Insufficient Staffing Leads to Missed Care and Compromised Dignity
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all 110 residents, resulting in missed or delayed care in several key areas. Certified Nursing Assistants (CNAs) reported being unable to complete all required tasks during their shifts, including providing scheduled baths or showers, assisting with transfers that require two staff members, and offering adequate eating assistance to residents who require help with activities of daily living (ADLs). Multiple residents confirmed that they did not receive showers as frequently as scheduled or desired, with some reporting only one or two showers per month instead of the expected two or three per week. Residents also reported long wait times for call lights to be answered and expressed frustration and dissatisfaction with the lack of assistance. Observations during meal times revealed that residents who required substantial or maximal eating assistance were not always helped in a timely manner. Some residents were left to attempt eating on their own, resulting in soiled clothing and incomplete meals, while staff confirmed that there were not enough personnel to assist all residents who needed help during meals. The use of the term "feeders" by staff to refer to residents needing eating assistance was observed and confirmed as common practice, raising concerns about the maintenance of resident dignity. Additionally, residents dependent on the facility for ADLs were observed with uncut and dirty fingernails on multiple occasions, indicating a lack of regular grooming and personal hygiene care. Interviews with staff and residents consistently pointed to inadequate staffing levels as the primary reason for these deficiencies, with staff stating they were "stretched too thin" and unable to provide the level of care required. Facility leadership acknowledged challenges with staffing and documentation but did not provide evidence of effective measures to address the shortfalls at the time of the survey.