Failure to Provide Consistent Quality Care Due to Staffing and Supply Issues
Penalty
Summary
The facility failed to provide consistent quality care and treatment according to physician orders, resident preferences, and goals for five of eight residents reviewed. Multiple residents and their family members reported significant delays in call light responses, missed scheduled showers, and incomplete two-hour checks. Facility records, including grievance logs and resident council minutes from March to May 2025, documented ongoing concerns about inadequate staffing, particularly the use of agency CNAs who did not complete assigned tasks, were frequently absent, or displayed unprofessional behavior such as using phones while on duty and being loud at night. Several residents with complex medical needs, including those with hemiplegia, COPD, diabetes, heart failure, and those on anticoagulant therapy, experienced lapses in care. For example, one resident was unable to find staff to assist with bedtime care, leading her daughter to intervene and search the facility, only to find staff unavailable or sleeping. Other residents reported waiting over 30 minutes for call lights to be answered, and delays in receiving essential blood work due to the facility lacking necessary PT/INR testing supplies. These delays resulted in late administration of critical lab tests and medication adjustments for residents on blood thinners. Staff interviews confirmed the issues, with LPNs and the DON acknowledging problems with agency staff reliability and accountability, as well as the impact on resident care quality. The DON confirmed ongoing complaints about missed showers, delayed call light responses, and incomplete care tasks. The facility assessment stated that supplies and equipment would be provided in a timely manner, but this was not consistently achieved, as evidenced by the lack of PT/INR test strips and the need to send blood samples to an outside lab, causing further delays in care.