own policy required care and services to be provided in a manner that maintains residents' highest practicable well-being, but observations and interviews demonstrated consistent failures to meet these standards for a substantial number of residents.