State inspectors found that staffing had dropped below state minimums at 115 homes -- nearly one of every three in Georgia -- at least once since 1999. The staffing violations were found at least twice at 55 of those homes.

But the state rarely fines or punishes nursing homes for understaffing, and it doesn't require homes to prove they have added workers after a spot check finds understaffing. As a result, some nursing homes show up repeatedly as staffing below the standard.

"That's one of the areas in which I think we've been lax," said Gary Redding, commissioner of the Georgia Department of Community Health, which oversees Medicaid reimbursements to nursing homes. "We're going to tighten that up."

State policy requires homes participating in the Medicaid program to hire enough staff to provide an average of 2.5 hours of care to every resident every day. At least 28 states require a minimum ratio of staff hours per patient, and Georgia's standard is among the more stringent.

Experts consider adequate staffing a crucial factor in delivering quality care in nursing homes. Without enough nurses and aides, residents often don't get help in eating, going to the bathroom, or changing positions to prevent bedsores.

"It's absolutely critical for homes to have adequate numbers of staff," said Becky Kurtz, Georgia's long-term care ombudsman. "They are the people who are hands-on in meeting all the needs of the residents."

The Office of Regulatory Services, part of the Georgia Department of Human ReĀsources, checks on staffing as part of its regular inspections of nursing homes. Reports of understaffing are forwarded to Redding's agency, which takes no action.

"If no one is going to enforce it, it's a useless standard," Kurtz said.

Repeat offenders

Inspectors typically analyze just two weeks of payroll records, so the full extent of understaffing at Georgia nursing homes could be far greater than state records indicate.

Some facilities are chronic violators of the staffing requirement. For example, inspectors have found Sunbridge Care & Rehab in Griffin short-staffed on seven occasions since 1999, for a total of 64 days. State inspection records show the home, owned by Albuquerque-based Sun Healthcare Group, has been one of the state's most frequently cited homes.

Last year inspectors found that the facility placed residents in "immediate jeopardy" by, among other things, failing to properly treat bedsores. In some cases the staff was not even aware residents suffered from the sores, inspectors said.

The facility was cited again this year for harming residents and failing to provide care as prescribed by doctors.

Spot checks found that 12 of Sun Healthcare's 16 Georgia facilities were below staffing requirements at least once since 1999. Most of those 12 were understaffed on more than one visit.

Sun Healthcare Group declined to address specifics of its staffing problems. But in a written statement, a spokeswoman said the company's new management team was "pursuing a number of initiatives to improve quality."

Redding, the state's commissioner for community health since September, said he wants to work with state inspectors to enforce the staffing standards, especially for repeat violators. Taking action against facilities without adequate staff might prevent care problems from occurring in the first place, Redding said.

He said providers agree to abide by the staffing rules when they sign up to participate in the Medicaid program. "They have to be accountable," Redding said.

Finding staff difficult

Inadequate staffing may be one reason problems with care at Georgia nursing homes have been on the rise, said David Dunbar, director of the long-term care section of the DHR office that inspects nursing homes.

"I do think there is a direct correlation between the problems we're seeing and the difficulties the facilities are having in attracting and maintaining adequate numbers of trained staff," Dunbar said.

Industry spokespersons say nursing home owners simply can't find enough workers willing to care for frail people for low wages, especially during recent years when the unemployment rate in Georgia reached near-record lows.

"I would think the majority, if not all, the operators in Georgia would be trying desperately to fulfill their minimum staffing requirements," said Gayle Sexton, legislative director for the Georgia Nursing Home Association.

Sexton said it would be difficult for homes to comply. "How are you going to enforce it if you can't find people to punch the time clock?" she said.

In May, a state task force confirmed there are widespread shortages in nursing home staff. Nearly 13 percent of all nursing assistant positions were vacant, as were 15 percent of all registered nurse positions, the task force reported.

Respect, pay crucial

While many in the industry agree it's difficult to hire and retain staff, one nursing home administrator says the problem can be overcome. Gary Westbury took charge of Winder Health Care last year. State inspectors repeatedly found the facility, formerly known as Russell Nursing Home, short-staffed.

But Westbury said he's now fully staffed and that care has improved. Solving the problem requires attention to detail and working to make the nursing home a place where people want to work.

"I think a lot of it has to do with how you treat the employees and how much you pay them," Westbury said.