Another nurse said a typical evening shift included one nurse and one certified nurse's aide. Review of the records showed there were approximately 17 residents for whom those two people would be responsible. Day shifts usually had two or three CNAs available.
The facility's director of nursing said she did not have staff to provide individualized care for the resident.
The death of a resident wasn't the only thing investigators took issue with. The report indicates two residents received inadequate care after episodes of incontinence, six failed to be bathed at least twice weekly, and three did not receive proper oral care. Fines for those cases total $500.
Investigators were told the facility had a shower aide who was responsible for bathing residents but that floor nurses pulled the aide off shower duty to help when they were shorthanded.
The report does not include a formal response. The facility has up to 30 days to request a formal hearing to contest the citation.