A 181-bed Brius nursing home in Marin County, Calif. has been cited for understaffing and providing such substandard care that a state investigator said it was “very dangerous” for certain residents.

Novato Healthcare Center was cited with 19 deficiencies in 2017, according to reports posted by the California Department of Public Health. Brius – the largest operator of nursing homes in Marin  – controls one in five nursing home beds across the county.

Most of the deficiencies stem from an inspection last May that found many residents struggling to get the care they needed as the home suffered from severe understaffing. The facility was also cited for stocking expired medications.

These new findings come as caregivers, patients and their loved ones recently testified about understaffing at the facility as well as a second nearby Brius home, San Rafael Healthcare and Wellness Center. A board composed of community leaders conducted a public hearing earlier this month and issued preliminary findings that both facilities need more staff and better pay to reduce turnover. The board is also considering whether to recommend that a new operator be identified  to replace than Brius.

Inspectors reviewing the Novato home last year found that staffing was such an issue that the family of one resident hired a private caregiver to sit with a terminally ill resident after the resident had suffered a fall.

One male resident was found with long, dirty fingernails, unkempt, greasy hair, and unshaved. A caregiver questioned about the man’s appearance suggested that it was due to the facility’s having hired many temporary nursing assistants from a nursing registry.

Investigators were also troubled by the care provided to a man who was paralyzed on his left side from a recent stroke. The man had been left for hours on his left side, unable to move or alert staff that he had soiled himself. The investigator noted that medical staff failed to properly instruct caregivers about the resident’s needs and care. This failure was especially dangerous because he was being cared for by temporary nurses and nursing assistants.

A separate investigation, stemming from a resident complaint made last April, further documented Novato Healthcare Center’s chronic understaffing.

One caregiver told investigators that staffing was so low they had to work double shifts and that there were so few nursing assistants that nurses had to take on their jobs.

Another staffer said she had been assigned as many as 28 residents during a single shift, and that the staffing situation is “overwhelming” for staff.

Even the staffing coordinator acknowledged that the home was relying on temporary workers, and that even with temps the facility was still shortstaffed.