Failure to Provide Adequate Supervision for High-Risk Resident Resulting in Unwitnessed Fall
Summary
The facility failed to provide sufficient nursing staff to maintain adequate supervision for a resident identified as a wanderer and at high risk for falls. The resident, an elderly female with multiple diagnoses including dementia, atrial fibrillation, and osteoarthritis, required hourly visual checks and wore a wander bracelet due to her high risk of elopement. Despite these interventions, the resident was able to leave her bed and room multiple times during the night, ultimately wandering outside onto the patio unsupervised, where she sustained an unwitnessed fall resulting in a laceration above her left eye that required hospital treatment and sutures. Review of records and staff interviews revealed that on the night of the incident, the certified nursing assistant (CNA) assigned to the resident was also tasked with being a 1:1 sitter for another high fall risk resident in a different room for several hours, leaving the original assignment unattended. The remaining CNA attempted to monitor both assignments but was also responsible for a large number of residents. Staff reported that during the night shift, there were fewer personnel available compared to the day shift, making it more difficult to provide adequate supervision for residents with high acuity and wandering behaviors. The resident's care plan included interventions such as a low bed, visual checks, and proximity to the nursing station, but no 1:1 sitter was assigned. Interviews with staff, including the charge nurse, director of staff development, and assistant director of nursing, confirmed that the resident was not identified as needing a sitter and that staffing assignments were adjusted due to a last-minute call-off. The facility's policy required adequate staffing to meet resident needs, but on the night in question, the combination of high resident acuity, staff reassignments, and reduced night shift staffing contributed to the failure to provide the necessary supervision, resulting in the resident's unsupervised exit and subsequent fall.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors found that the facility failed to ensure sufficient nursing staff and accessible, functional call lights for dependent residents. Several residents reported waiting from 30 minutes to hours for call bell responses, sometimes having to go to the nurses’ station themselves or, in one case, calling 911 when no call bell was available. During observation, multiple residents in bed had call lights on the floor and out of reach, and one room’s call system did not activate until an RN adjusted the wall connection. LPNs reported caring for 20–38 residents per shift, described triaging call lights due to workload, and stated they could not consistently meet expected response times. Grievance logs documented repeated, non-specific “call bell issues” over multiple review periods, and the Activities Director confirmed that residents continued to voice ongoing problems with delayed call light response during resident council meetings.
The facility failed to provide sufficient CNA staffing on a high‑census unit, resulting in only three to four CNAs caring for 49 residents while staff were floated to lower‑census units. A resident and multiple staff reported that showers were often replaced with bed baths due to inadequate staffing and the need to keep CNAs on the unit to answer call lights. Several residents described waiting 45–60 minutes for call light responses, including one who remained incontinent for several hours and another who slept in urine. Residents also reported rushed and incomplete hygiene care and noted that overworked staff argued about assignments and sometimes limited help to their own areas.
The facility failed to ensure adequate nursing staff on all shifts, leading to prolonged call light response times and unmet care needs. Multiple residents reported waiting from 45 minutes to several hours for assistance, including toileting and incontinence care, and described staff leaving the floor during smoke breaks and meal tray pass, leaving minimal coverage. Staffing records showed nursing HPPD below required minimums on at least one reviewed day, and an external report flagged low weekend staffing. One resident reported being left overnight in a soiled brief while having diarrhea, later found with raw, red skin to the sacral and scrotal areas, and this incident was not documented as a grievance or reportable event. A night-shift observation also revealed fewer staff on duty than posted, with one NA sleeping and another conducting personal business, while only two NAs were left to care for more than fifty residents.
A cognitively impaired, wandering resident with Alzheimer’s disease and behavioral symptoms was care planned as an elopement risk but was able to leave the memory care unit by holding an emergency exit door bar for 15 seconds and exiting into a stairwell and then to the employee parking lot. The door alarm functioned, but staff in the noisy dining room did not hear it while they were feeding multiple residents, including several needing extensive assistance, and only realized the resident was missing when another staff member encountered him outside and brought him back. In addition, several residents who required staff assistance for transfers and toileting experienced prolonged call light response times well beyond the facility’s 15‑minute expectation, including one who reported waiting up to an hour during meals and having an in‑room accident, another observed waiting about 25 minutes while calling out for help, and a third waiting about 17 minutes before a CNA responded.
The facility failed to respond to resident call lights within its stated goal of 7 minutes, with documented response times exceeding 30 minutes for multiple residents. A cognitively intact resident reported being left on the toilet for extended periods, and call system data showed call lights active for well over an hour on several occasions. Another resident with moderately impaired cognition had call lights unanswered for more than an hour, including after returning from dialysis. A third cognitively intact resident reported waiting up to two hours, with records confirming multiple call light activations lasting over an hour. The DON acknowledged that call light times over 30 minutes were not timely.
Insufficient staffing led to missed restorative exercise services for multiple residents with OT/PT discharge plans for ROM, strengthening, ambulation, and functional maintenance. Restorative aides were repeatedly pulled to the floor to work as NAs because of call-ins and short staffing, leaving many residents without ordered FMPs or exercise sessions, including one resident with no documented restorative exercises during the review period and others receiving services only a few times despite frequent opportunities.
Insufficient Nursing Staff and Call Light Accessibility Failures
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff and ensure accessible, functional call lights for dependent residents, as required by its own call light policy and federal regulations. The facility’s written policy states that residents must have a call light within reach, that call lights must be answered promptly by facility personnel, and that all personnel are expected to respond. During an initial tour at 8:45 a.m., multiple dependent residents were observed in bed with their call lights on the floor and not accessible, and the DON confirmed that these residents should have had call bells within reach. Photographic evidence was obtained of call lights on the floor. Multiple residents reported prolonged delays in call light response and difficulty obtaining assistance. One resident stated she had recently filed a grievance about call light response times and reported waiting about 30 minutes to an hour before anyone answered, sometimes having to walk to the nurses’ station herself. Another resident reported waiting “hours” after pressing the call bell and said that when staff did not come, she would go to the desk in her wheelchair; she believed there was not enough help at night and on weekends. A third resident reported that sometimes it took a very long time for staff to answer the call light, and that on one occasion when he did not have a call bell at his side, he yelled repeatedly and ultimately called 911 from his phone to get help. Additional residents described ongoing problems with unanswered call lights and unmet care needs. One resident reported that it could take up to an hour for staff to respond and that at the time of interview he had been waiting about an hour for a simple request for water; when he activated his call light, the indicator above the door did not illuminate until an RN adjusted the wall connection, confirming the call light had not been working. Another resident stated he had filed grievances about staff not answering call lights and reported that he sometimes waited two hours or more for toileting assistance, resulting in soiling himself; he said he did not think there was enough staff and that this had been an ongoing issue. Nursing staff interviews further described workload and response-time issues. One LPN stated that all staff are responsible for answering call bells, that the required response time was within 30 minutes, and that she had to triage which residents to see first; she reported sometimes being unable to respond timely and described working night shift with 35–38 residents, saying she did not feel her license or the residents were safe. Another LPN stated that everyone was responsible for answering call lights and that the expectation was a response within 10 minutes, but that this did not occur because staff were too busy; she reported caring for 20–29 residents per shift and had told management that, given resident acuity and needs, this was too many. Review of the grievance logs showed repeated, non-specific complaints about call bell issues over multiple review periods. For one review period, there were seven call light grievances, all documented as “call bell issues” and handwritten by the Activities Director, without specific times or dates. The facility’s documented resolution for these grievances was staff education and call bell audits, but the same audit documentation was used across different review periods, and for some periods there was no documentation that audits or education were actually completed. The Activities Director stated she wrote all resident grievance forms, knew many residents had issues with timeliness of call light response, and that residents could not recall specific times or dates. She reported that during resident council meetings, residents continued to voice that delayed call light response remained an ongoing problem. In an interview, the Administrator acknowledged that answering call lights was a “work in progress” and stated that they kept educating staff. He noted that when the issue was raised in resident council, residents would start to complain about it and that there were many similar complaints on the same day, sometimes from the same residents. He also stated that he could only staff according to what his management allowed. The DON reiterated that call lights should be within reach of each resident and answered as quickly as possible, stating that any time a call light is set off it could be an emergency. Despite these stated expectations, the observations, resident interviews, staff interviews, and grievance documentation collectively showed that dependent residents did not consistently have accessible, functional call lights and experienced significant delays in staff response, reflecting insufficient nursing staff to meet residents’ needs.
Insufficient CNA Staffing Leading to Delayed Responses and Incomplete Hygiene Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs and to ensure timely, thorough care. Multiple residents and staff reported that the unit was frequently short staffed, with only three to four CNAs assigned to care for a census of 49 residents, despite expectations that five or more CNAs were needed. On one day, the posted daily nursing staff report documented five CNAs for the unit, but only four were observed, and one CNA was reassigned to another unit with a lower census. Staff interviews confirmed that CNAs were often floated off the unit, leaving fewer staff to manage a higher resident load. As a result of this staffing pattern, residents reported delays in response to call lights and changes in the type and quality of hygiene care provided. One resident stated that when staffing was short, CNAs did not have time to provide showers and instead gave bed baths, and this was confirmed by CNA interviews and shower task documentation showing a bed bath provided on a specific date. CNAs reported that providing showers required leaving the wing, which they could not do without leaving insufficient staff to answer call lights, leading them to substitute bed baths, especially for residents who required more time and assistance. Staff also reported that when the unit was short staffed, they rushed care rather than providing quality care. Several residents described specific incidents of delayed incontinent care and prolonged waits for assistance. One resident reported remaining incontinent from approximately 8:00 AM until 12:30 PM after a bowel movement because staff did not respond to assist her. Anonymous residents reported waiting 45 minutes to an hour for staff to respond to call lights, including an instance where a resident slept in urine due to the delay. Residents also reported that staff were overworked, argued about incomplete assignments, and sometimes limited their assistance to their own assigned areas, contributing to incomplete or rushed hygiene care when bed baths were provided.
Insufficient Staffing Leading to Delayed Care and Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on all shifts to meet residents’ needs, resulting in delayed responses to call lights and inadequate incontinence care. During a resident council meeting, multiple residents reported waiting 1–3 hours for call lights to be answered, with staff sometimes stating they would return but not coming back for hours, and some residents reporting staff said they had been outside smoking with a resident. Individual resident interviews corroborated these concerns, with residents stating that night shift took a long time to answer call lights, that it could take 45 minutes to an hour or more to receive assistance, and that staff would delay changing residents during meal tray pass or after a scheduled smoke break when most aides and a nurse accompanied residents outside, leaving only one nurse to cover the floor. Staffing record reviews for specific dates showed Hours Per Patient Day (HPPD) below the minimum required 2.25 on at least one day, and the facility’s CASPER report triggered for low weekend staffing. A specific incident of neglect was identified for one resident who reported being left overnight in a soiled brief while experiencing diarrhea, despite requesting to be changed. Two CNAs independently stated that when they saw this resident the following morning, he reported not having been changed all night, and both described his skin as raw, bad, and red; one CNA stated she had changed him the previous day and that he reported no changes overnight, and both CNAs reported the condition to an LPN, who then notified an RN, leading to a wound care order for excoriation to the sacrum and scrotum. Prior skin assessments earlier in the month showed no issues in those areas, and the incident was not documented in reportables or grievances. Additionally, a night-shift observation found a discrepancy between the posted staffing sheet and actual staff present: the sheet listed two LPNs, three NAs, and no RNs, but only one LPN and two NAs were observed, with one NA found sleeping on duty and another engaged in personal business on a laptop, while a third NA was assigned 1:1 to a resident, leaving two NAs to cover 56 other residents. The administrator confirmed that the described incontinence incident would constitute neglect if accurate.
Elopement of Wandering Resident and Delayed Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for a cognitively impaired, wandering resident and failure to respond to resident call lights within the facility’s stated 15‑minute expectation. One resident with Alzheimer’s disease, bipolar disorder, and anxiety disorder had a care plan identifying risk for elopement due to wandering and documented behaviors of agitation, aggression, restlessness, and continuous pacing/wandering within the unit. This resident ambulated independently with a walker and had a BIMS score indicating impaired cognition. On the evening of the incident, the resident finished supper in the memory care dining room and then repeatedly walked the hallway with his walker, eventually approaching an emergency exit door at the far end of the hall, away from the dining room. Video and documentation show that the resident stood at the emergency exit door, held the door bar down for the required 15 seconds to release the egress, and then exited through the door into a stairwell and out to the employee parking lot. The door alarm and 15‑second egress functioned, but staff in the dining room did not hear the alarm due to noise from residents, staff conversation, and the television. At the time, two CNAs and one LPN were in the dining room feeding multiple residents, including several who required assistance, and staff reported that the resident was very quick, wandered constantly, and was difficult to keep seated. Staff interviews revealed that one CNA noticed the resident was no longer in the dining room around the same time another staff member reported they were looking for him, and only then did staff recognize the back exit door alarm sounding. A nurse arriving for her shift in the parking lot encountered the resident outside with his walker and escorted him back inside, after which he was assessed and found in stable condition. The deficiency also includes failure to respond to resident call lights within the professional standard of 15 minutes for multiple residents. One resident with intact cognition but dependent or substantial/maximal assistance needs for toileting reported that during meal hours it could take up to an hour for staff to answer the call light, resulting in an in‑room accident. Another resident, alert and oriented but occasionally forgetful and requiring two‑person assistance for transfers, was observed with the call light on for approximately 25 minutes in the morning while repeatedly yelling for help; staff walked past in the hallway without answering the light until a staff member finally entered the room. A third resident, requiring one‑person assistance for transfers, was observed with the call light on for about 17 minutes before a CNA entered to assist. The DON stated that the facility’s expectation is that call lights be answered within 15 minutes, and the facility’s policy directs all staff from all departments to respond to call lights and either assist or obtain appropriate help, but the observed response times exceeded this standard for the residents involved. Staff interviews further described the conditions contributing to these call light delays and supervision gaps. Staff on the memory care unit reported that typical evening staffing consisted of one nurse, one CMA, and two CNAs, and that while this was manageable when routines went smoothly, it became inadequate when residents had behaviors, were sundowning, or when events such as falls or changes in condition occurred. A CMA stated that at least three CNAs were needed on the memory care unit due to multiple residents requiring two‑person assistance, noting that when two CNAs were in a room providing care, they could not monitor the rest of the unit. Staff also reported that the back exit door alarm was faint and difficult to hear from the dining room, and some staff were not fully aware of the configuration of the back stairwell and exit leading to the parking lot. These conditions, combined with high resident care needs and noise levels during meals, contributed to the resident’s elopement and to prolonged call light response times for several residents. Maintenance and administrative staff confirmed that the south/back exit door from the unit led to another unalarmed door and then to the outside employee parking lot, and that the facility did not receive system reports when door alarms were activated. The Administrator was unable to verify when a door alarm went off or when an exit door was breached. The facility’s Wandering Resident policy stated that residents at risk for elopement should receive adequate supervision to prevent accidents and that staff must be vigilant in responding to alarms in a timely manner, and the call light policy required prompt response by all staff. Despite these policies, the documented events show that the resident at risk for elopement was able to leave the secured unit and reach the parking lot without timely staff detection, and that multiple residents experienced call light response times significantly longer than the facility’s stated 15‑minute standard.
Failure to Respond Timely to Resident Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely response to resident call lights, with multiple documented instances of response times far exceeding 30 minutes. One cognitively intact resident (BIMS score 13) reported being left on the toilet for a very long time in mid-January and again on a later date in April, though for a somewhat shorter period. Alarm Average Response Time Reports (AARTR) showed that this resident’s call light remained on for 167 minutes and 51 seconds on one January date, and for 46 minutes and 32 seconds and 73 minutes and 34 seconds during two separate call light activations in April. Another resident with moderately impaired cognition (BIMS score 12) had a family member report that the resident had to wait an hour to be laid down after dialysis. AARTR data for this resident showed call light durations of 61 minutes and 38 seconds and 76 minutes and 33 seconds on separate occasions in April. A third cognitively intact resident (BIMS score 15) reported having waited as long as two hours for a call light to be answered, and AARTR records documented call light durations of 65 minutes and 18 seconds and 63 minutes on two separate occasions. The DON stated that the facility’s goal for call light response was 7 minutes and confirmed that call light times over 30 minutes were not timely.
Insufficient staffing caused missed restorative exercise services
Penalty
Summary
The facility failed to provide sufficient staffing to carry out restorative exercise services for residents enrolled in restorative nursing and functional maintenance programs. The report states that 6 of 6 reviewed residents (R14, R20, R32, R40, R53, and R66) did not receive their ordered exercise programs as scheduled, and that the issue had the potential to affect all 38 residents who had exercise programs. The deficiency was tied to staffing shortages and restorative aides being pulled from restorative duties to work on the nursing floor. R20, R53, R40, R14, R66, and R32 each had restorative care plans with specific exercise or range-of-motion interventions ordered after discharge from OT and/or PT. The documentation reviewed showed that these residents received the ordered services inconsistently or not at all during the review period. For example, R40 had no restorative exercises documented during the 15-week period reviewed, R14 received exercises 3 times out of 105 opportunities, R66 received exercises twice during 15 opportunities, R20 received exercises once and refused three times, R53 received exercises five times and refused once, and R32 received FMP exercises twice with no ambulation services documented. The restorative program logs showed multiple weeks in which very few residents received services, including weeks with 0 residents served. During interviews, the restorative aide stated she was frequently pulled to the floor to work as a NA, could not get through the resident list, and that many residents did not receive FMP services because of short staffing and call-ins. The DON stated there were two part-time restorative aides, but for about 6 months the facility had only one part-time restorative aide, and that it was not acceptable to keep pulling restorative aides to the floor because they could not get to all residents in a week and residents went without their FMP.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.