Insufficient Nursing Staff and Inaccurate Staffing Assignments
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs and to ensure accurate staffing practices. The facility’s own policy dated 1/15/26 states it will maintain staffing practices consistent with federal regulations, state law, and professional standards while supporting safe and effective care. However, multiple residents reported that the facility was understaffed, resulting in missed showers, inadequate hygiene, and insufficient assistance with mobility and positioning. One resident stated they were not showered before a doctor’s appointment, did not have a buttocks wound dressed, and were left sitting on their buttocks all day. Another resident reported not getting out of bed for months due to lack of staff and not receiving regularly scheduled showers on Tuesdays and Fridays. Additional residents described similar issues related to inadequate staffing. One resident reported that when they get up during the day, there often are not enough staff to put them back to bed. Another resident stated that staff are “plugged into” nurse aide positions but do not provide care or remain on the floors. A resident with Lyme disease, whose skin becomes very itchy, reported receiving only five showers in six weeks despite being scheduled for two per week and stated there were days they were not cleaned up at all. Another resident reported waiting over an hour for staff to obtain a portable oxygen tank so they could leave their room. Staff interviews and staffing records further demonstrated insufficient and inaccurately represented staffing. A nurse aide reported there were not enough staff to turn and reposition residents and that it was hard to find help when two-person assistance was needed. Multiple staff members stated the facility “lies” on the staffing sheet by listing employees who are not actually providing resident care, including a cook and a social worker who were pulled to the floor without nurse aide job descriptions or orientation in their files, and a nurse aide who was scheduled but found folding linens in the laundry instead of providing care. On a shift with a census of 52 residents, an LPN reported having only two, possibly three aides, effectively leaving one aide per hallway. The interim administrator confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for the identified residents.
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