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F0725
D

Insufficient Nursing Staff Resulting in Delayed Resident Care

Oskaloosa, Iowa Survey Completed on 06-26-2025

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 its residents, as evidenced by multiple reports from residents and staff, as well as documentation review. One resident with intact cognition and multiple diagnoses, including heart failure and PTSD, required partial to moderate assistance with bathing and personal hygiene. This resident reported not consistently receiving scheduled showers twice per week, with some showers offered as late as 10:00 PM, leading to refusals due to the late hour. Bathing records confirmed refusals due to lateness, and a CNA corroborated that staffing shortages, especially on certain shifts, resulted in delayed care. Observations during interviews noted the resident's unkempt appearance, further supporting the deficiency. Additional residents with extensive care needs, including assistance with toileting and transfers, reported excessive wait times for staff response to call lights, sometimes up to an hour or more, particularly after meals and during evening hours. Staff interviews confirmed that weekend staffing was especially inadequate, with as few as 2-3 CNAs available, making it difficult to complete resident care tasks in a timely manner. Facility records and staffing data indicated a pattern of low staffing, particularly on weekends, and the Assistant Director of Nursing acknowledged ongoing staffing challenges over the past five years.

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