ALBEMARLE, NC - Federal inspectors found that Forrest Oakes Healthcare Center operated evening and overnight shifts with as few as one nursing assistant responsible for more than 50 residents on multiple occasions in January and February 2025, resulting in failures to provide basic hygiene and incontinence care for residents who depended entirely on staff assistance.
Single Aide Staffed Shifts for Weeks
A complaint-driven inspection completed on February 6, 2025 revealed a pattern of critically low staffing during afternoon and evening hours at the 54-resident facility on Heathwood Drive.
Record reviews of staff assignments and time cards documented the scope of the problem:
- January 12: One nursing assistant covered resident care from 3:40 PM to 7:00 PM for 50 residents - January 27: One nursing assistant from 4:00 PM to 7:00 PM for 52 residents - January 30: No nursing assistant at all from 4:00 PM to 7:00 PM, and one aide from 7:00 PM to 11:00 PM for 54 residents - January 31: One nursing assistant covered a full 16-hour stretch from 4:00 PM through 7:00 AM for 54 residents - February 1 and 2: One nursing assistant from 3:00 PM to 7:00 PM for 54 residents
Inspectors cited the facility under F-Tag 677 for failing to provide nail care and incontinence care to 8 of 13 residents who were fully dependent on staff for activities of daily living. A separate citation under F-Tag 725 addressed the insufficient staffing levels that drove those care failures.
What Understaffing Meant for Residents
When a single aide is assigned to more than 50 residents, the math alone makes adequate care impossible. Incontinence care standards call for residents to be checked and changed at minimum every two hours. With one aide and 54 residents, each person would receive roughly two minutes of attention per round — far below the time required for proper repositioning, cleaning, barrier cream application, and brief changes.
Prolonged exposure to moisture from unchanged incontinence briefs is a well-established risk factor for pressure injuries, skin breakdown, and urinary tract infections. For elderly residents with fragile skin and compromised immune systems, these are not minor inconveniences — they are conditions that can lead to hospitalization and serious medical complications.
Nail care, while less urgent, also carries medical significance. Untrimmed or improperly maintained nails can cause skin tears, harbor bacteria, and contribute to infection risk, particularly for residents with diabetes or peripheral vascular disease.
Staff Descriptions of Conditions
Interviews with nursing staff painted a consistent picture of a facility operating without a safety net.
A nursing assistant who typically worked overnight told inspectors she had to care for the entire building alone two to three times per week. She stated plainly that it was "not possible to keep every person dry" while working solo and that routine rounds every two hours could not be maintained. She concluded: "You just can't operate a building like that."
A nine-year veteran nursing assistant reported that she had "never seen staffing as bad as it was over the past three to four months." She described arriving for 11:00 PM shifts to find no aides in the building at all, then working overnight alone with a single nurse and a medication aide.
A nurse who had transitioned from day shift to nights — and eventually reduced to as-needed status — told inspectors she made the change because she was "overwhelmed on day shift due to not having enough nursing assistants." She described nights when no aide was present until 11:00 PM, meaning residents received incontinence care and were assisted to bed far later than appropriate. She noted the facility had no contingency plan for when an aide did not report to work.
Corporate Denied Staffing Requests
The facility's Director of Nursing acknowledged the staffing numbers were accurate and confirmed that the situation made it impossible to complete all required care tasks. She told inspectors she had requested permission to bring in agency staff and to offer bonuses to employees who picked up extra shifts.
Both requests required corporate approval. Corporate did not authorize the use of agency staff. The DON stated that qualified department heads would step in to help feed residents and provide incontinence care during shortages, but this stopgap measure was clearly insufficient given the scope of the documented failures.
Industry Standards and Expectations
Federal regulations under 42 CFR §483.35 require nursing homes to maintain "sufficient nursing staff" to provide care consistent with each resident's care plan. While no fixed federal ratio exists for nursing assistant-to-resident staffing, industry benchmarks generally recommend no fewer than one aide per 8 to 10 residents during evening shifts.
Forrest Oakes was operating at ratios of 1:50 or worse — five to six times beyond what most staffing guidelines consider safe. On January 30, the facility operated with zero aides for a three-hour window during a time when residents typically need assistance with dinner, toileting, and preparation for bed.
The facility was required to submit a plan of correction to the North Carolina Division of Health Service Regulation. Readers can view the complete inspection report, including all cited deficiencies and the facility's response, on the [full inspection detail page](/facility/forrest-oakes-healthcare-center-albemarle-nc-345442).
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Forrest Oakes Healthcare Center from 2025-02-06 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.