Failure to Provide Sufficient Nursing Staff and Activities
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate skill sets and competencies to meet the needs of multiple residents, resulting in unmet activities of daily living (ADL), lack of personal hygiene, and insufficient engagement in activities. Several residents with severe cognitive impairments, including dementia and Alzheimer's disease, were observed to be dependent on staff for all ADLs. Observations revealed that residents were left in unkempt conditions, such as uncombed hair, wrinkled or soiled clothing, and food debris on their faces and wheelchairs. Residents were also left unattended in the activity room for extended periods without staff interaction or access to drinks and snacks, and scheduled activities were not provided as outlined in their care plans. Certified Nurse's Aides (CNAs) and other staff consistently reported that there were not enough CNAs on shift to complete all required resident care, especially given that over half of the residents required two-person assistance for transfers. Staff stated that the lack of adequate staffing led to delays in morning personal hygiene, cold meals, and incomplete care. Activity staff were also absent, and replacement coverage was not observed, resulting in residents missing scheduled activities and spiritual support. Staff interviews indicated that activities were outdated and not tailored to residents' current needs, and administrative staff were not seen assisting with resident care. Administrative staff acknowledged the high acuity of the resident population and the need for two-person transfers for many residents but maintained that staffing was appropriate. However, they also admitted that the activity calendar was rarely updated and did not meet all residents' needs. The facility's own policy required sufficient nursing staff to ensure resident safety and well-being, but observations and staff interviews demonstrated that this standard was not met, leading to deficiencies in resident dignity, care, and quality of life.