F0725

E

Failure to Provide Adequate Nursing Staff, Timely Call-Light Response, and Hydration Care

Napa, California Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate nursing staff and services to meet residents’ hydration, skin care, toileting, and safety needs, despite care plans and policies requiring such care. Multiple residents with intact cognition and documented risks for dehydration, skin breakdown, and falls reported that water was not refreshed regularly and that they had to wait extended periods for call lights to be answered, particularly on night and swing shifts. Care plans for several residents required staff to encourage fluids, offer fluids between meals and at snack times, provide additional fluids during activities, and keep water within reach, as well as to monitor for incontinence and provide pericare after each incontinent episode, but observations and interviews showed these expectations were not consistently met.

One resident with acute on chronic heart failure, end stage renal disease, and diabetes, who had a care plan for dehydration risk and skin breakdown, stated that her water was from the previous evening, was room temperature, and that she had to ask staff for fresh water. She reported needing assistance with toileting and that call lights, especially at night, took about 30 minutes to be answered, resulting in her sitting in her own bowel movement long enough for it to burn her skin and cause pain. Another resident with cholecystitis, cystitis, and hemiplegia, who was care planned for dehydration, skin breakdown, and falls, reported that on swing shift his call light had once been answered an hour after activation when he had an incontinent bowel movement, and that similar events had occurred two or three additional times in recent months. He described his skin turning red and his groin burning, and his water bottle was observed nearly full but placed out of his reach, requiring him to call a CNA for help.

A third resident with metabolic encephalopathy, care planned for dehydration, skin breakdown, and falls, reported being dependent on staff for brief changes and stated she removed her own brief when soiled because staff took too long to respond to call lights, estimating a 15‑minute wait, which she felt was too long when needing a bowel movement. At her bedside, one water bottle was empty and another contained only a small amount of room‑temperature water, which she stated was from the previous evening, and she reported that residents only received additional water if they asked. A fourth resident with hemiplegia, care planned for dehydration, bowel incontinence, and skin breakdown, stated his water bottle was only changed and filled once per day, that the water present had been brought the previous night, and that he would not drink it when it was warm because it tasted bad. He reported that staff sometimes took up to an hour to answer call lights, especially on the graveyard shift, and that he had to sit in his own bowel movement and urine on several occasions, too many times to count.

Additional evidence of inadequate staffing and delayed response to resident needs was documented through Resident Council minutes and direct observation. Resident Council minutes over several months reflected repeated resident concerns about CNAs, including CNAs going into rooms to sleep or charge phones, questions about when facility CNAs would replace registry staff, reports that night shift CNAs did not answer call lights, and repeated requests to hire more CNAs and to have CNAs available to help. During one observation, a surveyor heard a call light sounding and saw the corresponding light illuminated above a resident’s doorway; one staff member entered the doorway only to take gloves and left without entering the room or addressing the resident’s need, and multiple staff walked past without checking on the resident. The call light remained on for 20 minutes before a staff member finally responded. Interviews with CNA staff and the DON confirmed that residents should have water refreshed every shift, fluids offered with each care intervention, and call lights answered quickly, and that leaving residents in soiled briefs was unacceptable, while the Administrator in Training confirmed there were no staffing waivers on file, despite the facility’s policy stating it would maintain adequate staffing on each shift to meet residents’ needs.