Staffing Deficiency Leads to Immediate Jeopardy
Summary
The facility failed to maintain sufficient levels of nursing staff, resulting in Immediate Jeopardy when only three LPNs and two STNAs were on duty to care for 105 residents. This staffing shortage affected the ability to provide routine care, monitoring, medication administration, and response to urgent needs. The lack of adequate staffing led to potential serious harm and negative health outcomes for residents, as they were unable to receive necessary care and supervision. Resident #41, who was in a persistent coma state and dependent on staff for all care, was not attended to until several hours after the shift began. The STNA responsible for Resident #41 had 20 residents to care for and was unable to provide timely care due to the overwhelming workload. Similarly, Resident #4, who required assistance with meals and had impaired skin integrity, was left unattended for nearly an hour with her lunch tray untouched, and her wound dressing was not properly maintained. Resident #50 was found with dried food on his chest and a soaked incontinent brief, indicating a lack of timely care. The facility's staffing assessment did not adequately address the needs of specialized units, such as the memory care and mental health units. Interviews with staff revealed that the facility consistently operated with insufficient staff, leading to incomplete care and supervision. The facility's administrator and staff were aware of the staffing issues but were unable to resolve them due to budget constraints and lack of agency staff.
Removal Plan
- Staffing levels will be increased to five nurses on day shift and four nurses on night shift, STNA's staffing levels will be increased to eight STNA's on first shift and six nursing assistants on night shift.
- Staffing levels will be increased by increasing hours for current staff, reassigning staff from sister facilities and signing contracts with two temporary staffing agencies. The shift charge nurse will authorize the use of the agency staff.
- The charge nurses will be provided with the agencies phone numbers and will be educated to call agency when there are call offs and our staff will not pick up open shifts.
- RDO #224 will develop a bonus structure for new hires.
- RDO #224 will develop a bonus structure for staff that will pick up extra shifts.
- RDO #224 will develop a bonus structure for staff who refer new candidates.
- Human Resource (HR) Director #6 will call all applicants for the last 60 days to re-offer interviews.
- The Director of Nursing (DON) or designee will conduct resident assessments to identify those with pressure ulcers and extensive assist from two staff members with ADL to prioritize their care and ensure immediate needs are addressed.
- RDO #224 or designee will notify residents and their representatives about the staffing situation, the steps that are being taken to address the issue and what they can expect in terms of care.
- An ad hoc quality assurance (QA) committee meeting will be held to review the plan.
- [NAME] President of Human Resources (VPHR) #800 or designee will develop and implement a long-term plan to recruit and retain qualified staff including offering competitive wages, benefits and professional development opportunities.
- RDO #224 or designee will review staffing levels daily and adjust as necessary depending on new admissions/discharges and significant changes. This may involve hiring additional permanent staff or adjusting the staff to resident ratio based on acuity levels.
- RDO #224 will educate the administrator, the DON and HR Director #6 on the appropriate staffing levels to meet the residents needs and to adjust the staffing levels depending on new admissions/discharges and significant changes.
- RDO #224 or designee will interview four residents and four direct care members to ensure appropriate staffing levels and quality of care.
- The data collected from the above audits and feedback will be used to make ongoing adjustments to the staffing plan and care protocols, ensuring compliance and that residents receive high-quality care. The audits will be submitted weekly to the QA committee for trending, tracking and recommendations.
Penalty
Resources
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The facility failed to maintain sufficient nursing staff to meet residents’ assessed needs, resulting in repeated reports of long call light response times, delayed or missed toileting assistance, and inadequate hygiene. Multiple residents described waiting hours for help to use the bedpan or be put to bed, being left in soiled briefs or on bedpans for extended periods, and having to seek staff in hallways or involve family to get assistance. Some residents reported being left in urine and feces for many hours, experiencing skin irritation and rashes, and not receiving proper washing before creams were applied. Others reported not being gotten out of bed, being left in the dining room after meals, not being set up for meals in bed, and having poor oral care, unchanged linens, and unclean skin and nails. Resident Council minutes, confidential group interviews, and grievances consistently documented these staffing-related care failures over multiple months, and facility leadership acknowledged that nursing staff levels were insufficient to provide required nursing and related services.
The facility failed to provide sufficient nursing staff, especially on weekends and during evening/night shifts, resulting in missed and delayed care. Confirmed grievances included a resident not receiving overnight incontinence care and being found wet in the morning, a resident’s catheter bag filling to 2,000 mL before being emptied, long call‑light response times, rushed CNA care, and delays in getting residents out of bed when two‑person assistance was needed. Staffing schedules showed consistently lower staffing hours on weekends despite a stable census, and residents who usually ate in an independent dining room were moved to an assisted dining room on weekends due to lack of supervision, corroborated by a posted weekend closure notice. Residents, family members, and staff all reported that low staffing on weekends and certain night‑shift hours led to longer waits for assistance and unavailability of staff when needed.
The facility failed to maintain sufficient weekend nursing staff to meet residents’ basic and individual needs, as defined in its facility assessment. The assessment set minimum/optimal staffing for day and evening shifts at two licensed nurses, two CMAs, and four CNAs, and for nights at two licensed nurses and two CNAs, with weekend requirements matching weekdays. CMS PBJ CASPER data showed excessively low weekend staffing, and schedule reviews over several months revealed that all or most weekends were staffed below these minimums. An LN and administrative staff confirmed that weekends were expected to be staffed the same as weekdays but were difficult to cover due to frequent call-ins, despite having an on-call list and occasional management coverage.
The facility failed to provide adequate nursing staff coverage, resulting in one nurse and sometimes no aide in a Villa, or one nurse and one aide shared between two separate Villas. Staff reported being unable to complete required care, including meal preparation, transfers requiring two staff, cleaning, and timely medication passes, when working short. Multiple residents with diabetes, pain, mobility limitations, and mechanical lift needs described long waits for call lights, toileting, transfers, and bedtimes, and consistently late medications, especially insulin and pain medications, when staff were covering more than one Villa or when no staff were present in a Villa for extended periods. MAR reviews confirmed repeated late administration of ordered insulin doses for several residents, correlating with the documented staffing shortages and split assignments between Villas.
A facility failed to maintain sufficient CNA staffing and timely call-light response when two scheduled CNAs, both from a registry, were unavailable for an evening shift and no replacements were secured. A resident with bowel incontinence and dependence for toileting activated the call light after becoming soiled and reportedly waited about two hours before an unassigned CNA responded, finding the resident crying, soiled, and with red skin. Staffing records showed one CNA called off and another left early without returning or clocking in/out, and there was no documentation of reassigned CNA coverage for the affected rooms. Staff interviews described unanswered call lights and reliance on registry staff, while facility policies required sufficient and competent staffing, call-light response within 3–5 minutes, adherence to protocols by registry staff, and treatment of residents with dignity and respect.
The facility failed to maintain adequate nurse and CNA staffing on multiple floors and shifts, resulting in delayed medication administration and delayed response to resident care needs. On several day and evening shifts, only one nurse or fewer nurses than scheduled were present at the start of the shift, causing 9:00 AM and 5:00 PM medications to be given outside the expected time windows. A resident with multiple comorbidities and intact cognition reported frequently receiving medications, including Gabapentin for leg pain, several hours late and described significant pain when doses were delayed. On high-census shifts, CNAs were assigned to care for 19–25 residents each, including many requiring total care and mechanical lifts, leading staff to prioritize basic rounds, incontinence care, call lights, and feeding while other tasks such as grooming, getting residents out of bed, and timely changes were not consistently completed. Staff, including the DON and an advanced practice nurse, acknowledged that these staffing levels were insufficient and that the facility lacked a formal staffing policy.
Insufficient Nursing Staff Leading to Delayed Care, Poor Hygiene, and Unmet Toileting Needs
Penalty
Summary
The deficiency involves the facility’s failure to maintain sufficient nursing staff with appropriate competencies and in adequate numbers on a 24-hour basis to meet residents’ assessed needs and care plans, as required by its facility assessment and federal regulations. The facility assessment dated 4/14/25 stated that staffing would follow state-required ratios to meet per patient day needs for ADLs, mobility and fall prevention, bowel and bladder care, and prompt response to bathroom assistance to maintain continence and dignity. However, multiple resident interviews, observations, Resident Council minutes, confidential group interviews, and grievance reviews showed that residents frequently experienced delayed or missed care, including long call light response times, inadequate toileting assistance, and insufficient hygiene and ADL support. Several residents reported prolonged waits for assistance and unmet toileting needs. One resident who stated she was not incontinent reported that staff did not help her onto the bedpan despite repeated requests, causing painful bladder holding and long call light waits, and she also reported not always receiving fresh water. Another resident reported having to leave her room to find staff to assist her roommate. Multiple residents described call light response times as very long, sometimes four to five hours, and one resident confirmed being left in a soiled brief for a long time, resulting in skin irritation. Observations included a resident with greasy-appearing skin and an unclean face who reported rushed care and late meals. Resident Council minutes over several months documented ongoing concerns about call light response, staff not being present on the floor, residents not being gotten out of bed, residents left in the dining room after meals, and call lights being shut off without care being provided. During a confidential resident group interview, numerous residents reported that staff turned off call lights without providing care, that residents needing assistance in and out of bed were not reliably helped, and that they experienced extremely long waits to be put to bed or assisted off bedpans. Specific accounts included being left in a chair from late morning until late at night with swollen, painful legs; being left on a bedpan through dinner after staff failed to return; sitting in urine and feces for up to eight hours with only cream applied over unwashed skin; and having to call family to contact staff because call lights were not answered. Grievances further documented concerns about lack of oral care, poor hygiene, unchanged bed linens, soiled pads with urine and feces, residents not being set up for meals in bed, being told to use briefs instead of a urinal, missed showers, and not being assisted to bed until midnight. The Nursing Home Administrator confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable well-being of multiple residents over several months.
Plan Of Correction
The facility will provide for sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical mental and psychosocial well-being. Staffing levels will be developed to meet the needs of the resident's care examples are ADL care, Incontinent care Transferring ,meal time, nail care, linen changes based on the facility assessment results. The facility will do this by Working with Veeshift/Eshift Staffing agency and Dropstat a scheduling oversite company to look at staff schedule to optimization the staff required to provide resident Care. The HR Director will develop a hiring plan based on the needs presented by the company Dropstat.Monthly staff meetings will be held by the HR Director to understand the needs of the staff and promote staff retention.Education will be provided To the nursing staff regarding What to do when unable to complete a care task. That they need to follow the change of command and let the nurse know they can not complete the task the nurse will then complete the task or notify their supervisor. Documentation will be completed by the staff or manager that completes the task. The Administrator/Designee will audit daily nursing staff to ensure the required number of staff are present to provide for sufficient nursing staff to meet the residents' needs. the DON/Designee will audit 90% of residents who have care concerns weekly times four and monthly time two Results of these audits will be presented to the QAPI committee for review and recommendations
Insufficient Weekend and Night Staffing Leading to Missed and Delayed Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff were available each day to meet resident needs according to their plans of care, particularly on weekends and during evening/night shifts. Review of grievances over a six‑month period documented confirmed incidents of missed or delayed care, including a resident not receiving incontinence care between 6:00 PM and 6:00 AM and being found wet the next morning, and another resident reporting that his catheter bag was allowed to fill to 2,000 mL before a CNA arrived to empty it. Additional grievances confirmed long call‑light wait times, rushed care by CNAs, and delays in getting residents out of bed when two‑person assistance was required. A three‑week staffing schedule review showed consistently lower total staffing hours on weekends compared to weekdays, while the census remained relatively stable. Residents and family members reported that staffing was low on weekends, that staff were not available when needed throughout the day, and that rooms were often unorganized and residents not ready for scheduled outings. Residents who normally ate in the independent dining room reported being required to eat in the assisted dining room on weekends due to lack of supervision, and this was corroborated by a kitchen whiteboard stating the independent dining room was closed on Saturdays and Sundays. During interviews, night‑shift licensed nurses reported that each wing had one CNA and one nurse on duty and acknowledged that between 4:00 AM and 6:00 AM residents might wait longer for assistance as more residents began calling for help. A CNA stated the facility was often low‑staffed on weekends and not always appropriately staffed from 6:00 PM to 10:00 PM, resulting in longer wait times to meet resident needs. The staffing coordinator confirmed that staffing was based on census and that the facility did not have many weekend staff. Resident council feedback further documented repeated concerns about low weekend staffing, closure of the independent dining room on weekends, and staff observed sitting at the nurses’ station charting while call lights remained unanswered.
Persistent Weekend Understaffing Below Facility-Defined Minimums
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on weekends to meet residents’ basic and individual needs, as required by its own facility assessment and CMS PBJ staffing expectations. The facility had a census of 54 residents and a capacity of 60, with a facility assessment (last reviewed 03/19/26) that established minimum/optimal staffing levels for weekdays and weekends: for day and evening shifts, two licensed nurses, two CMAs, and four direct care staff (CNAs); and for night shift, two licensed nurses and two direct care staff. A review of the CMS PBJ CASPER 1705D report for FY 2026 Q1 showed the facility triggered for excessively low weekend staffing. Review of actual nursing schedules from 10/01/25 to 02/28/26 showed weekend staffing below the facility’s own minimum/optimal levels on all weekends in October, November, December, and February, and on two of four weekends in January. Staff interviews confirmed that weekend staffing was expected to be the same as weekday staffing but was difficult to maintain. A licensed nurse stated that the typical goal for day and evening shifts was two nurses, four aides, and two medication aides, and for nights two nurses and two aides, and that weekends should be staffed the same way. Administrative nursing staff reported that an on-call schedule existed for weekends and that on-call staff and management were contacted to cover open slots, but also acknowledged that weekends had the most call-ins and were hard to cover. Administrative staff further confirmed that weekend staffing requirements were the same as during the week and were based on the facility assessment’s determination of the minimal number of staff needed to meet residents’ needs, yet the documented schedules showed repeated weekend shifts staffed below those minimums.
Insufficient Nursing Staff Leading to Delayed Medications and Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on multiple shifts, resulting in inadequate medication administration and assistance with activities of daily living for all residents. Staffing records and timecards for March 2026 showed repeated instances where individual Villas had only one nurse and no aide, or one nurse and one aide shared between two Villas, during both day and night shifts. On several nights, a single nurse and a single aide were responsible for residents in two separate free‑standing buildings, requiring them to leave one Villa without staff while they moved to the other. In at least one instance, a nurse scheduled for night shift did not clock in until early the following morning, further reducing coverage. Staff interviews confirmed that staffing was described as "awful" and that promised staffing levels of two aides per Villa or one nurse for two Villas with two aides were not consistently met. Because of this understaffing, nurses and aides were unable to complete required care tasks in a timely manner. Staff reported that when only one aide and one nurse were available for two Villas, the nurse had to pass medications in both buildings and also assist with transfers requiring two staff, causing delays in medication administration and resident care. One staff member reported working alone in a Villa with nine residents, having to prepare meals, wash dishes, administer medications, complete treatments, provide resident care, and perform charting without an aide. Another staff member stated that she could not complete cleaning and laundry tasks on most days and tried to do them only on Sundays when there were no showers. Staff also reported that residents who required full body mechanical lifts often had to wait to get up or be put to bed because two staff were needed for transfers and the second staff member was frequently in another Villa. Multiple residents with intact cognition reported not receiving medications and assistance in a timely manner due to lack of staff. One resident stated that insulin was received, but other medications were late, and another described medication timing as "hit and miss" when one nurse had to cover two Villas. Several residents reported consistently late medications and long waits for call lights to be answered, especially at night, with one resident stating they waited over an hour for a call light response and were frequently told by staff that there was not enough time. Residents who required mechanical lifts, including those with osteoarthritis, morbid obesity, diabetes, and lower extremity amputations, reported long waits to get out of bed, to use the bathroom, or to be put back to bed. One resident described waiting over 90 minutes for assistance to the bathroom, ultimately incontinent while waiting, and not receiving medications until late at night. Medication administration records (MARs) documented repeated late administration of insulin for several residents with diabetes. One resident ordered to receive long‑acting insulin between 8:00 p.m. and 11:00 p.m. had doses given after midnight on multiple dates, including one dose administered at 4:46 a.m. Another resident ordered fast‑acting insulin before meals at 7:00 a.m., 11:00 a.m., and 4:00 p.m. had numerous doses given significantly late, including morning doses after 8:40 a.m. and midday doses after 12:40 p.m. A third resident with orders for morning long‑acting insulin and pre‑meal and bedtime short‑acting insulin had many doses documented as late, with morning doses given after 10:00 a.m., midday doses after 12:40 p.m. or later, afternoon doses after 5:45 p.m. or later, and bedtime doses given close to or after midnight. Residents also reported periods when no staff were present in their Villa for extended times in the evening, during which they could not obtain pain medication or diabetic medication on time. These findings collectively show that the facility did not ensure adequate nursing staff each day to meet residents’ needs for timely medication administration and assistance with daily living. The facility’s own guideline document on Standard Supervision and Monitoring stated that staff assignments were to be based on resident needs and acuity, and that resident needs, including physical needs, would be met by providing as much hands‑on care as necessary. However, the documented staffing patterns, staff accounts, resident interviews, and MAR reviews demonstrate that the actual staffing levels did not meet these expectations. Residents experienced delays in transfers, toileting, and bedtimes, and insulin and other medications were repeatedly administered outside the ordered times, directly linked by staff and residents to the lack of sufficient nursing and aide coverage in the Villas.
Failure to Maintain Sufficient CNA Staffing and Timely Call-Light Response
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff were available on a specific evening shift, resulting in unmet care needs for a resident who was fully dependent on staff for toileting and hygiene. On that evening, two CNAs who were scheduled to work were unavailable: one CNA called off for the shift, and another CNA, a registry staff member, left early and did not return. No replacement staff were secured for either CNA, and the facility was unable to produce accurate documentation of how CNA assignments were regrouped or redistributed after these staffing losses. As a result, there was no documented reassignment for the resident care groups that included the affected resident’s room. The resident involved had diagnoses including constipation and Ogilvie syndrome and was documented as always incontinent of bowel and dependent for toileting and hygiene per the MDS Section GG and Section H. The resident was cognitively intact, with a BIMS score of 14, and resided on Station 1. On the evening in question, the resident reported becoming soiled due to her medical condition and activating the call light for assistance. She stated that the registry CNA assigned to her care left early and did not return, and that she waited approximately two hours after activating the call light before receiving help. During an interview and observation, the resident became teary while recounting the event and explained that managing her uncontrollable bowel movements was difficult. Multiple staff interviews and record reviews corroborated the staffing and response issues. Review of the NURSING STAFFING ASSIGNMENT AND SIGN-IN SHEET confirmed that one registry CNA called in and another registry CNA signed in for the shift but left early and did not clock in or out, with no replacement staff identified. The DSD, IP, and Human Resources/Maintenance Director confirmed there was no documentation of revised CNA assignments for the affected resident groups after the staffing changes. Staff, including a CNA who was not assigned to the resident, reported that call lights were not consistently answered that evening and that multiple call lights were observed unanswered. This CNA responded to the resident’s call light, found the resident crying and in a soiled brief, and observed that the resident’s skin appeared red when she was changed. Facility policies reviewed indicated that staffing should be sufficient and competent to meet resident needs, call lights should be answered within 3–5 minutes, registry staff should follow facility protocols and documentation requirements, and residents should be treated with respect, kindness, and dignity.
Inadequate Nurse and CNA Staffing Leading to Delayed Medications and Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nursing staff to ensure resident needs were met in a timely manner and medications were administered as ordered. On multiple occasions, nurse and CNA staffing on various floors and shifts fell below the facility’s usual staffing framework, resulting in delayed medication administration and delayed response to resident care needs. On one day shift, an LPN assigned to the first floor arrived around 10:14 AM to cover a 7-3 shift, causing some 9:00 AM medications on her assignment to be given after 10:00 AM. A registered nurse working that same day reported being the only nurse on the first floor at the start of the shift after another nurse called off, and stated that residents on the second set of rooms did not receive their 9:00 AM medications within the 8:00-10:00 AM window because of short staffing. A resident with diagnoses including chronic upper respiratory disease, congenital tracheal malformation, type 2 diabetes mellitus, morbid obesity, peripheral vascular disease, seizure disorder, schizophrenia, bipolar disorder, and anxiety reported often not receiving medications as scheduled, sometimes three hours late, and described one day when no medications were received until early afternoon. This resident, who receives Gabapentin for bilateral lower leg pain and has an intact cognition per MDS, stated that on a Saturday when the unit was short staffed and there was an emergency with another resident, his Gabapentin was not given on time and his pain level was eight out of ten. The RN confirmed that this resident’s standing 9:00 AM Gabapentin dose was administered around 11:15 AM and documented in the eMAR, outside the stated 8:00-10:00 AM window for 9:00 AM medications. The facility also failed to maintain adequate CNA staffing on several shifts. On one 7-3 shift with a census of 81 residents, only four CNAs worked on the second floor instead of the usual six, resulting in one CNA caring for approximately 19-20 residents, about half of whom required total care and three required a mechanical lift. That CNA reported prioritizing initial rounds, incontinence care, answering call lights, feeding residents, and passing out ice water, and stated that charting, nail care, shaving, and getting some residents who required a mechanical lift dressed or out of bed might not have been completed. Another resident with multiple comorbidities including partial traumatic amputation of the left lower leg, chronic venous hypertension with inflammation of both lower extremities, complex regional pain syndrome, dietary folate deficiency anemia, long-term insulin use, type 2 diabetes mellitus, long-term anticoagulant use, and chronic kidney disease, and who requires assistance with toileting, bathing, and transfers, reported that on a Saturday day shift there were only four CNAs working and that she had to wait a longer time for staff to respond to her call light and to be changed because staff were very busy. Additional staffing shortfalls occurred on other units and shifts. On one 3-11 shift on the third floor, only two nurses worked instead of the expected three, and an LPN reported that although all residents eventually received their 5:00 PM medications, some were administered outside the 4:00-6:00 PM timeframe due to the reduced staffing and the higher acuity of the dementia unit. On a separate 11-7 shift on the third floor, three CNAs worked instead of the usual four, with one CNA caring for 24-25 residents on the dementia unit and reporting that residents who wander and are at risk for falls could not all be watched and that residents had to wait longer to be changed if wet or soiled. On another morning, an LPN assigned to approximately 24 residents on the second floor arrived at 9:35 AM for a shift where 9:00 AM medications were to be given between 8:00-10:00 AM; by 10:01 AM she still had not completed the medication pass for all assigned rooms and acknowledged she would not be able to finish before 10:00 AM. The Director of Nursing and an advanced practice nurse both stated that inadequate staffing can delay medication passes, nursing assessments, accuchecks, and timely ADL care, and that CNA-to-resident ratios such as 1:20 and nurse shortages on heavier units like the locked dementia floor are problematic. The administrator reported that the facility does not have a staffing policy.
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