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F0725
E

Insufficient Nursing Staff Resulting in Missed Care

Grants Pass, Oregon Survey Completed on 05-01-2025

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 sufficient nursing staff to meet the care needs of all residents, resulting in missed and delayed incontinent care and resident showers for six sampled residents. Resident Council notes from January and March 2025 documented ongoing concerns about short staffing and unmet care needs, including missed scheduled showers. Review of shower records and staff documentation showed that multiple residents did not receive their scheduled showers, with reasons cited such as environmental limitations, refusals, or marked as not applicable. One resident's records indicated missed showers on two separate occasions. Interviews with residents and staff confirmed that staffing shortages were persistent, leading to untimely responses to call lights, missed showers, and delayed incontinent care. Several CNAs and licensed nurses reported being unable to meet care plan needs, with some residents found soaked in urine and not assisted out of bed. Staff consistently described the staffing situation as inadequate and chaotic, and facility leadership acknowledged the shortfall in CNA staffing and the resulting missed care for the identified residents.

See complete original report
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