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F0725
D

Insufficient Nursing Staff Resulting in Delayed Care and Missed Treatments

Springfield, Illinois Survey Completed on 05-05-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple reports of delayed and inadequate care. Certified Nurse's Assistants (CNAs) and residents reported that food was frequently served late and cold, with staff having to use microwaves to reheat meals due to insufficient staffing. Residents described long wait times for meals and care, with one resident stating that food was not hot and was served well after the scheduled time, and another resident reporting that it could take up to an hour to receive care or food. Staff confirmed ongoing staffing problems, noting that tasks took longer to complete and that there were not enough staff members to meet residents' needs in a timely manner. Additionally, documentation revealed that a resident with stage III pressure ulcers did not consistently receive prescribed wound care treatments, with several dates lacking evidence of treatment administration. An LPN reported that staffing shortages had worsened since a change in ownership, with management not assisting on the floor and wound care deteriorating as a result. The facility's Director of Nursing acknowledged the absence of a formal staffing policy, stating that they follow CMS guidelines. These findings collectively demonstrate a pattern of insufficient staffing leading to unmet resident needs and lapses in required care.

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