Failure to Provide Timely and Adequate ADL Assistance Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for three residents who required significant staff support. Multiple staff interviews revealed that only one CNA was typically assigned per building or villa, with additional help from nurses or floating aides only when available. Staff reported frequent delays in providing care, especially for residents needing two-person assistance or mechanical lifts, as the CNA often had to wait for another staff member to become available. CNAs were also responsible for a wide range of non-care duties, including meal preparation, serving, cleaning, and laundry, which further limited their ability to provide timely and complete resident care. Resident 3, who had multiple medical conditions including diabetes, chronic respiratory failure, and cognitive impairment, required maximal staff assistance for transfers, bed mobility, personal hygiene, and bathing. Observations showed that this resident repeatedly requested help getting out of bed and with personal care, but was told by the CNA that she was too busy with other tasks. Documentation indicated that the resident missed several scheduled showers and hair washes, and there was no record of refusal. The resident was observed remaining in bed, unkempt, and in the same gown over multiple days. Resident 41, diagnosed with Alzheimer's disease, Parkinson's disease, and other chronic conditions, also required substantial or maximum assistance for ADLs. Family members reported not seeing staff for extended periods, and records showed the resident did not have her hair washed for two months. The resident was observed in bed with a strong urine and body odor, and the CNA had to change urine-soaked bedding and clothing. Resident 10, with dementia and other significant health issues, was also found to have missed scheduled showers and received only a partial bath on one occasion, with no other bathing documented for two months. These findings demonstrate a pattern of insufficient staffing and unmet care needs for residents requiring assistance with ADLs.