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F0725
E

Insufficient Staffing for Resident Care and Meal Assistance

Lutz, Florida Survey Completed on 06-19-2025

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 needs of residents, particularly in assisting with activities of daily living (ADLs) and meal assistance. Multiple interviews with residents, family members, and staff revealed that residents were not receiving adequate supervision or help with walking and meal times. One resident reported becoming weaker and losing endurance after being discharged from therapy, as no staff were available to supervise walking except during family visits. Staff members acknowledged that there were not enough CNAs to complete all required tasks, including range of motion exercises and walking assistance, and that the restorative program was not operational due to lack of oversight. Observations over several days showed family members and even other residents stepping in to assist with meals and coffee service in the dining area, indicating a lack of available staff during critical times. Family members expressed frustration at having to help with basic care tasks, and staff confirmed that families regularly assisted with meals due to insufficient staffing. Staff also described challenges in completing their work, especially during meal times, and noted that the number of residents needing assistance exceeded the available staff capacity. Interviews with facility leadership, including the staffing coordinator, DON, and administrator, revealed a lack of awareness or acknowledgment of staffing concerns, despite direct evidence from staff and families. The staffing coordinator based assignments on census and was unaware of specific needs during meal times, while the DON and administrator did not recognize any issues with staff coverage or the expectation for families to assist. Additionally, the facility was unable to provide a requested staffing policy and procedure.

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