Chronic Understaffing Leads to Delayed Care, Missed Showers, and Inadequate Call Light Response
Summary
The deficiency involves the facility’s failure to provide sufficient and accurately reported nursing and direct care staffing to meet residents’ needs for timely call light response, showers, incontinence care, room cleaning, and fall prevention. The facility’s own Facility Assessment Tool for 08/2025–08/2026 documented expected CNA staffing levels (seven CNAs on days and evenings for 87–92 residents and three CNAs on nights for a census under 86), but the Administrator later stated the assessment had not been updated and did not reflect the actual number of CNAs needed. Daily staffing calculator reports for multiple dates in December 2025 showed CNA hours worked were below the calculated hours needed on numerous days. Staff schedules and interviews confirmed that on some shifts there were significantly fewer CNAs present than planned, including reports that at 6:00 AM on at least one day there were only two CNAs in the building when there should have been seven or eight. The facility also failed to accurately document staffing on its Daily Staffing Calculator reports. On two randomly selected dates, the calculator overstated therapy and activity staff hours compared to the actual treatment and direct engagement hours documented by the Therapy Director and Activity Director. The Administrator acknowledged relying on reported numbers from these department heads and was unaware they were inaccurate. Additionally, daily assignment sheets showed that the Administrator, the MDS Coordinator (RN), and the previous DON were working the floor for portions of shifts to cover staffing gaps, while the Laundry and Housekeeping schedule showed limited housekeeping/laundry coverage on certain evenings, with no staff scheduled 4:00 PM–12:00 AM on some dates. Resident and family interviews, Resident Council minutes, and grievance/concern forms documented repeated complaints of long call light response times, missed or delayed showers, and inadequate room cleaning. Residents reported waiting from an hour to several hours for call lights to be answered, including one resident who stated she remained in feces for approximately 90 minutes after receiving a laxative and that her bed linens were not changed afterward. Another resident reported having only one shower since admission and needing to ask multiple times for showers, while others stated they were given bed baths instead of preferred showers and had to “nag” staff. A family member reported having to toilet a resident himself due to call lights not being answered. Residents and staff also reported that staff were too busy or too few to get residents up as ordered, to provide showers as scheduled, or to remain present in the assisted dining room as required. Staff interviews further described chronic understaffing, particularly on evening and night shifts, frequent reliance on agency CNAs and nurses, and agency staff not completing all required care or answering call lights consistently. CNAs reported that staffing on some mornings started with only two CNAs in the building, that they often had to cover large halls and also assist in the assisted dining room, and that daily staffing sheets did not match the actual staff present. The Ombudsman reported receiving multiple complaints about call lights not being answered or being turned off without staff returning, including a call from a resident who said she sat in feces for 90 minutes with her call light on. The incident/accident log and Regional Nurse Consultant interview documented multiple unwitnessed falls for one resident in the assisted dining room and at the nurses’ station, including a fall on one date that was not documented on the log, while a CNA stated she believed residents were having falls because there was not enough staff. Resident Council minutes over several months consistently recorded concerns about call lights, showers, soiled items in rooms, and lack of room cleaning when housekeepers were off work. Overall, the observations, records, and interviews show that the facility did not maintain sufficient numbers of CNAs and licensed nurses on each shift to meet residents’ needs for timely assistance, personal hygiene, toileting, and environmental cleanliness, and did not maintain accurate staffing records or an updated facility assessment reflecting actual staffing needs for its census of approximately 83–91 residents.
Penalty
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Insufficient nursing staffing led to delayed toileting help, delayed meal assistance, and transfers done outside assessed needs and policy. A resident who was dependent for toileting and transfers was left in bed crying, incontinent, and told to stay in bed and pee her pants until staff could return, while another resident waited 45 minutes for help eating in the dining room. Surveyors also found repeated weekend staffing shortages, and staff described frequent short staffing, late or missing staff, and reliance on agency and float staff.
Insufficient staffing prevented the facility from providing ordered one-to-one supervision for two residents after resident-to-resident incidents. Observations showed the residents without staff supervision, and interviews with the Staffing Coordinator and DON confirmed the facility could not consistently implement the care-planned supervision because of staffing shortages and competing supervision needs.
Inadequate staffing and supervision resulted in unmet care needs and resident-to-resident altercations. A male resident with dementia who was exit seeking and wandered into other residents’ rooms required more 1:1 oversight than staff could provide, and staff reported they were unable to keep him safe while covering other duties. He was involved in multiple altercations with another resident when staffing was short. A second resident who required 2-person transfer assistance experienced repeated call light delays, with staff turning off the light before completing care and a 54-minute wait for transfer assistance. Staff and residents reported frequent call-offs, long wait times, missed breaks, and difficulty meeting resident needs when the unit was short-staffed.
Insufficient nursing staff led to delayed call light response and resident care needs not being met. Residents reported waiting 30 to 40 minutes or longer for toileting and other assistance, with some soiling themselves or being left in wet briefs. Staff and resident council concerns, grievances, confidential complaints, and observations of unkempt residents and incomplete shower documentation supported the finding. The NHA and DON confirmed the facility was short staffed and unable to consistently meet resident needs.
The facility failed to provide enough licensed nursing staff to meet resident needs and have a licensed nurse in charge on each shift. The staffing schedule and time records were inconsistent, and interviews showed the facility was short multiple LPN/RN hours across shifts after several call-offs and partial coverage from agency and sister-facility nurses. Staff and residents reported that there was no nurse on the 100 hall for much of the day, resulting in missed meds, delayed BG checks, and an insulin omission for a resident whose BG later measured 441.
Delayed call light response was identified for two residents who were totally dependent on staff for ADLs. One resident with quadriplegia reported waits of 30 minutes or more for help and missed repositioning, while another resident with spinal cord dysfunction, quadriplegia, and a suprapubic catheter reported waits of up to 4.5 hours, delays in being cleaned after BMs, and missed bed baths. Staff and the DON reported frequent call-offs, short staffing on multiple shifts, and response times often far beyond the facility’s expected 15-minute standard.
Insufficient Nursing Staffing Led to Delayed Care and Missed Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents’ assessed needs and provide required care and services. Surveyors found that staffing shortages resulted in delayed toileting assistance, delayed eating assistance, loss of dignity, and transfers performed contrary to assessed needs and facility policy for 2 of 6 residents reviewed. CMS PBJ Staffing Data Reports also showed excessively low weekend staffing triggers for multiple fiscal year quarters. On the day of survey entry, the facility was locked, the survey team had to call for entry, and an LPN stated the facility was working short because a day shift nurse did not show up and the night nurse had stayed until 10:30 a.m. before leaving. The LPN said she had been answering call lights, helping NAs, and trying to complete her own duties, while only two NAs were in the facility. One resident, who had mild cognitive impairment, dementia, non-traumatic spinal cord dysfunction, diabetes, and was dependent on staff for toileting and transfers, was observed crying in bed wearing only a sweatshirt and incontinent brief with no pants. The resident stated staff told her she had to stay in bed and could not get up, and that they told her to pee her pants and they would clean her up there. The resident said this happened all the time and that staff shut off her call light just about every day because they were short. NA-B later cleaned the resident after she was wet and incontinent of urine and feces, applied barrier cream, and then had to leave to get another staff member for a two-person mechanical lift transfer. The resident was then transferred to her wheelchair with two staff and taken to the dining room. Another resident, who was cognitively intact and independent with eating but had been identified as needing assistance with meals for optimal intake, was observed in the dining room with food in front of her and no staff helping her eat. At least two residents were sitting with food in front of them and were not eating or receiving staff assistance. The resident waited 45 minutes before staff assisted her to eat, and once assisted she ate well. Staff interviews described ongoing staffing problems, frequent use of agency staff, missed or late staff, difficulty getting help from float staff, and expectations that medication staff would assist with call lights and resident care when possible. The DON stated float staff lacked accountability because they had no assigned resident group and planned to change assignments so each nursing assistant, including float staff, would have assigned residents.
Insufficient staffing to provide ordered one-to-one supervision
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents who were care planned for one-to-one supervision after resident-to-resident allegations. A review of the investigation dated 04/27/2026 showed that Resident 102 was to receive one-to-one supervision related to the incident, but observations on 05/19/2026, 05/22/2026, 05/26/2026, and 06/01/2026 showed the resident either in the East Hall or in the room without staff supervision. A separate investigation dated 05/22/2026 showed that Resident 7 was to receive one-to-one supervision related to the incident, but observations on 05/26/2026 and 06/01/2026 showed the resident without staff supervision. During interviews, Resident 7 stated on 06/01/2026 that they were not receiving one-to-one supervision as discussed, and another resident in the same room stated they had not seen staff providing one-to-one supervision to Resident 7. The Staffing Coordinator stated there were three residents who required one-to-one supervision and that, due to a recent fire and the need for smoking aid, the facility did not have sufficient staff to provide one-to-one supervision each day. The Staffing Coordinator also stated that if a resident who required one-to-one appeared stable, staff would rotate between smoking supervision and one of the residents care planned for supervision. Review of the staff schedule for 05/26/2026 through 05/31/2026 showed no scheduled one-to-one supervision for Residents 102 and 7, and the DON stated the facility had not been able to implement the care planned one-to-one supervision due to lack of staffing.
Inadequate staffing and supervision led to unmet resident care needs and resident-to-resident altercations
Penalty
Summary
The facility failed to provide adequate staffing to meet resident needs and to have sufficient supervision for residents requiring close monitoring. Resident #22, a male with dementia and a care plan identifying him as at risk for elopement due to memory deficit, confusion, and inability to read or write, was repeatedly described by staff as wandering into other residents’ rooms, going through belongings, and exit seeking. Staff reported that he needed more one-to-one supervision than the facility could provide, especially when staffing was short, and that they could not keep him safe while also completing other resident care tasks. On 5/23/26, staff reported Resident #22 wandered throughout the day and was frequently in and out of other residents’ rooms. The facility schedule showed 1 nurse and 2 CNAs in the building at the time of the incident, although 3 CNAs were scheduled and one had called off. Staff interviews stated that when staffing was short, they were rushing through care, working through lunch, and unable to address psychosocial needs. An incident report documented that Resident #22 initiated a resident-to-resident altercation on 5/23/26 at 3:20 PM. Later, on 5/26/26, the family was told the resident would not receive 1:1 supervision because of staffing issues, and an incident report documented that at 4:44 PM he grabbed a female resident in a choke hold and punched her in the face, chest, and upper back multiple times. The schedule for that time showed 1 nurse and 3 CNAs in the building. Resident #26, who had reduced mobility and used a wheelchair, required a sit-to-stand mechanical lift for transfers and was identified on the care plan as needing care needs met. During observation, he activated his call light repeatedly while waiting to get out of bed, but staff entered, turned off the light, and told him to wait or that they would get help. It took 54 minutes from the first call light activation until two staff members arrived to transfer him from bed to wheelchair. Resident #26 reported that long call light wait times of more than 30 minutes happened regularly and that staff often turned off the light without completing the requested care. Other residents in a confidential meeting also reported long waits for assistance and frequent unsupervised wandering by a resident with advanced dementia. Staff interviews and payroll-based journal information further described repeated staffing shortages, missed breaks, and difficulty covering call-offs, including low weekend staffing.
Insufficient Nursing Staff and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs and have a licensed nurse in charge on each shift. Review of the facility’s call light policy stated that call lights should be answered as soon as possible and that resident requests should be addressed promptly. The report also cited the RAI User’s Manual definition of BIMS scoring and identified multiple residents with varying levels of cognitive and physical dependence who required assistance with toileting, bathing, transfers, and mobility. During a resident group interview, residents reported that there were not enough staff to provide care, that they had to wait for toileting and other care, that some residents soiled themselves while waiting, and that showers were sometimes replaced with bed baths because of staffing shortages. Residents also stated that staff sometimes turned off call lights without addressing the request, said they would return, and then did not come back promptly. Individual resident interviews described waits of 30 to 40 minutes or longer after using call lights, with one resident reporting being left in a wet brief overnight and another reporting soiling himself and the bed after waiting too long to be toileted. The clinical records and observations supported these concerns. One resident was dependent for toileting, bathing, and transfers and reported repeated delays in care; another resident with heart failure, depression, and a CVA was dependent for toileting, bathing, and transfers and reported waiting over an hour to be changed after using the call light. A third resident with heart failure, BPH, and hyperlipidemia required partial assistance and reported being unable to hold urine while waiting for staff. Observations also found a resident with long, soiled fingernails and another with matted, unkept hair, while shower documentation did not show that ordered showers were consistently provided. Grievances, confidential complaints, resident council minutes, and staff interviews all described ongoing concerns with care delays, call light wait times, and short staffing, and the NHA and DON confirmed the facility failed to provide sufficient nursing staff to meet resident needs.
Insufficient Licensed Nursing Staff and Missed Medications
Penalty
Summary
The facility failed to ensure an adequate number of licensed nursing staff were available to meet resident needs and to have a licensed nurse in charge on each shift. The facility assessment dated 4/1/26 stated the staffing plan required four licensed nurses on the day shift, four on the evening shift, and three on the night shift. However, the nursing schedule, timecards, and daily work assignment sheet for 5/10/26 were incongruent and/or illegible, and the staffing situation had to be clarified through interviews with facility leadership and staff. According to the Administrator, the facility had major staffing problems on Mother's Day, including two agency nurses and one facility nurse calling off. The Administrator stated the facility was three nurses short, the DON was on vacation, and two nurses from a sister facility worked partial shifts later in the evening. The Administrator also stated an LPN/MDS coordinator worked a partial shift from about 9:00 am to 4:00 pm or 4:30 pm, and that staffing issues affected both the 6:00 am to 6:00 pm and 6:00 pm to 6:00 am shifts. Based on interviews and document review, the facility was short approximately 15 licensed nurse hours on the day shift and approximately five hours on the evening shift. Residents and staff described missed care and medication omissions during the staffing shortage. One resident reported not receiving insulin in the morning and stated no accu-check was done until later in the day, when the first blood sugar recorded was 441 and required 12 units of insulin. Another resident stated there was no nurse on duty all day and medications were not received. A CNA stated residents were upset because none of them got their medications on the 100 hall, and that only one nurse came over briefly in the afternoon. The Interim DON confirmed that insulin and other medication errors on the 100 hall were due to nurse staffing issues, and multiple staff members stated there was no nurse on the 100 hall for the day shift.
Delayed Call Light Response and Staffing Shortages
Penalty
Summary
The facility failed to provide enough nursing staff every day to meet resident needs and to have a licensed nurse in charge on each shift, as shown by delayed responses to call lights for two residents. Resident #6 was admitted with quadriplegia, seizure disorder, anxiety, depression, asthma, skin graft failure, and a stage 4 pressure ulcer. His MDS showed intact cognition, total dependence on staff for all ADLs, and inability to stand or ambulate. He reported that he used a device to activate his call light and often waited 30 minutes or more for staff to respond, with delays occurring 3 to 4 times per week and some repositioning needs going unmet for over 2 hours on the night shift. Resident #8 was also cognitively intact and totally dependent on staff for all ADLs, with diagnoses including traumatic spinal cord dysfunction, quadriplegia, neurogenic bladder, and diabetes mellitus. He had an indwelling suprapubic catheter and reported multiple instances of prolonged waits for call light response, including waits of 1.5 hours, over 2 hours, and up to 4.5 hours. He described delays in being cleaned after bowel movements, including sitting in stool for extended periods, and stated that bed baths were missed on multiple occasions. During observation, he was seen in bed wearing a hospital gown with red stains near the neckline and his catheter drainage bag positioned below bladder level in a dignity bag. Staff interviews supported the residents’ reports of staffing shortages and delayed call light response. The DON stated there were staffing problems, with daily call-ins on second and third shift and management staff working off shifts to fill gaps. CNA staff reported that call lights should be answered within 15 minutes but often took 30 to 45 minutes or longer, and that there were not enough staff to provide needed care, especially because many residents required two-person assistance and mechanical lifts. The Administrator stated she expected call lights to be answered within 15 minutes, and the facility policy directed staff to answer call systems immediately and complete requests within five minutes if possible.
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