Failure to Ensure Adequate Staffing and Meal Service
Penalty
Summary
The facility failed to administer its operations in a manner that enabled effective and efficient use of resources, specifically regarding staffing and meal service. Multiple interviews and record reviews revealed ongoing issues with insufficient staffing, resulting in long call light wait times, missed showers, and inadequate assistance with transfers and care. Residents reported that aides were overworked, and staff often responded to call lights without returning to provide needed care. Staff interviews confirmed that holes in the schedule frequently went unfilled, with night shifts sometimes staffed by only one or two nurses for the entire building, including high-acuity units. Staff were reportedly discouraged from contacting the DON about staffing concerns, and showers were often not completed when staffing was low. Additionally, the facility failed to provide adequate meal service, with residents and staff reporting small portion sizes, unrecognizable or inedible food, and inconsistencies between the posted menu and actual meals served. There were instances where basic food items, such as bread and syrup, were unavailable, and dietary supplements were not consistently provided. Both residents and the Ombudsman reported that these concerns had been communicated to management, but no improvements were observed. The administration acknowledged awareness of these issues but did not implement effective corrective interventions, resulting in ongoing deficiencies impacting all residents.