Federal inspectors documented response times that stretched far beyond what the facility's own administrator considered acceptable. On June 23, Resident 22 waited a full hour after pressing her call button. The administrator later told inspectors he wanted response times under 15 minutes and "anything longer than 15 minutes would be an issue."
The facility's call light tracking sheets revealed a pattern of dangerous delays. Resident 22, who fractured her hip and needs moderate to maximal assistance with daily activities, regularly waited 20 to 40 minutes for help between June and July. Her longest recorded wait was 60 minutes on June 23 at 8:03 PM.
Resident 25, a stroke survivor with paralysis on one side of her body, faced similar delays. Her care plan specifically required staff to keep her call light within reach because she needed assistance when sitting in her chair. Yet inspectors found she waited up to 49 minutes for help, with multiple instances of 30-to-40-minute delays.
"Sometimes I waited over 30 minutes, pretty much daily, for someone to answer my call light," Resident 35 told inspectors. "Long call light times occurred across all shifts."
The facility struggled with severe staffing shortages that began in January and persisted through the July inspection. Of 62 residents, 23 required two-person mechanical lifts for transfers, 47 needed extensive help with bathing and toileting, and 11 required two-person assistance for all care. Yet the facility consistently operated one to two certified nursing assistants short, especially on weekends.
Multiple complainants contacted state officials between February and June describing the deteriorating conditions. One February complaint alleged residents weren't being toileted timely and basic care wasn't being met due to CNA shortages "for months." Another in April reported residents missing showers and inadequate supervision during meals for those at risk of choking.
Staff members confirmed the crisis during interviews. Three CNAs told inspectors the facility was "consistently short staffed one to two CNAs, especially on the weekends." They reported often skipping breaks and lunches, delaying showers for residents, and being unable to provide proper supervision for residents eating in their rooms.
"Residents who required two person mechanical lift transfers often had to wait a long time," one CNA reported. Another said the facility had "difficulty retaining CNA staff."
Resident 36, who requires two people and a mechanical lift for transfers, told inspectors she was sometimes told there weren't enough staff to move her to her chair.
One witness described the situation as a "dumpster fire since 1/2024." The witness reported staff couldn't provide showers, complete safe two-person transfers, or toilet residents timely, "which resulted in a lack of dignity for the residents." Many staff members quit during this period.
Another witness expressed concern about residents at high risk for aspiration who weren't properly supervised during meals. "She was concerned residents might choke," inspectors noted.
The facility continued admitting new residents despite knowing it couldn't adequately staff CNAs to meet their needs. One witness reported this practice "had the potential to result in injuries to the resident and/or staff."
The administrator acknowledged the crisis when inspectors interviewed him. He "stated he was aware the facility had staffing issues and struggled to maintain adequate staffing levels."
Yet the problems persisted throughout the inspection period. The staffing coordinator confirmed that "from 2/2024 through 7/14/24, CNA staffing was short on many shifts."
The facility's 62 residents included 28 with behavioral healthcare needs requiring monitoring, 14 at high fall risk, and 5 at risk for elopement. Multiple witnesses reported that low staffing led to increased falls because staff couldn't properly monitor residents.
One witness specifically noted that "the facility did not have the right staffing for the level of acuity of the residents."
The chronic understaffing affected basic dignity. Residents waited hours for toileting assistance, missed scheduled showers, and faced extended delays when they needed help. For Resident 22, those delays meant the humiliation of soiling herself while waiting for care that should have come within minutes, not hours.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avamere Rehabilitation of King City from 2024-07-19 including all violations, facility responses, and corrective action plans.
Additional Resources
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