F0725

F

Chronic Understaffing Leads to Delayed Care, Missed Showers, and Inadequate Call Light Response

Morton, Illinois Survey Completed on 01-06-2026

Penalty

No penalty information released

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.