On January 30, no nursing assistant worked the floor from 4:00 PM until 7:00 PM. One aide then arrived to care for all 54 residents alone until 11:00 PM.
The next night, January 31, one nursing assistant provided care for 54 residents from 4:00 PM until 7:00 AM — a 15-hour stretch covering two shifts.
Federal inspectors found the facility failed to provide adequate nail care and incontinence care for eight residents who depended entirely on staff for basic activities of daily living. Time cards and assignment sheets revealed dangerous staffing patterns that left residents waiting hours for help.
Nursing Assistant #8 told inspectors she normally worked the 7:00 PM to 7:00 AM shift and had to work the whole building by herself two to three times a week. "It was not possible to keep every person dry when working by herself or conduct routine rounds and provide incontinent care at least every two hours," she said.
She concluded her interview with a stark assessment: "You just can't operate a building like that."
Another aide who had worked at the facility for nine years said she had never seen staffing as bad as the past three to four months. When she arrived for the 11:00 PM shift, she often found no nursing assistants in the building and had to work alone through the night.
"There was no way to keep all of the residents dry and do all of the required tasks when there were only 2 NAs on first shift or 1 NA at any time," she told inspectors. The census was normally above 50 residents.
A nurse who left the facility described the breaking point that drove her away. She started on day shift but switched to nights because she was "overwhelmed on day shift due to not having enough Nursing Assistants working." Even then, she reduced her hours to work only as needed because of staffing concerns.
During her night shifts from 7:00 PM to 7:00 AM, she would arrive to find no nursing assistant until 11:00 PM. She had to supervise a medication aide, pass medications from her own cart, check blood sugars, and help with resident care. "There were times the residents received incontinent care and/or were assisted to bed later than they should have," she said.
The nurse felt the facility needed a plan for when nursing assistants didn't show up for work, but no such plan existed. Nurses helped when they could, but they were trying to pass medications.
Director of Nursing acknowledged the staffing crisis during her interview with inspectors. She had requested permission to use agency staff and give bonuses to employees who worked extra shifts. Corporate had not approved either request.
She confirmed the dangerous staffing numbers inspectors documented: one nursing assistant for 50 to 54 residents during multiple evening shifts in late January and early February. She admitted that even with two nursing assistants on day shifts, it was impossible to complete all required showers and tasks.
The staffing shortage created cascading problems throughout the facility. Meals arrived hours late because dietary staff also called out without notice.
On February 2, four residents sat waiting in the dining room at 12:30 PM for lunch scheduled to begin at noon. The administrator walked around assuring them their meals were coming soon. Lunch trays finally arrived at 1:28 PM.
Family Member #1 of Resident #206 told inspectors that one family member was always present for mealtimes. Supper had been served 1.5 hours late on January 31, and lunch was late again on February 2. "It was hard to encourage Resident #206 to eat without knowing when meals would be delivered," he said.
At 1:00 PM on February 2, the family member was heard asking staff why the resident's lunch tray hadn't been delivered. He said Resident #206 had waited a long time and was hungry. Staff said trays were due out soon.
The meal cart for Resident #206's hall arrived at 2:00 PM — 1 hour and 15 minutes after the scheduled delivery time.
The Regional Dietary Manager explained that a staff member had called out that day without notice, and a meal had been dropped during service and needed to be remade. The new Dietary Manager said she had to buy bread that morning and redo meal tickets, which delayed the kitchen.
Breakfast on February 3 started 35 minutes late because pureed eggs and ground sausage were below proper holding temperature and had to go back in the oven. The first meal cart left the kitchen at 7:50 AM instead of 7:15 AM.
The new Dietary Manager attributed the delay to training a new cook while another staff member called out. She told inspectors, "Staff will say they will work then fail to show up for work."
The former Dietary Manager had walked out on January 31 without notice, leaving the department in chaos.
Food safety violations compounded the problems. Inspectors found undated, open containers of butter, mozzarella cheese, sour cream, honey, and lemon juice in the walk-in refrigerator. A box of cucumbers had white fuzzy spots. A metal pan of gelatin dessert was covered with foil that had a frozen white substance on top.
In the freezer, western-style beef patties sat unwrapped and open to air with ice crystals on them. Bags of shrimp and frozen carrots had no dates.
Dietary Aide #1 explained that the former Dietary Manager was responsible for dating food and disposing of expired items. With her sudden departure, no one had taken over those duties.
The District Dietary Manager confirmed the former manager had walked out on Friday, January 31, leaving the department without leadership during a critical period.
The Director of Nursing expressed optimism that new dietary staff would improve meal service, but the underlying staffing crisis remained unresolved. Corporate had still not approved the use of agency nurses or staff bonuses that might attract workers.
Nursing Assistant #8's words echoed through the inspection report: "You just can't operate a building like that." Yet for weeks, that's exactly how Forrest Oakes Healthcare had operated, with residents paying the price in delayed meals, inadequate incontinence care, and basic dignity compromised by a system stretched far beyond its breaking point.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Forrest Oakes Healthcare from 2025-02-06 including all violations, facility responses, and corrective action plans.