Insufficient nursing staffing was identified after review of PBJ staffing data and staff interview. The facility had a one-star staffing rating and excessively low weekend staffing for FY Q1 2026, and the Administrator confirmed awareness of the staffing concerns. The deficiency was investigated under a complaint and had the potential to affect all residents in the facility.
Inadequate staffing and delayed call light response: Residents, CNAs, and an LPN reported that staffing was not sufficient to meet resident needs, and call light logs showed repeated response times far beyond the facility’s 15- to 20-minute expectation. A resident with incontinence needs was found with a saturated brief, and multiple residents described prolonged waits for ADL assistance and call light response, while staff reported being assigned across units and unable to complete timely checks, incontinence care, and other care tasks.
The facility failed to maintain adequate nursing staffing and a licensed nurse on each shift to meet resident needs. Residents and families reported slow call light response, missed or delayed incontinence care, and difficulty finding staff, especially on weekends and shift changes. An observed call light remained unanswered for over 30 minutes, and the resident said she had been waiting to be changed after becoming sick. Staffing records showed multiple shifts below the facility’s stated staffing levels, with some shifts having as few as two nurses and five CNAs.
Insufficient nursing staffing led to delayed call light response and resident care delays. Multiple residents and a resident representative reported that staffing was short on all shifts, call lights were not answered timely, and residents waited a long time for toileting, incontinence care, and showers. One resident’s call light was observed unanswered for about 22 minutes, and the resident stated delays sometimes resulted in incontinence and extra linen and clothing changes. A CNA confirmed the facility used agency CNA and nursing staff to help cover staffing needs.
Insufficient staffing was cited after PBJ review and interview showed low weekend staffing and low RN hours, with a one-star staffing rating for the quarter. The facility failed to provide enough nursing staff each day and did not maintain a licensed nurse in charge on each shift, affecting all 81 residents.
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.
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