ALBEMARLE, NC - A February 2025 inspection at Forrest Oakes Healthcare Center documented chronic understaffing that left vulnerable residents without adequate care, including instances where a single nursing assistant was responsible for more than 50 residents during evening shifts.
Severe Staffing Crisis Compromised Basic Resident Care
The inspection at the 54-bed facility revealed a pattern of dangerous staffing shortages throughout January and early February 2025. Documentation showed multiple shifts where only one nursing assistant (NA) provided care for the entire resident population, creating conditions that staff members described as impossible to manage safely.
On January 30th, no nursing assistant was present on the floor from 4:00 PM to 7:00 PM, leaving 54 residents without direct care staff during the critical dinner and evening care period. The following evening, January 31st, a single NA worked continuously from 4:00 PM through 7:00 AM the next morning—a 15-hour shift covering 54 residents alone.
The staffing crisis extended over multiple weeks. Records documented similar conditions on January 12th, 27th, and throughout early February, with single nursing assistants regularly assigned responsibility for 50-54 residents during evening shifts from 3:00 PM or 4:00 PM until 7:00 PM or later.
Nursing Assistant #8, who worked the overnight shift, told inspectors she "had to work the whole building by herself two to three times a week." She stated directly that it was not possible to keep residents dry when working alone or to conduct routine incontinence care rounds every two hours as required. Some nurses would assist with basic care tasks, she explained, but others would not.
Medical Implications of Inadequate Staffing Ratios
Industry standards typically recommend one nursing assistant for every 8-10 residents on day shifts and one for every 10-15 residents on night shifts, depending on residents' care needs. The documented ratios at Forrest Oakes—one nursing assistant for 50-54 residents—represent staffing levels approximately one-fifth to one-tenth of recommended standards.
These extreme ratios have direct medical consequences. Incontinent residents who are not changed regularly face increased risk of urinary tract infections, skin breakdown, and pressure injuries. Proper incontinence care protocols call for checking and changing residents at minimum every two hours, more frequently for those at high risk for skin complications.
The inspection documented that eight residents dependent on staff for activities of daily living failed to receive adequate nail care and incontinence care. Neglected nail care can lead to ingrown toenails, infections, and painful mobility problems—particularly serious concerns for residents with diabetes or circulatory disorders who face elevated amputation risk from untreated foot problems.
Beyond documented hygiene failures, inadequate staffing creates cascading safety risks. Residents may wait extended periods for assistance with toileting, medication administration, fall prevention, eating assistance, and emergency response. A nursing assistant responsible for 50+ residents cannot reasonably monitor residents for changes in condition, respond promptly to call lights, or provide the supervision necessary to prevent falls and other adverse events.
Staff Members Raised Concerns About Impossible Workloads
Nursing Assistant #6, a nine-year employee, stated she "had never seen staffing as bad as it was over the past three to four months." She reported working alone on night shifts after arriving at 11:00 PM to find no other nursing assistants in the building. With only one nurse, one medication aide, and herself caring for more than 50 residents, she confirmed there was no way to keep all residents dry and complete required care tasks.
Nurse #2 described leaving full-time employment due to overwhelming conditions caused by insufficient nursing assistant staffing. She explained that she transitioned from day shift to night shift because she "was overwhelmed on day shift due to not having enough Nursing Assistants working." Eventually she reduced her schedule to working only as needed because of her concerns about staffing levels.
When working the 7:00 PM to 7:00 AM shift, Nurse #2 reported multiple occasions when she arrived to find no nursing assistant until 11:00 PM. During these shifts, she supervised a medication aide, managed her own medication cart, performed blood sugar checks, and attempted to provide basic care—all while residents "received incontinent care and/or were assisted to bed later than they should have." She emphasized the facility lacked any contingency plan for when nursing assistants failed to report for scheduled shifts.
Administrative Response to Documented Staffing Crisis
The Director of Nursing acknowledged during her February 6th interview that staffing was difficult. She stated she had requested permission to use agency staffing and to provide bonuses for staff who worked additional shifts, but both requests required corporate approval. The facility had not been approved to use agency nurses or nursing assistants.
When the facility was short-staffed, the DON explained that qualified department heads would assist nursing assistants with feeding and incontinence care. She stated her expectation that all residents be fed and provided incontinence care in a timely manner. However, she acknowledged that when only two nursing assistants were scheduled for day shifts, "it was not possible to complete all showers and tasks."
The DON verified the accuracy of the documented staffing numbers, confirming that on multiple dates in January and early February, only one nursing assistant provided care during evening hours for the facility's census of 50-54 residents.
Delayed Meal Service Created Additional Resident Hardships
Beyond staffing and hygiene failures, the inspection documented that the facility failed to serve meals at posted times, affecting residents' nutrition and daily routines. The posted schedule indicated breakfast at 7:15 AM, lunch at 12:00 PM, and dinner at 5:15 PM.
On February 2nd, four residents waited in the dining room for lunch while the Administrator assured them meals were coming soon. Lunch trays were not served until 1:28 PM—88 minutes after the scheduled time. Meal carts did not reach some hallways until 2:00 PM, despite a scheduled delivery time of 12:45 PM.
Family Member #1 of Resident #206 stated that "one of Resident #206's family members was always at the facility for mealtimes." He reported that supper was served 1.5 hours late on January 31st and lunch was served late on February 2nd, adding: "it was hard to encourage Resident #206 to eat without knowing when meals would be delivered."
Consistent meal timing is medically important for residents with diabetes who require coordination between food intake and insulin or other diabetic medications. Delayed meals can cause blood sugar fluctuations, increasing risk of hypoglycemia or hyperglycemia. For residents with dementia or cognitive impairment, disruption of established routines can increase confusion and agitation.
The Regional Dietary Manager attributed the February 2nd delay to a staff call-out and a dropped meal that required preparation of replacement food. However, kitchen staff reported the delay was also caused by the presence of state surveyors in the kitchen, the need to purchase bread, and having to redo meal tickets. On February 3rd, breakfast service was delayed when food temperatures were found to be inadequate and required reheating, combined with training a new cook and another staff call-out.
Food Safety Violations Identified in Kitchen Storage
Inspectors documented multiple food safety violations during the February 2nd kitchen inspection. In the walk-in refrigerator, staff found undated and opened items including butter, mozzarella cheese, sour cream, parmesan cheese, and honey. One container of sour cream bore a January 18th date—15 days old. A pan of gelatin dessert was covered with aluminum foil that had frozen white substance on top. A box of cucumbers showed white fuzzy spots indicating mold growth.
The walk-in freezer contained undated items including frozen carrots, shrimp, and toast. Notably, a box of western-style beef patties was stored unwrapped and open to air with visible ice crystals—signs of freezer burn that indicate improper storage and potential quality degradation.
Proper food dating and storage procedures are critical infection control measures. Undated food items make it impossible to enforce first-in, first-out rotation or to identify potentially spoiled items before they are served to residents. Moldy produce and improperly stored frozen items should be discarded immediately to prevent foodborne illness.
Dietary Aide #1 explained that the Dietary Manager, who was responsible for dating food and disposing of outdated items, had walked out without notice on January 31st. The cook similarly attributed the storage violations to the manager's sudden departure. The District Dietary Manager confirmed he had spoken with dietary staff on January 31st about the need to date food items, and a new Dietary Manager was scheduled to begin on February 3rd.
Additional Issues Identified
The inspection narrative detailed eight residents who failed to receive adequate nail care in addition to incontinence care failures. Proper nail care is essential for preventing infections, painful ingrown nails, and mobility problems—particularly critical for elderly residents and those with diabetes or circulatory conditions.
The facility's meal service problems extended beyond timing delays. On February 3rd, breakfast service did not begin until 7:40 AM, and the first meal cart left the kitchen at 7:50 AM—35 minutes after the scheduled 7:15 AM service time. The new Dietary Manager attributed this delay to training a new cook, a staff call-out, and the need to reheat pureed eggs and ground sausage that were below safe holding temperatures.
The Director of Nursing stated that dietary had hired new staff and she expected meal service timing to improve. The District Dietary Manager similarly expressed confidence that service would improve with the new Dietary Manager and additional staff members beginning work.
The inspection findings at Forrest Oakes Healthcare Center document systemic failures in fundamental care delivery—failures directly attributed to inadequate staffing that staff members at multiple levels described as impossible to manage safely. The documented conditions represent significant departures from accepted standards of care and regulatory requirements for skilled nursing facilities.
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.
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