Failure to Maintain Adequate Staffing Levels
Penalty
Summary
The facility failed to maintain adequate staffing levels to meet the needs of all residents, as evidenced by multiple resident and staff interviews, observations, and review of staffing records. Several residents and their family members reported delays in receiving care, such as assistance with meals, hygiene, and toileting. One resident's daughter stated she had to come in the mornings to help her mother because staff were unable to provide timely care, including giving dentures and washing hair. Other residents reported long wait times for call light responses, delayed delivery of pain medication, and cold or late meals due to insufficient staff. Observations revealed that non-clinical staff, such as the medical records coordinator, were assigned to pass meal trays, and did not provide necessary assistance with meal setup or communication. Staff interviews confirmed that there was typically only one CNA per hall, which was not sufficient to meet resident needs, especially when residents required two-person assistance for transfers or toileting. Staff reported having to rush through care, leaving residents waiting for assistance, and not having enough time to spend with each resident. Some staff also indicated that additional help was only provided when surveyors were present. Review of staffing assignments and time sheets for multiple days confirmed that the facility routinely operated with minimal staffing, often with only one CNA and one nurse per hall, and sometimes with nurses splitting coverage between halls. The DON stated that she believed staffing was adequate, but staff and residents consistently reported otherwise. The lack of sufficient staff led to delays in care, unmet resident needs, and the use of non-clinical staff for direct resident services.