Failure to Provide Sufficient Staffing and Supervision on Secured Unit
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, specifically on the secured locked unit, resulting in inadequate supervision for a resident with a known history of elopement and exit-seeking behaviors. This resident, a cognitively intact female with cardiac issues, seizures, and a traumatic brain injury, was admitted to the memory care unit due to her high risk for elopement. Despite care plan interventions requiring close supervision and 1:1 observation following an elopement incident, staff were not consistently present to provide the required supervision, and there was confusion among staff regarding the implementation of 1:1 supervision. Observations revealed that the resident was left alone in her room and in the hallway without staff in close proximity, even after being placed on 1:1 supervision. Interviews with CNAs and nursing staff indicated that they were not informed about the need for 1:1 supervision for this resident, nor were they provided with documentation tools or clear instructions. The DON and ADMN both stated that their expectation was for the resident to be within line of sight at all times, but acknowledged that staff were not always aware of or following this requirement. There was also no existing policy for 1:1 supervision at the time of the incident. The facility's failure to ensure adequate staffing and communication regarding supervision requirements led to repeated lapses in monitoring a resident at high risk for elopement. The medical director confirmed that the staffing levels on the secure unit were insufficient to meet the needs of all residents, particularly those requiring enhanced supervision. The deficiency was identified as Immediate Jeopardy due to the risk posed to resident safety and well-being.
Removal Plan
- Notify the Medical Director of the immediate jeopardy.
- Assess all residents residing on the secure unit for appropriate placement and complete elopement risk assessments.
- Create policies for one-on-one supervision, including criteria for 1:1, assignment of a third designated person not part of usual staffing, and required interventions prior to 1:1 placement.
- Discharge Resident #3 to a different facility with a more secure unit.
- Initiate in-service training for all staff (including new hires and agency) prior to working next scheduled shift, covering adequate supervision, secure unit staffing, and elopement protocols.
- Reassign staffing from other departments to work in the secure unit as needed for both day and night shifts to ensure two staff members are always present.
- Discuss residents’ change of condition with the care plan team during morning meetings, quarterly, and as needed, and evaluate the need for additional interventions.
- Hold an Ad-Hoc QAPI meeting with the Medical Director, NHA, Regional Nurse Consultant, DON, and ADON to review the deficiency, policy, and plan for removal.
- IDT (including Administrator, DON, and ADON) to review staffing schedules in the secure unit to ensure two staff are always present daily Monday to Friday, and Manager on Duty on weekends.
- Any negative findings for sufficient staffing to be immediately brought to the Administrator/Designee for further action, including sending additional staff as needed.
- RDO or designee to provide physical oversight at the facility weekly for 4 weeks, then monthly for 2 months.
- Administrator/designee to monitor compliance by reviewing staffing schedules and assignment sheets Monday through Friday; Weekend Manager on Duty to monitor on weekends.
- Any identified concerns to be addressed immediately, and if trends/patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss additional interventions for the next 2 months.
- Administrator responsible for ensuring completion of the plan.
- RDO/Designee to provide oversight of Administrator to ensure plan items are reviewed and completed.
Penalty
Resources
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The facility failed to provide adequate nursing staff to meet residents’ needs in a timely manner, resulting in prolonged waits for assistance with meals, toileting, and call light responses. Multiple residents and a family member reported delayed call light response, lack of timely help with ambulation and incontinence care, and concerns about safety. Surveyors observed several residents waiting extended periods between breakfast tray delivery and staff assistance, with food left uncovered and no offers to reheat or provide alternatives, while only two CNAs assisted about 13 residents in the dining room. Staff interviews confirmed that CNAs had to finish serving other residents before helping those needing feeding assistance, causing breakfast to be served much later than residents preferred. During meal periods, most CNAs were pulled into the dining room, leaving one CNA to monitor the hall, respond to call lights, and feed a resident, which led to call lights remaining unanswered for over 20 minutes and residents waiting in soiled briefs or in the bathroom without timely help.
The facility failed to maintain continuous licensed nurse coverage and adequate CNA staffing, resulting in periods when no nurse was present in the building and routine delays in care. On one afternoon, all nurses left the building, leaving dozens of residents without access to a nurse while they requested medications and IV care. Multiple CNAs, LPNs, and residents reported chronic understaffing, especially on nights, with only one CNA per hall and two nurses and two CNAs for nearly 70 residents, causing late medications, delayed incontinence care, missed showers, prolonged call-light response times, and residents remaining in bed or on the toilet for extended periods. Residents also described inadequate supervision, including confused residents wandering into rooms, and a resident with a PICC line reported walking the halls with IV tubing hanging from her arm without finding a nurse. The admission agreement promised 24-hour nursing care and assistance with ADLs, but the facility assessment did not specify needed licensed nurse numbers or detailed recruitment and contingency plans, despite acknowledged staffing chaos and high-acuity residents requiring intensive supervision and assistance.
A resident with severe cognitive impairment, dysphagia, and total dependence for ADLs was brought to the dining room in an open-back hospital gown, leaving the resident exposed, and left sitting alone with a full breakfast tray and no staff assistance for an extended period. Breakfast had been delivered earlier, but no staff were present in the dining area, and the resident, who required full assistance with eating, was not fed until a CNA arrived from another unit and provided feeding without reheating the food. Staff interviews indicated there were not enough personnel or time to dress the resident appropriately before breakfast and that morning medication pass limited nurses’ ability to assist with feeding, despite a facility policy requiring care that maintains resident dignity and privacy.
The facility failed to maintain adequate nursing staff and to respond promptly to resident call lights. Staffing records showed that nurse staffing fell below the facility’s minimum requirement on multiple days, and call light logs documented that dozens of residents had call lights activated for more than 30 minutes before staff responded. Several residents reported routinely waiting over 30 minutes for assistance after activating their call lights. The facility’s own policy requires timely response to call lights by any staff who see or hear them, but this was not consistently followed.
A high fall-risk resident with dementia, prior fractures, and impaired mobility experienced multiple falls, including one with head impact and another causing painful limited ROM, despite a care plan identifying fall risk and interventions such as transfer assistance, nonskid footwear, and dycem on the wheelchair. The resident was found on the floor in the room and hallway on several occasions, sometimes after becoming anxious when family left, and was not assessed post-fall for further injury or vital signs. Staffing schedules showed only three CNAs and two nurses on night shifts for nearly 50 residents, with each nurse covering two hallways and CNAs covering one hallway plus extra rooms. A CNA reported that residents needing increased supervision could not be adequately monitored under the usual staffing pattern, and the family reported difficulty locating staff responsible for the resident’s care due to staff being assigned across multiple hallways.
A facility failed to maintain adequate nursing staff levels, resulting in missed blood sugar checks and insulin administration for a resident with type I diabetes. Due to insufficient staffing and communication breakdowns, the resident was not properly monitored, was later found on the floor with severe hyperglycemia and other critical symptoms, and required transfer to the hospital for multiple acute conditions.
Insufficient Nursing Staff Leading to Delayed Meals and Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs in a timely manner, particularly during meals and in response to call lights. During confidential interviews with 25 residents, nine residents and one family member reported that staffing levels were inadequate to provide timely assistance. Reported concerns included delayed responses to call lights, staff turning off call lights and not returning, lack of assistance with ambulation, and untimely toileting and incontinence care, as well as worries about safety in an emergency. The facility’s staffing policy required adequate staffing on each shift to ensure residents’ needs and services were met, but observations and interviews showed this was not consistently achieved. Multiple observations during breakfast service showed residents waiting extended periods between tray delivery and staff assistance, with food left uncovered and no offers to reheat meals. One resident was seated in the dining room shortly before 9:00 A.M., but her tray was not uncovered until after 9:30 A.M., and staff did not begin assisting her until nearly 10:00 A.M., after which she consumed only a small portion of her meal and was not offered to have it warmed. Another resident had a meal placed in front of her without a cover and did not receive feeding assistance for over 20 minutes; she ate toast with encouragement but stopped after the first bite of eggs, and staff did not offer to warm the food. A third resident’s tray was placed in front of him uncovered, and he did not receive assistance for about 18 minutes; after one bite he refused further food, and no alternative or reheating was offered. CNAs reported that residents who required assistance with eating had to wait until CNAs finished serving other residents on the units, resulting in breakfast often not starting until around 9:30–10:00 A.M. for those needing help, with typically only two staff assisting about 13 residents in the dining room. Additional observations showed delayed responses to call lights and untimely toileting and incontinence care. One resident activated his call light at 11:00 A.M. because he was wet and needed changing; the light remained on until 11:41 A.M., when a CNA returned from break and provided incontinence care, finding the resident’s brief full of urine. The CNA and the DON both acknowledged that a 41‑minute wait was too long. In another instance, a resident’s call light remained on for approximately 25 minutes while she waited for assistance to get out of the bathroom; she eventually ambulated to the nurses’ station to report the delay. A CNA explained that during meals, all but one CNA were required to assist in the dining room, leaving a single CNA to monitor the hall, respond to call lights, and feed a resident, which prevented timely responses to all call lights. Family and therapy staff also reported that residents were receiving breakfast significantly later than they had previously, and that one resident who required one‑on‑one supervision for safe eating could not be accommodated in her room due to insufficient staffing.
Failure to Maintain Continuous Licensed Nurse Coverage and Adequate Staffing
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient licensed nursing staff on all shifts and adequate CNA staffing to meet resident needs, including a period when no nurse was present in the building. On one afternoon, two nurses left the facility, resulting in a gap of approximately 40 minutes to 1.5 hours with no licensed nurse on site while about 65–70 residents remained in the building. During this time, residents requested medications and nursing interventions, including removal of IV tubing from a PICC line, but no nurse was available to respond. A resident with diagnoses including peritoneal abscess, anemia, and a history of substance abuse reported that medications were often late and that on the day she left against medical advice, she walked the halls with IV antibiotic tubing hanging from her arm and could not find any nurse in the facility. Multiple CNAs and nurses reported that staffing was routinely insufficient across shifts, especially on nights, with only one CNA on each side of the building and two nurses and two CNAs for nearly 70 residents. Staff described being unable to complete timely incontinence care, showers, toileting, feeding assistance, and medication and treatment administration. They reported residents being found soaked in incontinence products at shift change, residents remaining in bed most or all day due to lack of staff to get them up, and residents waiting extended periods for call lights to be answered, sometimes 30 minutes or longer. Staff also reported that medications were consistently late, often documented as being “in the red,” and that nurses and CNAs frequently had to stay hours past their shifts due to call-offs and high workload. Residents and a resident representative corroborated that there were not enough staff to supervise and assist residents. Residents reported long waits for call lights to be answered, delays in receiving water and other basic assistance, and instances of being left on the toilet for prolonged periods while waiting for staff to return. Some residents described other residents wandering into their rooms without staff intervention, and one resident reported that she had to redirect confused residents herself. Another resident reported not receiving migraine medication after notifying a nurse leader and activating the call light twice more, with no staff response. Residents also noted that staff appeared frustrated and that staff turnover was high. Review of the facility’s admission agreement showed that the facility agreed to provide 24-hour nursing care and assistance or supervision with activities of daily living, including toileting, bathing, feeding, and ambulation. The facility assessment stated that its purpose was to determine necessary resources to care for residents during routine operations and emergencies and to inform staffing decisions, including day, evening, and night shifts, recruitment and retention, and contingency planning for staffing shortages. However, the assessment only identified the need for a full-time DON, ADON, MDS nurse, and part-time wound care nurse and did not specify how many licensed nurses were needed for the resident population or provide details on recruitment or contingency plans. This lack of detailed staffing planning, combined with ongoing staff departures and reliance on minimal staffing, contributed to repeated instances where resident care and supervision needs were not met. Human resources staff acknowledged difficulty filling night shift schedules for both nurses and CNAs and described recent initiation of agency use to fill open shifts. A newly hired LPN reported being scheduled to work independently on a unit during what was supposed to be an orientation day, without prior training on that unit. Staff interviews consistently described high-acuity residents, including geriatric psychiatric residents with behavioral issues, residents with frequent falls, and residents requiring 1:1 supervision or two-person mechanical lift transfers, being cared for with staffing levels that staff considered inadequate. The facility’s failure to ensure continuous licensed nurse coverage and adequate direct care staffing on all shifts, as well as its incomplete facility assessment regarding licensed nurse staffing and contingency planning, led to delays and omissions in resident care and supervision for the entire resident population.
Insufficient Staffing Led to Delayed Feeding and Inappropriate Attire in Dining Area
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to maintain the highest practicable psychosocial well-being of a resident who was dependent for all ADLs and required full assistance with eating. The resident had severe cognitive impairment (BIMS score of 0), highly impaired vision, unclear speech, and multiple medical diagnoses including dementia, dysphagia, psychosis, delusional disorder, depression, anxiety, and significant physical limitations such as muscle weakness, difficulty walking, and unsteadiness. The MDS documented that the resident was dependent for eating and all ADLs, required a mechanically altered diet, and needed to be up in a chair for meals with assistance for intake per speech therapy. On the morning of the survey observation, breakfast trays arrived to the memory care unit shortly before 8:00 A.M. At 8:55 A.M., the resident was observed sitting alone in the dining room in a wheelchair, wearing a hospital gown that was open in the back, leaving his back and legs exposed, with a full breakfast tray in front of him. No staff were present in the dining area, and the resident was not feeding himself. A CNA confirmed that the resident had been brought to the dining room in the hospital gown because there was not enough time or enough staff to get him dressed before breakfast, despite knowing this attire was not appropriate for the dining room. The care plan included interventions for fall risk and having the resident eat meals in the all-purpose room for closer monitoring when awake. The resident remained without feeding assistance until 9:23 A.M., when another CNA arrived from a different unit and began feeding him, giving a few bites without reheating the food and then completing the meal. This CNA believed the resident sometimes fed himself and was unsure why he had not been fed earlier, estimating that breakfast trays arrived around 8:00 A.M. An LPN stated that nurses helped feed residents when they could but that mornings were very busy with medication pass, and she believed it was acceptable for a resident to be in the dining area in a hospital gown, even though the resident could not choose his clothing due to cognitive impairment. The resident’s spouse reported that he had required assistance with eating since a recent hospitalization for pneumonia and that she came daily to feed him lunch, noting that staff response could be delayed because they were very busy. The facility’s Dignity, Respect, and Privacy Policy required that residents be treated with respect and cared for in a manner that protected their privacy.
Insufficient Staffing and Delayed Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet resident needs and to ensure timely response to call lights. Review of the facility’s staffing tool showed that staffing levels fell below the Minimum Staffing Requirement on three identified dates. Review of call light system logs for a four-day period showed that 42 residents had call lights that remained activated and unanswered for 30 minutes or longer before staff responded. The facility’s own policy, dated 12/01/25, states that call lights will relay to staff or a centralized location to ensure appropriate response and that all staff who see or hear an activated call light are responsible for responding or notifying appropriate personnel. Multiple resident interviews corroborated the call light data, with several residents reporting that call lights were not responded to in a timely manner and that they often waited more than 30 minutes for a response. These interviews occurred over two days and consistently described prolonged wait times for assistance. The Administrator confirmed that staffing fell below the Minimum Staffing Requirement on the identified dates, and an RN confirmed that 42 residents had call lights unanswered for 30 minutes or longer during the reviewed period. This deficiency was investigated under Complaint Number 2743940.
Inadequate Staffing and Supervision Leading to Multiple Falls
Penalty
Summary
The facility failed to provide sufficient staffing and supervision to prevent falls for a high-risk resident. The resident was admitted with multiple diagnoses including a displaced subtrochanteric fracture of the right femur, anemia, cerebral ischemia, urinary retention, Alzheimer's disease, dementia, prior falls with fractures, and adult failure to thrive. A fall risk assessment showed a high fall risk score of 22, and the care plan identified risk for falls related to impaired mobility, medication side effects, and history of falls, with interventions such as keeping the call light and personal items within reach, providing nonskid footwear, assisting with transfers, and therapy evaluation. Additional interventions later included use of dycem on the wheelchair and having the resident in a common area after family left in the evening. Despite these identified risks and interventions, the resident experienced multiple falls within a short period. On three separate occasions, the resident was found on the floor after attempting to self-transfer or falling from the wheelchair, including one fall in the hallway where the resident hit his head and was sent to the ER, and another fall resulting in painful and limited range of motion in the lower extremity. Post-fall investigations documented that the resident became anxious after family left and attempted to self-transfer, and that the resident was to be kept at the nurse’s station or in a common area for supervision. However, the medical record showed the resident was not assessed after the falls for further injury, including vital signs. Staffing schedules for the relevant dates showed three CNAs and two nurses on the night shift for 47–48 residents, with each nurse responsible for two hallways and each CNA for one hallway plus additional rooms. A CNA reported that with the usual staffing pattern, residents requiring increased supervision could not be adequately supervised, and the resident’s family reported difficulty finding CNAs or nurses responsible for the resident’s care due to staff covering multiple hallways. The administrator acknowledged an issue with falls that had been taken to QAPI and a pattern to when falls occurred.
Failure to Maintain Adequate Nursing Staff and Monitor Resident with Diabetes
Penalty
Summary
The facility failed to maintain adequate nursing staff levels to meet the needs of all residents, resulting in a deficiency that directly affected one resident and had the potential to impact others. On the day in question, the facility did not have the required number of licensed nurses on duty due to call-offs and scheduling issues. The staffing plan called for at least three LPNs or RNs on dayshift, but only two nurses were present, and attempts to secure additional coverage were unsuccessful. Communication breakdowns occurred between the nightshift nurse, the Director of Nursing, the Administrator, and Human Resources, leading to confusion about who was responsible for medication administration and resident care during the shift change. A resident with type I diabetes and a history of unstable blood glucose levels experienced significant lapses in care. The resident did not receive scheduled blood sugar checks or insulin administration as ordered by the physician. Documentation showed that the resident's blood sugar was not monitored for an extended period, and there was no evidence that insulin was administered when indicated. The resident was later found on the floor in her room, lying in vomit, with critically low blood pressure, irregular pulse, and severe hyperglycemia. Staff were initially unaware of the resident's whereabouts, and it was only after a search that she was located and assessed. The resident was subsequently transferred to the emergency department, where she was diagnosed with diabetic ketoacidosis, high anion gap metabolic acidosis, acute urinary tract infection, non-ST elevated myocardial infarction, and sepsis. The facility's failure to provide adequate staffing and ensure proper monitoring and care for the resident's complex medical needs contributed to the adverse outcome. The deficiency was further evidenced by the lack of a root cause analysis for the resident's fall and the absence of timely interventions in response to her deteriorating condition.
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