Widespread Neglect Due to Insufficient Staffing and Missed Care
Penalty
Summary
Surveyors identified multiple deficiencies related to neglect and insufficient care for residents, primarily due to inadequate nursing staff. Observations and interviews revealed that residents did not receive essential care such as showers, assistance with eating, toileting, personal hygiene, skin care, and timely administration of medications. Several residents were observed with unwashed hair, long uncut nails, and soiled clothing for extended periods. One resident was found incontinent for hours, with soiled linens and clothing, and staff were unable to recall when incontinence care was last provided. Staff consistently reported that low staffing levels made it impossible to meet all residents' needs, with some units having only one nurse and one aide for up to 40 residents. Residents with significant care needs, such as those requiring two-person assistance or mechanical lifts, often remained in bed and did not receive adequate care. One resident, who required hand splints to prevent loss of range of motion, was repeatedly observed without them, resulting in actual harm. Another resident developed two new stage two pressure ulcers, with no evidence that a medical provider was notified or treatments initiated until three days after the skin breakdown was identified. Staff interviews confirmed that medication passes were missed or delayed for many residents, with hundreds of residents not receiving multiple significant medications over several days due to lack of available nursing staff. The facility's own policies acknowledged the risk of neglect due to staffing deficiencies and required measures to address residents' needs. Despite this, staff and management interviews confirmed ongoing challenges with maintaining adequate staffing levels, leading to missed care, delayed or omitted medication administration, and insufficient supervision during meals for residents on aspiration precautions. Staff, residents, and family members all reported concerns about the inability to provide necessary care, and documentation supported that these deficiencies resulted in actual harm to residents, though not at the level of immediate jeopardy.