Residents repeatedly reported waiting 30 to 60 minutes for call lights to be answered, including when they needed help getting out of bed, dressing, or using the restroom. Resident council notes documented ongoing concerns about timely response, and one note stated staff were turning off call lights and leaving without addressing issues. The charge nurse for one hall stated she had no CNA help, while the CNA assigned there said she was the only CNA on the hall and could take up to 20 minutes to respond. The DON and ADM stated there was no written policy for staffing or call light response, and both acknowledged that 30 minutes was too long.
Insufficient Nursing Coverage During Required Lunch Breaks: The facility repeatedly had only one nurse on duty on multiple shifts, and that nurse was required to clock out for a 30-minute lunch break even when no other nurse was present to cover the unit. Staff interviews confirmed that nurses were told to take lunch breaks by the DON/Administrator, including overnight shifts, and that the only available coverage at times came from administrative nurses or no nurse at all.
The facility failed to maintain sufficient nursing staff and continuous supervision in a locked memory care unit and on an adjacent station housing residents with dementia and Alzheimer’s disease. Records showed nearly all memory care residents had dementia, yet staffing patterns routinely assigned one CNA and one medication aide to cover both the memory care unit and another station by day, and only one CNA to both areas at night. A family member reported poor night and weekend care and an occasion when no staff were present in the memory care unit. Staff interviews revealed that the med aide frequently left the unit to pass meds on another hall, leaving residents without direct supervision, and that night-shift CNAs were solely responsible for residents on both units. Surveyors observed periods when no staff were present in the memory care unit while multiple residents were in the common area and moving about the hallway. Several CNAs, LVNs, and the ADON acknowledged that there should always be staff in the memory care unit and that staffing was not adequate to meet residents’ supervision needs.
The facility failed to provide sufficient CNA staffing on multiple overnight shifts, leaving the secured memory care unit without a CNA and the building without any CNA coverage for part of the night while only two RNs were on duty. Two residents with severe cognitive impairment, extensive ADL dependence, incontinence, and pressure-ulcer risk had no documented overnight care during these shifts, despite care plans requiring close supervision, two-hour rounding, incontinence care, repositioning, and monitoring for behaviors and medication side effects. Staff interviews confirmed that one NA was the only aide in the building for much of the night, did not enter the secured unit, and could round on residents only once, while RNs did not perform CNA-level care or routine rounding. Multiple CNAs, an LVN, and an RN described frequent understaffing, lack of a dedicated CNA on the secured unit, and absence of a facility policy specifying minimum staffing levels or required actions when staff failed to report.
Insufficient CNA staffing led to a secured unit being left without staff present at times, with CNAs floating off the unit to cover other areas because only 3 aides were working on some day shifts instead of the facility’s expected staffing level. A grievance also reported staff could not be found over the weekend, and interviews with the CNA, LVN, ADON, DON, Administrator, and Treatment Nurse confirmed that short staffing caused delays in care, missed tasks such as showers and toileting, and difficulty supervising residents.
No 24-hour licensed nurse coverage was provided on multiple days, according to PBJ staffing data. Interviews with an LVN, another LVN, the MD, the DON, and the ADM showed differing awareness of the staffing gaps, while the facility policy required licensed nurses and CNAs to be available 24/7 and a licensed nurse to serve as charge nurse on each shift.
Insufficient nursing staff led to missed ADL care, bathing, incontinent care, repositioning, and delayed meds for multiple residents. A resident with CVA and hemiplegia remained soiled, unbathed for days, and reported missed meds, while other residents with high ADL needs had little or no documented bathing and were observed with body odor, urine saturation, and poor hygiene. CNAs and an LVN described impossible workloads, COVID isolation demands, and shifts with too few staff to complete required care, and the facility’s staffing levels were below its own assessment expectations.
Surveyors found that the facility failed to maintain sufficient CNA staffing to meet resident care needs in accordance with its 3.0 PPD facility assessment. Multiple CNAs reported being the only aide on a hall with residents needing two-person assistance, missing showers and baths, finding residents dirty at shift change, and being unable to get some residents out of bed for meals. Staff stated that requests for help from MAs and management were often declined, while the DON and Administrator reported they were not told staff could not complete tasks and asserted staffing needs were met despite having no staffing policy. Review of staffing records showed that direct-care PPD fell below 3.0 on several reviewed days, and full monthly staffing data requested by surveyors was not provided.
Surveyors found that the facility repeatedly staffed shifts with only one direct care worker despite its own assessment requiring at least two, resulting in multiple care failures. A resident with a hip fracture and severe cognitive impairment, care-planned for two-person mechanical lift transfers, was transferred alone by an NA without a lift because no help was available. Another resident with heart failure, kidney disease, and severe cognitive impairment, identified as high fall risk and needing prompt call light response, fell after using the call light for toileting and attempting to ambulate alone when no staff responded. A third resident with colon cancer, muscle weakness, and moderate cognitive impairment experienced numerous falls, including falls that led to rib fractures and hospitalization, while only one direct care staff was on duty. A fourth resident with depression, anxiety, severe cognitive impairment, and incontinence waited about two hours to be changed despite repeated requests to staff, remaining wet, crying, and attempting to remove her clothes before finally receiving assistance. Facility leaders and staff acknowledged chronic short staffing, difficulty hiring, reliance on a single aide on multiple shifts, and that resident care suffered as a result.
The facility did not maintain adequate nursing staff, resulting in missed showers, delayed call light responses, and delayed incontinent care for multiple residents. Staff and residents reported that CNAs were unable to make regular rounds or provide timely assistance due to high resident assignments and ongoing CNA shortages. Grievance records and staffing schedules confirmed repeated understaffing and unresolved complaints about care delays.
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