Failure to Provide Sufficient Nursing Staff for Resident Care
Penalty
Summary
Surveyors identified that the facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in multiple instances where residents did not receive timely incontinence care and assistance with activities of daily living. Several residents with significant medical conditions, such as hemiplegia, aphasia, visual loss, and dementia, were observed or reported to have waited extended periods—sometimes several hours—before being checked or changed. In one case, a resident's call light was activated for over 28 minutes before staff responded, and the resident was found sitting in a wet brief with a strong odor of urine. Another resident reported not being changed since early morning, resulting in a saturated brief and wet bedding, with staff confirming that due to staffing shortages, residents were sometimes only checked and changed twice in a 12-hour shift. Additional observations and interviews revealed that residents were left in soiled conditions for prolonged periods, with one resident found with dried stool and urine, deep red and sensitive skin, and soiled bedding. Family members of a former resident reported having to change their loved one themselves after staff failed to respond to repeated requests for assistance over several hours, and provided photographic evidence of saturated bedding and briefs. Staff interviews consistently indicated that there were not enough CNAs and nurses to provide timely care, with some residents only receiving incontinence care once or twice per shift, and showers often being replaced with bed baths due to lack of staff. The facility's own assessment documented the need for a specific number of licensed nurses and CNAs per shift to meet resident acuity needs, but interviews and observations confirmed that these staffing levels were not consistently met. Staff reported being unable to complete daily care tasks, and residents who were dependent on staff for mobility, hygiene, and toileting were not assisted in a timely manner. The deficiency affected multiple current and former residents and had the potential to impact the majority of the facility's population.