NIAGARA FALLS, NY - A federal inspection at Elderwood at Wheatfield revealed a severe staffing crisis that compromised basic resident care, with multiple instances of residents waiting hours for assistance and going weeks without scheduled showers.
Chronic Staffing Shortages Documented
The August 2024 federal inspection found that Elderwood at Wheatfield consistently failed to meet its own minimum staffing requirements between July 8 and August 14, 2024. The facility's master staffing plan required specific numbers of certified nurse aides (CNAs) and nurses for each shift, but documentation showed shortfalls on eight separate dates.
The facility's policy required one nurse and two CNAs for day and evening shifts (6 AM-2 PM and 2 PM-10 PM), and one nurse with one CNA for night shifts (10 PM-6 AM). However, staffing records showed they were consistently short by 0.5 to 1 CNA across multiple shifts.
During interviews, the Director of Nursing acknowledged they were aware of not meeting minimum staffing levels and had personally worked supervisor shifts when nurses were unavailable. The Administrator stated they expected staff to work as a team, with nurses and therapists assisting with resident care to compensate for shortages.
Residents Report Delayed Care and Missed Services
Multiple residents documented significant delays in receiving basic care. One resident reported waiting up to an hour for pain medication on some nights due to insufficient staffing. Another resident was found still in bed at 10:13 AM, stating they had to eat breakfast in bed 1-2 times per week because staff couldn't get them up on time.
Certified Nurse Aide #19 explained the reality of working with inadequate staffing: "Today the unit had a census of 40, therefore they had 20 residents on their assignment. There was not enough staff to provide all the care necessary according to the resident's care plans such as showers, incontinent care, getting residents out of bed according to their preferences and toileting."
The aide reported that residents often waited up to an hour for toileting assistance and sometimes became incontinent while waiting for care.
Hygiene and Personal Care Compromised
Perhaps most concerning were the documented instances of compromised hygiene and personal care. Resident #82 was observed being transferred from bed with a brief "saturated with urine and feces oozing out of the edges," with bed sheets also soaked. The CNA stated this was the first time they had been able to provide care to the resident since starting their 6 AM shift due to short staffing.
Multiple residents reported missing their scheduled showers due to staffing shortages. Resident #55's family member stated "it had been three weeks since the resident had a shower." Resident #1's healthcare proxy reported the resident "did not receive their showers as scheduled and sometimes they did not get a shower for a week or longer because there was not enough staff."
Staff Acknowledge Inability to Provide Adequate Care
Licensed Practical Nurse #9 told inspectors they "felt that the residents were being unintentionally neglected because of the lack of staff." Multiple CNAs reported they could not complete all their assigned tasks and had to prioritize incontinence care over showers when working alone.
Certified Nurse Aide #18 stated nurses told staff "to do their best to keep the residents dry and fed" when staffing was insufficient. Another aide reported having to choose between providing care and completing required documentation.
The Acting Unit Manager/Assistant Director of Nursing acknowledged that "2 nurses and 2 certified nursing assistants for Unit 2 was not enough staff to provide adequate care to all residents due to the high acuity of the unit."
Medical Implications of Inadequate Care
Prolonged delays in personal care create serious health risks for nursing home residents. When residents remain in soiled conditions for extended periods, they face increased risk of skin breakdown, urinary tract infections, and pressure ulcers. The elderly population in nursing homes often has compromised immune systems, making them particularly vulnerable to infections that can result from poor hygiene practices.
Regular bathing and personal hygiene are essential components of infection control protocols. When showers are missed for weeks at a time, residents may develop skin conditions, experience dignity issues, and face increased risk of healthcare-associated infections.
Delayed response to toileting needs can lead to falls as residents attempt to reach bathrooms independently, urinary tract infections from prolonged exposure to waste, and psychological distress from loss of dignity and autonomy.
Industry Standards and Regulatory Requirements
Federal regulations require nursing homes to provide sufficient staffing to ensure residents receive care and services to maintain their highest level of physical, mental, and psychosocial well-being. The facility's own assessment determined minimum staffing levels needed to meet resident needs, yet they consistently failed to meet these self-determined standards.
Standard nursing home protocols require residents to receive assistance with activities of daily living according to their individualized care plans. This includes scheduled bathing, toileting assistance within reasonable timeframes, and positioning changes to prevent complications.
Facility Response and Attempted Solutions
The facility had developed a policy requiring nurses to assist with resident care when only two aides were scheduled, but the Director of Nursing admitted they had not verified whether nurses were actually providing this assistance. They acknowledged receiving complaints from families and residents about delayed responses to requests.
Staff reported the facility offered $100 bonuses for staying late and was working to cross-train employees from other departments to help during shortages. However, Activities Aide #1 reported they "often couldn't do activities with the residents because they were busy helping the Certified Nurse Aides."
Resident Council Concerns
Resident Council minutes from June 2024 documented that four of 10 residents attending a meeting reported concerns about "late get ups," specifically noting they "had not been gotten up until after lunch." The Director of Nursing responded by promising to reinforce early get-up procedures with staff and unit managers.
During council interviews, residents reported that low staffing caused staff to "ignore residents and shut off call lights and say they would be right back, but staff did not return."
Ongoing Impact
The staffing crisis affected all aspects of resident care, from basic hygiene to medication administration to social activities. Family members reported having to assist with meals because there weren't enough staff members available.
One family member described the situation as "not intentional, but it was neglect due to insufficient numbers," acknowledging that while staff members were well-intentioned, the systemic understaffing created conditions where residents' needs could not be met adequately.
The inspection findings highlight the critical importance of adequate staffing in nursing homes and the direct impact that staffing shortages have on resident quality of life and safety. The facility received a citation for failing to ensure residents could make choices about important aspects of their lives, as inadequate staffing prevented residents from receiving care according to their preferences and care plans.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Elderwood At Wheatfield from 2024-08-14 including all violations, facility responses, and corrective action plans.
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