Failure to Provide Sufficient Nursing Staff and Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple reports of long call light wait times, missed showers, and unmet personal care needs. Several residents, all cognitively intact, reported not receiving scheduled showers, experiencing delays in assistance, and being left in situations where their hygiene and dignity were compromised. Documentation confirmed missed showers for multiple residents, and interviews revealed that these issues were linked to both short-staffing and, in some cases, lack of hot water. Staff interviews consistently described inadequate staffing levels across various shifts and units, with frequent unfilled positions and minimal attempts by management to address these gaps. Nurses and CNAs reported that when staffing was low, essential care tasks such as showers were the first to be omitted, and residents often waited extended periods for assistance. Staff also indicated that management rarely assisted on the floor, and that holes in the schedule were common and not proactively filled, sometimes leaving only one CNA on a unit for several hours. The facility's own assessment and staffing policies outlined higher staffing expectations than what was routinely provided, particularly on the River and View Units. Despite these documented standards, actual staffing often fell below the stated requirements, with staff and residents both reporting that care was delayed or omitted as a result. The deficiency was further corroborated by the facility's policies, which require prompt response to call lights and sufficient staffing to meet resident needs, both of which were not consistently met according to the findings.