Nursing home manager, Kim Ombler, says this is "a problem that's been festering for years".
Care home staff have been left "traumatised" and "in despair" after two days of trying and failing to reach out-of-hours services for help with a patient who has since died.
Staff at Glan Rhos Nursing Home in Brynsiencyn tried numerous avenues to get anticipatory end of life medication on standby for a resident, which are used to ensure someone "dies with dignity".
Nursing home manager, Kim Ombler, explained how the experience highlights how "alone you are in this sector" and that her staff felt "let down by the system".
Ms Ombler said her care workers had tried to phone district nurses, a community palliative care nurse, two local hospices, a hospice in Wrexham where they get advice from, 111 and a GP - none of which were a success on December 17 and 18.
Ms Ombler explained: "I'm upset for my staff and the residents, because on a weekend we were unable to get hold of an out-of-hours GP. The staff tried for two days to phone 111, they were on the phone for an hour and a half constantly, and the phone died because the battery had gone.
"It's a problem that's been festering for years, I've complained for a number of years and my mother who was a nurse before me in the home was complaining years before me about the out-of-hours service - something seriously needs to be done."
The care home on Anglesey has a total of 52 beds, caring for patients as old as 101 currently. Ms Ombler has since made a complaint to the local health board.
In a statement, Director of primary care at Betsi Cadwaladr University Health Board, Karen Higgins, said: "The pressures across our entire health system have been well documented but both the family and care home staff can rest assured we will address any issues within our control.
"On the weekend in question the GP out of hours service was under extreme pressure and we prioritised all calls according to clinical need. We do have a dedicated NHS line for professionals to contact our GP out of hours service and this would have been the correct route to seek help and advice in these circumstance. It was fully staffed on the days in question.
"However, despite having a full complement of doctors on our rota, during peak times on those days we were taking around 40 calls an hour, just from health professionals alone. In addition to this the NHS111 Wales helpline was referring members of the public to our GP out of hours service.
"We will be working with Glan Rhos care home to understand why they were unable to access our services on those days and where we can improve in the future."
Around 70,000 people work in direct care in Wales according to latest Social Care Wales figures, but there are over a 1,000 advertised vacancies.
The number of hours dedicated to domiciliary care has halved, because providers do not have enough staff to cover the hours.
Mr Drakeford said recruitment pressure in the social care system is "real" and argued paying social care workers the real living wage is part of the government’s effort to recruit more people into the sector which he described as an "important and rewarding job".
Mary Wimbury, Chief Executive of Care Forum Wales, said investing in social care in order to provide better pay for frontline staff would help relieve the NHS crisis in Wales.
She explained: "There's pressure from all directions on the care sector. We know that providing direct care in the community, both in care homes and in people's own homes, it can keep people out of hospital in the first place and then help support them to come out of hospital. But we need the staff and resources to be able to do that.
"I haven't spoken to a care provider who isn't struggling to both retain and recruit staff. It's a really pressurised job and it's just not being valued sufficiently to be able to keep people working in the sector", Ms Wimbury added.
Staff are covering shifts for the NHS instead of working in care, which is something Care Forum Wales believes can be tackled if care workers are paid more than a real wage and one that is comparative to the NHS sector.
According to Ms Wimbury, something has to be done urgently to sort out the problem of so-called "bed blocking" with hospitals struggling to admit patients, because many of those already there were unable to be discharged as there was nowhere for them to go.
In response to the case at Glan Rhos Nursing Home and on behalf of 111, Executive Director of Operations at the Welsh Ambulance Service Lee Brooks said: "We are deeply sorry to hear about this patient’s experience, which we know will have been distressing for all involved, not least the nursing home staff who were trying to organise help – our thoughts and condolences are with the patient’s family at this difficult time.
"Community-based palliative care provision is firstly the responsibility of the Local Health Board, but as an ambulance service, we are making great strides to improve the quality of care that we deliver to patients at the end of their life."
Flintshire’s Chief Officer for Social Services, Neil Ayling, said they face the "same pressures of social care workforce availability as every authority in Wales and across the UK" and. that the "health-social care pressures are being reviewed at least daily to ensure the best possible service is maintained".
A Welsh Government spokesperson explained: "We are sorry that the service delivered to the individual fell below expected standards on this occasion. Healthcare services are under unprecedented pressure and professionals are managing high volumes of patients seeking advice or treatment for influenza, covid-19 and Strep A.
"We encourage people who want advice for a minor illness to use the NHS 111 Wales online website first to conserve phone lines for those in most need of urgent medical advice."