Insufficient staffing and lack of consistent nurse leadership affected resident care needs. Surveyors found no DON or ADON present, and staffing schedules showed limited CNA coverage on some units despite many residents needing mechanical lifts, incontinence care, feeding assistance, and showers. Residents were observed or reported to be left in bed for meals, waiting too long for toileting help, and having soiled briefs, skin irritation, and missed bathing care. Staff and family members described frequent agency use, call-offs, and difficulty completing routine care when only two CNAs were assigned to a unit.
Insufficient nursing staffing led to delayed resident care, including slow call light response and delayed incontinence care. The facility had below-expected CNA, LPN, and RN coverage on multiple shifts, with the DON repeatedly working as a floor nurse to fill gaps. A resident was observed with stool on the skin, a strong odor, and delayed changing, while staff and other residents reported short staffing, unanswered call lights, and delays in trays, showers, and care.
The facility failed to provide enough nursing staff to meet resident needs and to maintain licensed nurse coverage on each shift. Residents and staff reported delayed call light response, late or incorrect medications, incomplete care such as showers and incontinence care, and difficulty getting timely follow-up. The ADON and other management staff were covering multiple roles and working the floor due to shortages, while infection control tracking and concern logging were not being maintained.
Insufficient staffing led to delayed resident care, including missed or postponed showers, delayed transfers, and long waits for call light response. A resident missed a shower because staff were too busy, another resident who needed shower assistance was told there were too many other showers to complete, and staff said there were not enough aides on the unit to meet needs. Observations also showed residents waiting over an hour for help getting out of bed or into bed, while another resident reported waiting hours for incontinence care and call lights to be answered.
Insufficient staffing led to delayed meal service and missed resident care. A resident was observed with a saturated brief and liner with a strong urine odor after not being toileted for quite some time, while the DON stated the facility was understaffed and resident care was being missed. The Administrator confirmed meals were not being served on time, and staffing records showed direct care staffing fell below the minimum requirement on two days.
The facility failed to provide enough nursing staff to meet resident needs, resulting in prolonged call light response times and unsafe use of mechanical lifts. Multiple residents reported that call lights often went unanswered for 30 minutes to over two hours, care felt rushed, and medications, including evening doses, were given late, especially on night shift. A resident on airborne precautions for COVID-19 had her call light activated for over 25 minutes while staff walked past without responding. Surveyors also observed a CNA performing a mechanical lift transfer alone, while residents reported that lifts were routinely operated by only one staff member because only one aide was assigned to the hall. In another case, a resident requesting incontinence care had her call light deactivated twice by non-nursing staff without the need being addressed or communicated, resulting in a delay of about 34 minutes before care was provided.
The facility failed to maintain sufficient nursing staff and clear staffing plans, resulting in delayed call light responses, missed ADL care, and incomplete treatments for multiple residents. Residents and families reported long waits for assistance, especially at night and on weekends, with some residents lying in urine for hours, not receiving scheduled showers, and being left without proper bedding or repositioning. Staff confirmed that halls were sometimes staffed with only one CNA despite several residents requiring mechanical lifts, and that lifts were at times performed by a single staff member contrary to policy. Nurses described heavy treatment loads across multiple halls, leading to missed wound care and, in some cases, documentation that treatments were completed when they were not. One resident with complex wounds did not receive ordered daily leg dressings, another dependent resident was bathed only twice in 18 days, and a resident with a urinary catheter continued to have catheter care documented after the catheter had been removed by a urologist, with later orders to remove the catheter not carried out promptly. High staff turnover and miscommunication contributed to these care and documentation failures.
The facility failed to maintain sufficient nursing staff to meet residents’ care needs, resulting in prolonged call light response times and missed ADL care, including bathing and toileting. On survey entry, staffing levels were significantly below the facility’s own assessment and staffing plan. Several residents reported waiting from 30 minutes up to two hours for call lights to be answered, remaining on bedpans for extended periods, becoming incontinent while waiting for assistance to the bathroom, and rarely being transferred into wheelchairs due to lack of staff. Staff described chronic understaffing, difficulty completing expected showers, and being told not to shower residents requiring mechanical lifts due to time constraints. Record reviews showed multiple residents with complex medical conditions and documented needs for assistance with bathing and hygiene who received far fewer showers than scheduled, with refusals not followed by documented interventions. Call light audits confirmed numerous response times over 30 minutes, some exceeding two hours, consistent with resident and staff reports of inadequate staffing.
The facility failed to provide adequate nursing staff to meet residents’ needs in a timely manner, resulting in prolonged waits for assistance with meals, toileting, and call light responses. Multiple residents and a family member reported delayed call light response, lack of timely help with ambulation and incontinence care, and concerns about safety. Surveyors observed several residents waiting extended periods between breakfast tray delivery and staff assistance, with food left uncovered and no offers to reheat or provide alternatives, while only two CNAs assisted about 13 residents in the dining room. Staff interviews confirmed that CNAs had to finish serving other residents before helping those needing feeding assistance, causing breakfast to be served much later than residents preferred. During meal periods, most CNAs were pulled into the dining room, leaving one CNA to monitor the hall, respond to call lights, and feed a resident, which led to call lights remaining unanswered for over 20 minutes and residents waiting in soiled briefs or in the bathroom without timely help.
The facility failed to maintain continuous licensed nurse coverage and adequate CNA staffing, resulting in periods when no nurse was present in the building and routine delays in care. On one afternoon, all nurses left the building, leaving dozens of residents without access to a nurse while they requested medications and IV care. Multiple CNAs, LPNs, and residents reported chronic understaffing, especially on nights, with only one CNA per hall and two nurses and two CNAs for nearly 70 residents, causing late medications, delayed incontinence care, missed showers, prolonged call-light response times, and residents remaining in bed or on the toilet for extended periods. Residents also described inadequate supervision, including confused residents wandering into rooms, and a resident with a PICC line reported walking the halls with IV tubing hanging from her arm without finding a nurse. The admission agreement promised 24-hour nursing care and assistance with ADLs, but the facility assessment did not specify needed licensed nurse numbers or detailed recruitment and contingency plans, despite acknowledged staffing chaos and high-acuity residents requiring intensive supervision and assistance.
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