Failure to Provide Sufficient Nursing Staff for Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents in a timely manner, as evidenced by multiple observations, interviews, and record reviews. Several residents reported long wait times for assistance, including delays in being transferred out of bed, call light responses, and receiving basic care such as water or showers. One resident, who required a mechanical lift and two-person assistance for transfers, was left in bed during breakfast because there was not enough staff available to help, despite her preference to eat in the dining room. Staff interviews confirmed that when staffing was low, residents requiring more assistance were sometimes left in bed, and priority was given to residents who needed less help. Staff members, including CNAs and LPNs, consistently reported frequent staffing shortages across all shifts, particularly at night and during weekends. They described situations where only one CNA was available per unit, and management did not consistently provide support or cover the floor when call-ins occurred. Staff also reported that management would sometimes instruct them to pass incomplete care tasks, such as dressing changes, to the next shift due to time constraints and insufficient staffing. This led to uncertainty about whether essential care tasks were completed for residents. Resident council minutes and referral forms documented ongoing concerns from residents about long wait times for call lights, delays in receiving showers, and urinals not being emptied at night. The facility census indicated that 73 residents were present at the time of the survey. Multiple staff and resident interviews corroborated that these issues were persistent and affected the quality and timeliness of care provided to all residents in the facility.