On October 1st, inspectors found only seven certified nursing assistants working the day shift when the facility's plan calls for eight. The shortage has become routine — over an 18-day period in September and early October, the facility ran short-staffed on 16 day shifts and 11 night shifts.
"About 35% of the time we work with less than that with only 2 on each unit," said one nursing assistant during interviews with federal inspectors.
The chronic understaffing affects residents throughout the building. Resident council meeting minutes from June through September document complaints about slow call light responses, missed evening water service, and showers not given on scheduled days.
One nursing assistant explained the ripple effects when the facility operates with six CNAs instead of eight: "We are assigned to 15 residents, showers get missed, and it affects our ability to reposition residents every two hours."
Another CNA described how repositioning — critical for preventing pressure sores — gets delayed: "We try to stay on top of repositioning residents, but it depends on the day and sometimes it is closer to 3 hours between repositioning."
The facility cares for residents with significant medical needs. According to its own assessment, Goldwater Care houses an average of 10-15 residents with stage three or stage four pressure ulcers — the most severe categories that can be life-threatening without proper care.
Of the facility's 83 residents, 41 require two-person assistance for transfers and basic care, meaning staff must work in pairs to safely move these residents.
When staffing falls short, nursing assistants must abandon their assigned areas to help colleagues. "At times they have to pull a CNA from the East wing to make 2 CNAs on each hall, and the resident rooms have to be divided up between the CNAs, which doesn't seem to be enough staff," said one registered nurse.
The staffing problems create cascading delays. "When there are less than 8 CNAs on day shift, it is harder to get to call lights quickly and residents have to wait while we find help to assist with transferring them out of bed," one CNA told inspectors.
Night shift conditions appear even more problematic. One day-shift CNA reported arriving at work to find residents who had been left in wet conditions overnight: "V37 doesn't feel like one CNA for middle wing is enough for night shift, sometimes the heavy wetters are soaked in the morning."
The facility's Director of Nursing acknowledged the staffing shortfalls during the inspection. She confirmed that daily staffing sheets accurately reflected CNA levels that "does not match the staffing plan as outlined in the facility assessment."
Management has attempted various scheduling changes to address night shift problems, but these efforts have failed. The director described switching to a system with four 12-hour CNAs and two working shorter shifts, but "recently the CNAs said that wasn't working so now we are doing five for 12 hour shifts."
Staff members report being frequently called in on their days off. "Management tries to get people to come in when there are call offs and V28 often gets calls on her days off asking if she is able to come in to work," one CNA explained.
The staffing crisis stems partly from recent departures. One nursing assistant mentioned "call offs and two employees recently quitting" as factors in the ongoing shortage.
Federal regulations require nursing homes to provide sufficient staffing to meet residents' needs every day. The inspection found that Goldwater Care's staffing failures affect the facility's entire population of 83 residents.
The facility's own staffing plan calls for eight CNAs during day shifts — four on the East wing, two on Middle, and two on West. Night shifts should have six CNAs, with two assigned to each wing. Instead, the facility routinely operates below these levels.
Inspectors documented the human cost of these shortages through multiple resident council meetings where families and residents raised concerns about delayed responses to call lights and missed care services.
One nursing assistant summed up the daily reality: "We have to help each other with the mechanical lifts and call light response is also affected."
The inspection occurred following a complaint, suggesting that the staffing problems had become visible enough to prompt outside concerns about resident care at the 90-bed facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Goldwater Care Danville from 2025-10-02 including all violations, facility responses, and corrective action plans.