The facility's chronic understaffing left residents waiting up to 45 minutes for incontinence care and missing scheduled showers, federal inspectors found during a March 19 complaint investigation.
Resident #1 told inspectors the facility lacked adequate staff to meet her needs. When only two certified nurse aides worked her unit, she didn't receive showers and incontinence care was delayed. She was supposed to receive showers Tuesday, Thursday, Saturday and Sunday.
The representative for Resident #2 said the resident hadn't received adequate showers for months. She had to call the facility repeatedly to get staff to provide showers, sometimes calling multiple days in a row.
CNA #1 described working alone in February to care for 45 residents, including two who required two-person mechanical transfers, two with foley catheters, four with colostomy bags and one requiring total assistance. When residents needed two-person help and the facility was short-staffed, "the resident was left in bed soiled," she told inspectors.
This happened because CNAs either lacked time or help to provide incontinence care, or there weren't two staff members available to assist. When she brought staffing concerns to management, "she was told to just do what she could."
The day before the inspection, a CNA worked alone for two hours caring for 24 residents. Most nurses refused to help with personal care, she said.
CNA #2 said the main floor housed 50 residents but should have three to four CNAs scheduled. When short-staffed, CNAs couldn't complete resident care or scheduled showers. Only two CNAs had worked the prior two evenings.
"The CNAs did the best they could to care for the residents, but there were times when incontinence care and oral care did not always get done," she said. Management didn't help work the floor during shortages.
CNA #3 said staff shortages forced CNAs to rush resident care. She often stayed late to finish charting. Day shift was supposed to have four to five CNAs, but when only two worked the unit, scheduled showers weren't completed.
When residents required two-person transfers with only two CNAs working, one aide had to wait up to an hour for the second CNA to become available.
CNA #4 said shortages delayed personal care and prevented scheduled showers. Finding a nurse to assist could take 20 to 30 minutes. For incontinence care, CNAs had to "triage the residents who had a bowel movement to be changed over residents who were wet."
When CNAs brought concerns to management, "they were told to work it out."
Licensed practical nurse #1 confirmed the facility had been short on CNAs "for a while," frequently operating with only two CNAs for more than 40 residents. Her physical limitations prevented her from helping much. Residents requiring two-person assistance "would have to stay wet or soiled until a second CNA was available to help."
Grievances from January through March documented the staffing crisis. A January 6 complaint noted there was no restorative CNA for two weeks and no CNA for an entire day. CNAs complained to residents about being short-staffed on January 23 and 30.
A February 8 grievance documented a resident having to call the front desk to request help getting out of bed. March complaints included concerns about residents not receiving timely care and CNAs rushing through care duties.
The facility's November 2024 assessment documented caring for 78 to 85 residents with a desired 2.26 hours per patient day for CNAs. The assessment stated assignments were reviewed daily based on resident needs and available staffing.
But the Director of Nursing seemed unaware of the problems. She told inspectors she didn't know why showers weren't completed, suggesting it might be a documentation error. She claimed to be "super confident about the facility staffing" and said managers would help with transfers and showers when CNAs called off.
She wasn't aware of issues with showers and daily living care, believing residents were receiving proper care.
The regional vice president said the administrator had worked at the facility only three days and claimed no staffing concerns. She attributed missed showers to documentation issues and said the Director of Nursing needed education on documentation and time management.
She worried about "the perception of the families and staff related to staffing."
The facility's own policy required maintaining adequate staff on each shift to meet residents' needs, using facility assessment as the foundation for determining staffing levels. But CNAs described a year-long shortage that left vulnerable residents waiting in soiled conditions while overworked staff struggled to provide basic care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Villa Manor Care Center from 2025-03-19 including all violations, facility responses, and corrective action plans.
