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.
A resident with severe cognitive impairment, dysphagia, and total dependence for ADLs was brought to the dining room in an open-back hospital gown, leaving the resident exposed, and left sitting alone with a full breakfast tray and no staff assistance for an extended period. Breakfast had been delivered earlier, but no staff were present in the dining area, and the resident, who required full assistance with eating, was not fed until a CNA arrived from another unit and provided feeding without reheating the food. Staff interviews indicated there were not enough personnel or time to dress the resident appropriately before breakfast and that morning medication pass limited nurses’ ability to assist with feeding, despite a facility policy requiring care that maintains resident dignity and privacy.
The facility failed to maintain adequate nursing staff and to respond promptly to resident call lights. Staffing records showed that nurse staffing fell below the facility’s minimum requirement on multiple days, and call light logs documented that dozens of residents had call lights activated for more than 30 minutes before staff responded. Several residents reported routinely waiting over 30 minutes for assistance after activating their call lights. The facility’s own policy requires timely response to call lights by any staff who see or hear them, but this was not consistently followed.
A high fall-risk resident with dementia, prior fractures, and impaired mobility experienced multiple falls, including one with head impact and another causing painful limited ROM, despite a care plan identifying fall risk and interventions such as transfer assistance, nonskid footwear, and dycem on the wheelchair. The resident was found on the floor in the room and hallway on several occasions, sometimes after becoming anxious when family left, and was not assessed post-fall for further injury or vital signs. Staffing schedules showed only three CNAs and two nurses on night shifts for nearly 50 residents, with each nurse covering two hallways and CNAs covering one hallway plus extra rooms. A CNA reported that residents needing increased supervision could not be adequately monitored under the usual staffing pattern, and the family reported difficulty locating staff responsible for the resident’s care due to staff being assigned across multiple hallways.
A facility failed to maintain adequate nursing staff levels, resulting in missed blood sugar checks and insulin administration for a resident with type I diabetes. Due to insufficient staffing and communication breakdowns, the resident was not properly monitored, was later found on the floor with severe hyperglycemia and other critical symptoms, and required transfer to the hospital for multiple acute conditions.
The facility failed to maintain adequate CNA staffing, resulting in only one CNA being available to care for all residents during a critical period. This led to significant delays in call light response, missed showers, and unmet ADL needs for several residents with complex medical conditions. Staff and residents reported long wait times for assistance, episodes of incontinence, and missed activities, with documentation confirming the staffing shortfall and its impact on resident care.
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